August 2015 JMSMA by Journal MSMA

VOL. LVI • NO. 8 AUGUST 2015

STAY ON THE ROAD TO

ICD-10

OCT 1, 2015

STEPS TO HELP YOU TRANSITION The ICD-10 transition will affect every part of your practice, from software upgrades, to patient registration and referrals, to clinical documentation and billing. CMS can help you prepare. Visit www.cms.gov/ICD10 to find out how to: •

Make a Plan—Look at the codes you use, develop a budget, and prepare your staff

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Train Your Staff—Find options and resources to help your staff get ready for the transition

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Update Your Processes—Review your policies, procedures, forms, and templates

•

Talk to Your Vendors and Payers—Talk to your software vendors, clearinghouses, and billing services

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Test Your Systems and Processes—Test within your practice and with your vendors and payers

Now is the time to get ready. www.cms.gov/ICD10

Official CMS Industry Resources for the ICD-10 Transition

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VOL. LVI • NO. 8 AUGUST 2015

EDITOR Lucius M. Lampton, MD

President Claude D. Brunson, MD

ASSOCIATE EDITORS D. Stanley Hartness, MD Richard D. deShazo, MD

President-Elect Daniel P. Edney, MD

MANAGING EDITOR Karen A. Evers PUBLICATIONS COMMITTEE Dwalia S. South, MD Chair Philip T. Merideth, MD, JD Martin M. Pomphrey, MD and the Editors

Secretary-Treasurer Michael Mansour, MD

Tuberculosis Containment among the Homeless in Metropolitan Jackson, Mississippi Mario J. Azevedo, PhD, MPH; David E. Conwill, MD, MPH; et al.

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Speaker Geri Lee Weiland, MD

Clinical Problem-Solving Case: Straight from the Horse’s Mouth Andrew Adams. MD

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Vice Speaker Jeffrey A. Morris, MD Executive Director Charmain Kanosky

THE ASSOCIATION JOURNAL OF THE MISSISSIPPI STATE MEDICAL ASSOCIATION (ISSN 0026-6396) is owned and published monthly by the Mississippi State Medical Association, founded 1856, located at 408 West Parkway Place, Ridgeland, Mississippi 39158-2548. (ISSN# 0026-6396 as mandated by section E211.10, Domestic Mail Manual). Periodicals postage paid at Jackson, MS and at additional mailing offices. CORRESPONDENCE: Journal MSMA, Managing Editor, Karen A. Evers, P.O. Box 2548, Ridgeland, MS 39158-2548, Ph.: 601-853-6733, Fax: 601-853-6746, www.MSMAonline.com. SUBSCRIPTION RATE: $83.00 per annum; $96.00 per annum for foreign subscriptions; $7.00 per copy, $10.00 per foreign copy, as available. ADVERTISING RATES: furnished on request. Cristen Hemmins, Hemmins Hall, Inc. Advertising, P.O. Box 1112, Oxford, Mississippi 38655, Ph: 662-236-1700, Fax: 662-236-7011, email: cristenh@watervalley.net POSTMASTER: send address changes to Journal of the Mississippi State Medical Association, P.O. Box 2548, Ridgeland, MS 39158-2548. The views expressed in this publication reflect the opinions of the authors and do not necessarily state the opinions or policies of the Mississippi State Medical Association. Copyright © 2015 Mississippi State Medical Association.

Official Publication

SCIENTIFIC ARTICLES Multi-hospital Community NICU Quality Improvement 237 Improves Survival of ELBW Infants Jack D. Owens, MD MPH; Thomas Soltau, MD; Danny McCaughn, MD; Jason Miller, MD; Patrick O’Mara, MD; Kenny Robbins, MD; David M. Temple, MD; and David F. Wender, MD

MSMA • Since 1959

Top Ten Facts You Need to Know about the Treatment 252 of Venous Thromboembolism Dominique J. Pepper, MD; J. Michael Brewer, DO PRESIDENT’S PAGE The Official Address of the 147th President Claude D. Brunson, MD

254

EDITORIAL The Future of Population Health in Mississippi Bettina M. Beech, DrPH, MPH; Keith Norris, MD, PhD

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DEPARTMENTS From the Editor- A Busman’s Holiday Lucius M. Lampton, MD

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Legalese- Telemedicine and Rural Communities Andrew Chevalier

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Poetry in Medicine: Let Us All Stand and All Sing 264 John D. McEachin, MD ABOUT THE COVER – “NO GLITZ IN THE RITZ” The Ritz Theatre in Natchez opened in 1935 but has been dark for over 30 years. The 500-seat Art Deco style theater was operated by Gulf States Theaters and Paramount, until it closed around 1986. Located on Commerce Street, the old cinema was used for storage until its roof collapsed in 2000. The Historic Natchez Foundation (HNF), owner of the building, has been looking for a restoration developer since it acquired it as a donation in 2002. Subsequently, the HNF has spent more than $130,000 restoring the front facade and marquee with the theater’s neon and other repairs to stabilize the structure. The marquee has been featured in the Coen brothers movie Ladykillers with Tom Hanks, My Dog Skip, and possibly other movies as well. Now, the only thing left is the front facade. Behind the wall, Dr. Brahan says trees and bushes grow from the old floor. Photo by internist Robert “Bob” Brahan, MD; Hattiesburg. VOL. LVI • NO. 8 AUGUST 2015

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F R O M

T H E

E D I T O R

A Busman’s Holiday

ach summer, like many other physicians in Mississippi, I volunteer as a camp doctor for two weeks. My camp is Keewaydin Canoe Camp at isolated Lake Temagami in Canada. Most of my work there is with kids, although I am blessed with patients of all ages seeking out my medical services. My cases at camp included: “blueberries up the nose” in a 2-year-old child, an initially perplexing (but easily solved) dilemma; the dreaded “Beaver Fever” (Giardia); homesickness; “foot rot” (tinea pedis); and even a bat bite requiring rabies prophylaxis. And why is it that only the kids who are allergic to bee stings get stung, and usually repeatedly? I leave my stethoscope in the cabin, and as I make my rounds, my best weapon besides my brain and equanimity is a chest pocket full of Band-Aids (the cure for most of what ails you at a summer camp!).

Several years ago, a camp parent told me, “Doc, you are not on vacation: you are on a Busman’s Holiday.” The archaic phrase dates to Victorian London, referring to a bus driver when city buses were pulled by horses. It was said that the bus drivers so loved their horses that they would ride the buses even on their days off, just to make sure their horses were being well treated. Thus the phrase came to mean someone doing their usual work while off duty or on vacation. Medicine seems to lend itself easily to this situation. It is often difficult for us to shed our profession: it’s not as easy as just taking off our white coats. A physician is not only “what” we are but “who” are. Such is the nature of our art. Perhaps my afternoon swims in the cold waters of the lake will be cut short by a sick camper. Perhaps I will return late to dinner with my food cold and my hands smelling of betadine from suture repair. But even a Busman’s Holiday is still a joyous holiday, and I thank God for it! Contact me at LukeLampton@cableone.net. —Lucius M. Lampton, MD, Editor

JOURNAL EDITORIAL ADVISORY BOARD Timothy J. Alford, MD Family Physician, Kosciusko Medical Clinic Michael Artigues, MD Pediatrician, McComb Children’s Clinic Diane K. Beebe, MD Professor and Chair, Department of Family Medicine, University of Mississippi Medical Center, Jackson Jennifer J. Bryan, MD Assistant Professor, Department of Family Medicine University of Mississippi Medical Center, Jackson Jeffrey D. Carron, MD Professor, Department of Otolaryngology & Communicative Sciences, University of Mississippi Medical Center, Jackson Gordon (Mike) Castleberry, MD Urologist, Starkville Urology Clinic Thomas E. Dobbs, MD, MPH State Epidemiologist, Mississippi State Department of Health, Hattiesburg Sharon Douglas, MD Professor of Medicine and Associate Dean for VA Education, University of Mississippi School of Medicine, Associate Chief of Staff for Education and Ethics, G.V. Montgomery VA Medical Center, Jackson Bradford J. Dye, III, MD Ear Nose & Throat Consultants, Oxford

234

Daniel P. Edney, MD Executive Committee Member, National Disaster Life Support Education Consortium, Internist, The Street Clinic, Vicksburg Owen B. Evans, MD Professor of Pediatrics and Neurology University of Mississippi Medical Center, Jackson Maxie L. Gordon, MD Assistant Professor, Department of Psychiatry and Human Behavior, Director of the Adult Inpatient Psychiatry Unit and Medical Student Education, University of Mississippi Medical Center, Jackson Scott Hambleton, MD Medical Director, Mississippi Professionals Health Program, Ridgeland J. Edward Hill, MD Family Physician, North Mississippi Medical Center, Tupelo W. Mark Horne, MD Internist, Jefferson Medical Associates, Laurel Ben E. Kitchens, MD Family Physician, Iuka Brett C. Lampton, MD Internist/Hospitalist, Baptist Memorial Hospital, Oxford Philip L. Levin, MD President, Gulf Coast Writers Association Emergency Medicine Physician, Gulfport

AUGUST 2015 • JOURNAL MSMA

William Lineaweaver, MD Editor, Annals of Plastic Surgery Medical Director, JMS Burn and Reconstruction Center, Brandon Michael D. Maples, MD Vice President and Chief of Medical Operations, Baptist Health Systems Alan R. Moore, MD Clinical Neurophysiologist, Muscle and Nerve, Jackson Paul “Hal” Moore Jr., MD Radiologist, Singing River Radiology Group, Pascagoula Jason G. Murphy, MD Surgeon, Surgical Clinic Associates, Jackson Ann Myers, MD Rheumatologist , Mississippi Arthritis Clinic, Jackson Darden H. North, MD Obstetrician/Gynecologist , Jackson Health Care-Women, Flowood Michelle Y. Owens, MD Associate Professor, Vice-Chair of Obstetrics and Gynecology, University of Mississippi Medical Center, Jackson Jimmy L. Stewart, Jr., MD Program Director, Combined Internal Medicine/Pediatrics Residency Program, Associate Professor of Medicine and Pediatrics University of Mississippi Medical Center, Jackson

Samuel Calvin Thigpen, MD Hematology-Oncology Fellow, Department of Medicine, University of Mississippi Medical Center, Jackson Thad F. Waites, MD Clinical Cardiologist, Hattiesburg Clinic W. Lamar Weems, MD Urologist, Jackson Chris E. Wiggins, MD Orthopaedic Surgeon, Bienville Orthopaedic Specialists, Pascagoula John E. Wilkaitis, MD Chief Medical Officer, Brentwood Behavioral Healthcare, Flowood Sloan C. Youngblood, MD Assistant Medical Director, Department of Anesthesiology, University of Mississippi Medical Center, Jackson

HIS INSURANCE MUST BE WITH MACM. What’s one way to guarantee a few extra minutes of sleep? Know that Medical Assurance Company of Mississippi is working to protect you and your medical practice. MACM insureds don’t worry when it comes to decisions regarding their professional liability coverage. For almost 40 years, Mississippi physicians have depended on the security and financial stability of MACM. Today, we remain an organization governed by physicians helping protect those who have put their faith and trust in us. Tammi Arrington

Marketing Representative

(800) 325-4172 tammi.arrington@macm.net

If you are losing sleep over your current professional liability coverage, call Tammi Arrington at MACM for information and a quote. Let us help you rest easy. AUGUST 2015 • JOURNAL MSMA

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S C I E N T I F I C

A R T I C L E S

Multi-hospital Community NICU Quality Improvement Improves Survival of ELBW Infants JACK D. OWENS, MD MPH; THOMAS SOLTAU, MD; DANNY MCCAUGHN, MD; JASON MILLER, MD; PATRICK O’MARA, MD; KENNY ROBBINS, MD; DAVID M. TEMPLE, MD; AND DAVID F. WENDER, MD Introduction There is significant variability reported in the literature of outcomes for very low birth weight (VLBW, <1500 grams) and extremely low birth weight (ELBW, <1000 grams) infants. Regionalized efforts to improve outcomes of these vulnerable populations have included defining hospital resources and patient volume. Mortality has been shown to be inversely proportional to patient volume, with improved survival being associated with higher hospital VLBW patient volume.1,2 Volume and hospital specific characteristics, however, address only a fraction of the variability of neonatal intensive care quality.3 It is possible that volume is only a proxy for other indicators or drivers of quality. Organized multi-center quality-improvement programs such as the Vermont Oxford Network NICQ and state organized collaboratives have also been shown to improve outcomes of newborn infants requiring intensive care.4,5,6 There are also data to suggest that a proactive, “all or none” approach versus a selective, less aggressive approach to fetal and neonatal management at the margins of viability (<25 wks) may improve survival.7,8 Additionally, underestimating outcome statistics of extremely low birth weight (ELBW, <1000 grams) infants may lead to treatments being withheld.9,10 Outcomes of extreme preterm infants are likely dependent on multifactorial components of quality. There are other variables that have not been thoroughly studied, such as NICU design, the impact of 24/7 in-house neonatal nurse practitioners (NNP’s) or neonatologists, the availability of maternal -fetal medicine consultation, either onsite or via telemedicine, or the availability of onsite pediatric surgical services. Once again, these need to be studied in the context of adequately applied quality models. QI efforts would ideally be individualized to address different variables in different contexts. An outpatient-based pediatric cardiology practice in Wichita, Kansas, for example, demonstrated improved outcome of their cardiac patients by implementing evidence-based referral decisions.11 It is unlikely that sustained quality in health care settings can be achieved through addressing only proxies of quality such as volume. Instead, improving quality should involve a continuously adapting, individualized, agile model

with outcome data being monitored in “real-time” via dashboards with response through multiple iterations of Plan-Do-Study-Act (PDSA) cycles. The Vermont Oxford Network collects data from over 950 US and international centers, including 90% of the very low birth weight infants in the US, as well as expanded database options. The Network provides unique, reliable, and confidential reporting to participating members for use in their clinical care, quality improvement, internal audit, and peer review. In addition to data submission, select Vermont Oxford Network centers choose to engage in a quality membership, with the goal of turning their data into actionable information to improve clinical outcomes. Quality members participate in one of two-tiered options of structured multi-institutional and, in some cases, state-wide quality improvement collaboratives. The first tier is the VON Newborn Intensive Collaborative for Quality (NICQ), a program which engages 40 to 60 teams in a content-specific homeroom or affinity group (for example, minimizing lung injury, The Golden Hour, etc.). The homerooms are led by a team of content and quality improvement experts as well as a family improvement leader. Local center teams meet “virtually” in homerooms throughout the year. Teams use a content-specific Improvement Toolkit, containing potentially better practices, tools, and measurement strategies which they evaluate and implement, using the plan-dostudy-adapt (PDSA) model. NICQ teams participate in two face-toface meetings yearly, one of which is conducted at a host site and offers an immersion learning experience and the opportunity to benchmark with eight to twelve centers immersed in improvement. The second face-to-face meeting is a NICQ Symposium, featuring improvement data from centers from around the world. A second tier of QI engagement is the VON Internet-Based Quality Improvement Collaborative (iNICQ) which is conducted almost entirely in a web-based virtual classroom using a toolkit, the model for improvement and similar peer-to-peer learning strategies. The iNICQ teams also use the VON Day Quality Audits, an enhanced project specific audit that adds a structured measurement tool to evaluate opportunities for improvement. All of the NICQ and AUGUST 2015 • JOURNAL MSMA

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ABSTRACT Quality improvement or high reliability in medicine is an evolving science where we seek to integrate evidence-based medicine, structural resources, process management, leadership models, culture, and education. Newborn Associates is a community-based neonatology practice that staffs and manages neonatal intensive care units (NICU’s) at Central Mississippi Medical Center, Mississippi Baptist Medical Center, River Oaks Hospital, St Dominic’s Hospital, and Woman’s Hospital within the Jackson, Mississippi, metropolitan area. These hospitals participate in the Vermont-Oxford Neonatal Network (VON), which is a voluntary national network of about 1000 NICU groups that submit data allowing them to benchmark their patient outcome. This network currently holds data on 1.5 million infants. Participation may also include the Newborn Improvement Quality Collaborative (NICQ) which is an intensive quality improvement program where 40-60 of the almost 1000 VON centers participate each year or the iNICQ, which is an internet-based collaborative involving about 150 centers per year. From 2008-2009, our group concentrated efforts on quality improvement which included consolidating resources of three corporately managed hospitals to allow focused care of babies under 800-1000 grams at a single center, expanding participation in the VON NICQ to include all physicians and centers, and establishing a group QI

focused committee aimed at sharing practice bundles and adopting quality improvement methodology. The goal of this article is to report the impact of these QI activities on survival of the smallest preterm infants who weigh less than 1500 grams at birth. Two epochs were compared: 2006-2009, and 2010-2013. 551 VLBW (<1500 grams) infants from epoch 1 were compared to 583 VLBW infants from epoch 2. Mortality in this group decreased from 18% to 11.1% (OR 0.62, 95% CI 0.44-0.88). Mortality in the 501-750 grams birth weight category decreased from 45.7% to 18% (OR 0.39, 95% CI 0.21-0.74). Improved survival was noted in all centers over the time period. These findings suggest that a physician-driven, multidisciplinary, individualized and multifactorial quality improvement effort can positively impact the care of extremely preterm infants in the community NICU setting.

iNICQ collaborative teams develop a clinical aim, a value aim, and a family-centered care aim. Additionally, they focus on standardization as a mechanism to achieve improved high-reliability results.

born services, including both NICU and well-baby care, to these five community hospitals. The quality efforts were historically characterized by a hospital-specific, de-centralized model, and there was no differentiation of levels of NICU care. All centers were reporting outcome data to the VON database by 2007; however, there was only one center participating in the quality collaborative arm of VON prior to 2007. Between 2007 and 2009, there were efforts to improve the structure of quality improvement in the practice including centralizing the quality efforts, increasing awareness and utilization of quality methodology through increased VON NICQ participation, and individualization of hospital levels of care according to local center resources. These efforts came to fruition by 2010. The purpose of this article is to report the retrospective results of physician-driven, multi-hospital, individualized quality improvement efforts aimed at improving the quality of care and survival of VLBW infants managed by the group in these five neonatal intensive care units.

In Mississippi, the perinatal regionalization system has only recently differentiated community hospitals with NICU services from community hospitals without these services. The university hospital had been designated at the only level III NICU in the state, while community perinatal centers were designated as either level I or II. Currently, the state recognizes the 2012 AAP definitions of levels of perinatal care where community NICU’s are designated as level III and the university NICU is the state’s only level IV center. For the purpose of this report, national definitions prior to the most recent 2012 changes were used to define the levels of perinatal care as these guidelines were in place during most of the comparison periods.12 A level III NICU has historically been defined as the appropriate level of service for VLBW infants. The 2004 AAP guidelines allowed for differentiation of two different VLBW infant populations based on birth weight and required levels of support. A level III-a neonatal intensive care unit was defined as one where care was offered to babies weighing more than 800-1000g not requiring prolonged mechanical ventilation. A level III–b neonatal intensive care unit was defined as one where services included advanced ventilation technology (high-frequency ventilation, inhaled nitric oxide, and prolonged mechanical ventilation) for infants of any birth weight, including those weighing less than 800-1000 grams. Level III-c care included pediatric surgical services which have historically been offered at the university hospital. Until 2010, level III-b NICU care was offered at all five community hospitals referred to above. Our practice is a large, single specialty, community-based neonatology group in Jackson, Mississippi, that provides comprehensive new-

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AUGUST 2015 • JOURNAL MSMA

Key Words: perinatal, quality, quality improvement, process improvement, collaborative, Vermont Oxford, NICQ, preterm birth, premature infant survival, hospital quality, VLBW, ELBW, prematurity, outcome, mortality, neonatal, NICU, outcome variability, survival, birth weight, regionalization, culture, neonatal intensive care, low birth weight, very low birth weight, extremely low birth weight, high-reliability

Methods Between 2007 and 2009, data were reviewed and physician driven, and multidisciplinary quality improvement efforts were planned and implemented with the goal of improving care for all VLBW and ELBW infants in NICUs staffed and managed by our neonatology practice. Three hospitals are part of a single ownership corporation (hospitals A, C, and E), and prior to this initiative all of these hospitals offered care to infants whose birth weight was <1000 grams. Also, until this point, while all centers reported data to the Vermont-Oxford Network Database, only two hospitals participated in the Vermont Oxford Network NICQ collaborative prior to 2009 and only one prior to 2007. Between 2008 in 2009, the following quality improvement efforts were implemented:

1) Within the three corporately managed hospitals, ELBW infant care was centralized in one hospital which offered individual rooms and in-house neonatal nurse practitioners.

2) Two additional level III-b NICUs were enrolled in the Vermont Oxford Network NICQ collaborative, resulting in 100% hospital and physician participation within the group.

3) The group participated in three hospital specific VON NICQ improvement initiatives.

4) A group QI committee was established through which outcome data is shared and practice bundles are disseminated.

improved via utilization of delivery room checklists and admission debriefing tools, improving DR utilization of thermoregulation practices, standardizing ventilator management on admission to include volume targeted ventilation, oxygen targeting in the DR, and focused communication with parents and family during the admission process. Our nutrition efforts included implementing a policy of exclusive use of human milk for infants under 1200 g, establishing guidelines for adding protein to IVF on admission, and establishing guidelines for initiating and advancing enteral feeds. Lastly, establishing a group quality improvement committee allowed the NICQ initiatives to be informally disseminated among other centers affiliated with the group. The impact of participation in these collaboratives and establishing a group committee created a culture of improvement among physicians as well as within each hospital NICU team which was an intangible component of improvement that potentially had the most significant impact on outcome.

Centralization of ELBW baby care within a multi-hospital system to a single center allowed those infants to benefit from focused tiny baby protocols, a single-room NICU design and 24/7 in-house neonatal nurse practitioners. The latter represent prevalent potentially better practices (PBP’s) that have the potential to improve care depending on the context but lack adequate research. Implementation of standardized quality improvement methodology was facilitated through expanded participation in the Vermont Oxford network NICQ collaboratives. The NICQ quality improvement collaboratives for VLBW infant care from 2009-2012 included preventing nosocomial infection, improving delivery room management during the “Golden Hour” admission process, and improving nutritional management of the very low birth weight infant. While implementation of these programs was physician initiated and driven, successful implementation was a multidisciplinary effort including nursing, respiratory care, social service, lactation, physical/speech/occupational therapy, nutrition, parent advocates, and administration. Infection prevention practices implemented at the group level as a result of these initiatives included efforts to foster unit culture and improve hand hygiene, utilization of closed central line systems, and standardizing line utilization guidelines. “Golden Hour” care (delivery room and admission process) was

Two epochs were compared: 2006 – 2009 and 2010 – 2013 (tables 1 and 2). Average mortality rates with 95% confidence intervals were compared with risk ratios. During the second epoch, infants under 800-1000 grams were transported from hospitals A and E to hospital C. Within the VON database, infants transferred between hospitals are not tracked, which can cause infants to be counted twice. To avoid double counting infants, only inborn infants were counted at the receiving hospital. This did lead to the exclusion of infants who were born in referring hospitals outside of the Jackson metropolitan area and transported to hospital C. For infants < 1000 grams, this data reflects infants born within this corporately managed group of hospitals. Infants transported from hospitals A and E were counted under the referral hospital database. Enrollment in the Vermont Oxford Network at hospital D did not occur until 2007, so this hospital’s data from 2006 is excluded. Data was collected via the Vermont Oxford network database and the network data was used for comparison. Mortality rates were plotted on run charts and compared to the Vermont Oxford network mean, 25th percentile and 75th percentile mortality rates. Mortality rates for each epoch were compared using risk ratios. 95%

TABLE 1. HOSPITAL CHARACTERISTICS (LEVEL III-A AND III-B) (EPOCH 1 AND EPOCH 2) NFP=not for profit. ADC=average daily NICU census. VLBW=very low birth weight. VON=Vermont- Oxford Network. NICQ=Newborn Improvement Quality Collaborative. Table 1: Hospital Characteristics (Level III-a and III-b) (Epoch 1 and Epoch 2) MFM=maternal-fetal medicine. NNP=neonatal nurse practitioner. Hos pi tal Owners hi p

Epoch

NICU Level

Ave Del per yea r

Ave NICU Ave VON ADC VLBW/yea r Da taba s e

1325

8.3

34.8

corpora te

III-b

III-a

858

5.6

28.8

NFP

III-b

1227

8.9

34.5

III-b

1291

10.2

42.8

C D E

corpora te NFP corpora te

III-b

1930

10.1

32.5

III-b

1869

11.2

III-b

1444

7.6

III-b

1472

10.6

31.8

III-b

1620

7.9

25.8

III-a

1377

5.4

15.5

NICQ

1999-

2000-

2007-

2002-

2009-

Ons i te MFM

In-hous e NNP

yes

20102007-

2009-

2002-

2009-

yes

NFP=not for proﬁt. ADC=average daily NICU census. VLBW=very low birth weight. VON=Vermont- Oxford Network. NICQ=Newborn Improvement Quality Collaborative. MFM=maternal-fetal medicine. NNP=neonatal nurse practitioner. AUGUST 2015 • JOURNAL MSMA

Table 2: Patient Characteristics (Epoch 1 and Epoch 2)

239

NFP=not for for proﬁt. proﬁt. ADC=average ADC=average daily daily NICU NICU census. census. VLBW=very VLBW=very low low birth birth weight. weight. VON=VermontVON=Vermont- Oxford Oxford Network. Network. NICQ=Newborn NICQ=Newborn NFP=not Improvement Quality Quality Collaborative. Collaborative. MFM=maternal-fetal MFM=maternal-fetal medicine. medicine. NNP=neonatal NNP=neonatal nurse nurse practitioner. practitioner. Improvement

TABLE Table2.2: 2: Patient Patient Characteristics Characteristics (Epoch (Epoch 11 and and Epoch Epoch 2) 2) Table PATIENT CHARACTERISTICS (EPOCH 1 AND EPOCH 2) Hospi pita tall Hos

Epoch Epoch

Africa cann Afri American can Ameri Race Race

Multi tipl ples es Mul

VLBW VLBW Antenata tall Antena Steroids ds Steroi

Congenita tall Congeni Ma l forma ti ons Ma l forma ti ons

Prenata tall Prena Ca re Ca re

A A

11 22

93% 93% 95% 95%

18% 18% 25% 25%

60% 60% 69% 69%

1% 1% 3% 3%

90% 90% 95% 95%

11 22

68% 68% 72% 72%

37% 37% 26% 26%

66% 66% 82% 82%

2% 2% 1% 1%

93% 93% 97% 97%

nd EE CC aand

11 22

53% 53% 51% 51%

28% 28% 23% 23%

76% 76% 78% 78%

3% 3% 3% 3%

99% 99% 98% 98%

D D

11 22

56% 56% 64% 64%

15% 15% 23% 23%

70% 70% 82% 82%

1% 1% 2% 2%

98% 98% 99% 99%

tient randomization or prospective study design, and IRB approval was not required for any of these individual internal QI projects. There are no patient identifiers and specific hospitals are de-identified. IRB approval was not required for publication as there was no intent to publish at the time of the QI projects and research was not specifically a part of any of the activities.

Results Table 1 shows the hospital characteristics comparing epochs 1 and 2. NICU TABLE 3. levels of care, delivery volumes, number of VLBW infants per year, Table 3: 3:CHARACTERISTIC Patient Characteristic Characteristic Comparison Table Patient Comparison PATIENT COMPARISON involvement in VON (data collection and NICQ), the availability (Epoch111VS. vs.EPOCH Epoch2,2, 2,ALL all hospitals hospitals combined) combined) (Epoch vs. Epoch all (EPOCH HOSPITALS COMBINED) *Pearson Chi Square of an on-site MFM, and the presence of in-house NNP’s are demonstrated. During this eight year period, comparison of the Epoch 11 Epoch 22 P-Va ll ue* ue* Epoch Epoch P-Va two epochs showed a trend toward increased steroid use that was not statistically significant (69% vs. 79%, p=0.139). Otherwise, the Afri ca ca n n Afri 396/599=66% 405/592=68% 405/592=68% 0.708 396/599=66% 0.708 Ameri ca ca n n Ra Ra ce ce potentially confounding demographic variables between the epAmeri ochs were similar (tables 2 and 3). There was a significant imMul ii tpl tpl es es 153/599=26% 141/592=24% 141/592=24% 0.592 Mul 153/599=26% 0.592 provement in survival of VLBW infants over time (figure 1). ImVLBW Antena Antena ta ta ll VLBW proved survival was most notable in the smallest infants between 411/596=69% 465/591=79% 465/591=79% 0.139 411/596=69% 0.139 teroi d d ss teroi 501 and 750 grams (figure 2). When mortality rates were consoliCongeni ta l dated within each epoch, risk ratio comparisons showed statisticalCongeni ta l 12/598=2% 13/591=2% 0.82 12/598=2% 13/591=2% 0.82 Ma ll forma forma ti ti ons ons ly significant improved mortality rates in the latter epoch (table 4). Ma For all VLBW infants, there was a 38% mortality rate reduction Prena ta ta ll Ca Ca re re 570/598=95% 575/592=97% 575/592=97% 0.87 Prena 570/598=95% 0.87 (RR 0.62, 95% CI 0.45-0.86). This reduction was mostly due to TABLE 4. improved survival in the 501-750 gram birth weight category, Table 4: Epoch 1 vs.2 MORTALITY Epoch 2 Mortality Rate Ratios EPOCH 1 VS. EPOCH RATE RATIOS where a 61% relative mortality rate reduction was demonstrated *Pearson Chi-Square, **includes infants < 501 grams (RR 0.39, 95% CI 0.22-0.68). There was a trend toward improved *Pearson Chi Chi Square Square *Pearson survival in the 751-1000 gram birth weight group; however, this n N % RR 95% CI p* was not statistically significant due to low power from relatively low VLBW** mortality rates in this population. 2006-2009 104 599 17.4% 0.64 0.48-0.86 <0.01

Figure 2: 501-750g Mortality Rates

2010-2013

583

11.1%

Discussion The science of quality improvement/high reliability is being embraced by medicine as a way of improving the care delivered to our 2010-2013 20 111 18.0% 751-1000g patients. In 2001, the Institute of Medicine published the following 0.77 0.33-1.74 0.49 2006-2009 15 130 11.5% statement: “Healthcare harms patients too frequently and routinely 2010-2013 10 113 8.8% fails to deliver its potential benefits. Indeed, between the health 1001-1500g care that we now have and the health care that we could have lays 1.13 0.45-2.84 0.78 2006-2009 10 335 3.0% not just a gap but a chasm”.13 Ongoing quality improvement efforts 2010-2013 11 326 3.4% seek to integrate knowledge gained from clinical trials and integrate it into clinical practice. This is a complex and evolving science that confidence intervals and Pearson Chi-Square analyses were calculated involves more than just data collection and identifying evidence based with MedCalc statistical software. Pearson Chi-Square analysis was practices. It also involves measuring and addressing processes and work *Pearson Chi-Square, **includes used to compare mortality rates asinfants well as< 501 othergrams potentially confoundflow, culture, education, leadership models, community demographics ing risk variables. and norms, and community organization. Patients, families, hospitals, This is a retrospective report of QI activities that were initiated with- payers and providers are all stakeholders, and should sit at the table in out the intention to publish. There were no novel therapies initiated community efforts to improve our health care system. that were not already considered standard of care. There was no pa501-750g

2006-2009

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105

45.7%

0.39

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0.24-0.63

<0.01

Figure 1: VLBW Mortality Rates (includes infants <501 g)

FIGURE Figure 1:1.VLBW Mortality Rates (includes infants <501 g) VLBW MORTALITY RATES (INCLUDES INFANTS <501 G)

FIGURE Figure 2:2.501-750g Mortality Rates 501-750G MORTALITY RATESRates Figure 2: 501-750g Mortality

This multi-hospital quality improvement effort demonstrates the benefit of physician groups applying methodology Table 4: Epoch 1 vs. Epochstandardized 2 MortalityQIRate Ratios to a serviceline specific patient population multidisciplinary Table 4: Epoch 1 vs. Epoch 2 through Mortality Rate Ratios teams. This population health approach to maximize patient outcome requires RR quality 95%improvement. CI p* integrating the nsciences Nof public %health and VLBW** n N to each hospital % RR 95% CI p* Efforts were individualized ownership system, allowing 2006-2009 104 599 17.4% 0.64 0.48-0.86 <0.01 VLBW** each system to safely offer the highest possible level of care given the 2010-2013 65 583 11.1% 2006-2009 104 599 0.48-0.86 <0.01 resources of each hospital. The 17.4% result was0.64 a significant reduction in 501-750g 2010-2013 65 583 11.1% VLBW infant mortality, especially those born at 501-750 grams. The 0.39 0.24-0.63 <0.01 2006-2009 48 105 45.7% 501-750g data suggest that survival of extremely preterm infants can be in or close 2010-2013 20 111 18.0% 0.39 0.24-0.63 <0.01 2006-2009 48 105 45.7% to751-1000g the VON top20quartile 111 despite having 2010-2013 18.0% VLBW and total infant delivery 0.33-1.74 0.49 2006-2009 130 rates below the15VON averages of11.5% about 50 0.77 and 2500 infants per year, 751-1000g 2010-2013 10 efforts130 113 8.8% consolidation respectively. The did include of ELBW 0.49 infants 0.77 0.33-1.74 2006-2009 15 11.5% 1001-1500g 2010-2013 10 hospital 113 within a corporate system, 8.8% so patient volume does likely partially 0.78 2006-2009 10 335 3.0% 1001-1500g contribute to the results. The data presented1.13 in this0.45-2.84 article also suggest 2010-2013 11 326 3.4% 1.13 are 0.45-2.84 0.78 to 2006-2009 3.0% that the smallest10preterm335 infants (<750 grams) most vulnerable 2010-2013 11 326 3.4% 14 variation in outcome, which is consistent with Colorado data and that focused quality efforts can improve survival in this high risk population. *Pearson Chi-Square, **includes infants < 501 grams The smallest preterm infants are a patient population deserving focused *Pearson Chi-Square, **includes infants < 501 grams quality improvement efforts at multiple levels: individual hospitals, multi-hospital systems, and the state health department. There are some caveats and limitations to this data. A common response

to those who advocate for efforts to improve survival of extremely preterm infants is that morbidity and handicap rates will increase. Previous studies that have demonstrated improved survival in extremely preterm infants have not shown concomitant increases in morbidity.7,8 It is, however, important to demonstrate that the improved survival rate in our tiny infants was not associated with increased morbidity. This article shows an association between our QI efforts and outcome, but this is not a controlled trial investigating any of the specific changes such as inhouse NNPâ&#x20AC;&#x2122;s or a single room NICU design. Each of the NICQ projects required vigorous documentation of process and outcome improvements however, the goal of this article is not to demonstrate the relationship of these specific improvements to outcome. The goal is to demonstrate that participation in such collaboratives has a positive effect on patient outcome. A statistically significant difference in mortality rates between two four year epochs is demonstrated; however, there was also a modest positive trend in overall survival of preterm infants in all VON centers during this period (figures 1 and 2). During this eight year period, the groupâ&#x20AC;&#x2122;s VLBW and 501-750 gram infant mortality rates did cross individual year quartiles and the magnitude of improvement was significant relative to the VON trends. Four year epochs were used to achieve statistical significance, however, control charts with year-to-year statistically significant confidence intervals would be more compelling. Of note, between the two epochs there was an increase in steroid administration that did not reach statistical significance (table 3). Antenatal steroid administration improves many aspects of premature infant outcome including death, intraventricular hemorrhage, respiratory distress syndrome, and necrotizing enterocolitis. While this increase in steroid administration possibly played a role in decreasing mortality between these epochs, it is likely that increased use of antenatal steroids was an indirect effect of a changing culture within our centers. This increase, however, did not reflect a specific effort to improve antenatal steroid utilization. Increasing utilization of antenatal steroid for preterm infants is an effort worthy of a future multi-hospital quality effort. Lastly, one could argue for providing data trends for individual hospitals as it is possible that improvement of a single center could account for the findings. The goal was to investigate the impact of integrating QI methodology into our practice across multiple hospitals, so individual hospital performance or improvements are not reported. Also, data on each individual center would lack the statistical power to demonstrate a trend, though improvement was noted at each location. No other potentially confounding variables that were measured were significantly different between the two epochs. The findings presented in this article have generalizable implications for the organization of neonatal healthcare in Mississippi. The most effective way to improve infant mortality is to prevent preterm birth, and state public health efforts ultimately need to focus on improving pre-conception and prenatal care. The data presented in this article, however, suggest that there may still be room for improvement in the hospital care of the tiniest preterm infants. Regionalization is often referenced as the most effective public health tool for improving NICU care; however, these efforts have historically focused on patient volume and/or geographic distribution. Data from California suggest better outcome in centers that have an average daily NICU census of 15, or > 50 VLBW

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infant admissions per year.2 German data suggest improved outcome in hospitals with delivery rates > 1000 infants/year, or > 36 VLBW admissions per year.1 There is likely a threshold of NICU volume, above which quality is optimized; however, further studies are needed to establish that minimal safe volume when other drivers of quality are in place. Data collection with transparency, rigorous and standardized QI methodology, multi-center collaboration, education, and a culture of change are likely more critical components of an effort to improve outcome than patient volume. Focusing on improved utilization of quality improvement methodology by community NICU teams, allowing individualized restructuring of perinatal healthcare delivery by multi-hospital systems, and increasing the rate of preterm infants being delivered in current hospitals that offer level III NICU care might be the most effective areas of focus for a state regionalization effort to improve the hospital care of preterm infants, as is indeed happening by the recent initiation of the Mississippi State Perinatal Quality Collaborative (MSPCQ). Mississippi has recently redefined the levels of care so that community hospitals that offer NICU care can be differentiated from community centers without such services.15 This could improve the organization of newborn intensive care in Mississippi and increase the rate of delivery of preterm infants in hospitals with appropriate services. Under this new system, community NICU’s are designated as level III centers and UMMC is the state’s only regional level IV center, offering care to infants requiring pediatric surgical subspecialty services. Further research might include investigating the effects of NICU design, nursing ratios and training, improved access to pediatric subspecialists via telemedicine, inhouse NNP’s or neonatologists, and increased availability of MFM services in existing perinatal centers. Most critical, however, is the need to promote the culture and methodology of both quality improvement and population health such that the benefits are sustained and available to all of Mississippi’s most vulnerable newborn infants. These implications are likely generalizable to other areas of medicine, and this approach to physician management of healthcare service lines could be considered an evolving standard of care.

2. Cifuentes J, Bronstein J, Phibbs CS, Phibbs RH, Schmitt SK, Carlo WA. Mortality in low birth weight infants according to level of neonatal care at hospital of birth. Pediatrics 2002; 109: 745 –751. 3. Horbar JD, Badger GJ, Eugene ML, Rogowski J, Shiono PH. Hospital and Patient Characteristics Associated With Variation in 28-Day Mortality Rates for Very Low Birth Weight Infants. Pediatrics 1997; 99; 149-156. 4. Horbar JD, Rogowski J, Plsek PE, et al. Collaborative quality improvement for neonatal intensive care. Pediatrics 2001; 107: 14 –22. 5. Payne NR, Finkelstein MJ, Liu M, Kaempf JW, Sharek PJ, Olsen S. NICU Practices and Outcomes Associated with 9 Years of Quality Improvement Collaboratives. Pediatrics 2010; 125; 437-446. 6. Wirtshafter DD, Powers RJ, Pettit JS, Lee HC, Boscardin J, Subeh MA, Gould JB. Nosocomial Infection Reduction in VLBW Infants With a Statewide Quality Improvement Model. Pediatrics 2011; 419-426. 7. Hakansson S, Farooqi A, Holmgren PA, Serenius F, Hogberg U. Proactive Management Promotes Outcome in Extremely Preterm Infants: A PopulationBased Comparison of Two Perinatal Management Strategies. Pediatrics 2004; 114; 58-64. 8. Zayek MM, Trimm RF, Hamm CR, Peevy KJ, Benjamin JT, Eyal FG. The Limit of Viability: A Single Regional Unit’s Experience. Arch Pediatr Adolesc Med. 2011; 165(2):126-133. 9. Haywood JL, Morse SB, Goldenberg RL, Bronstein J, Nelson KG, Carlo WA. Estimation of Outcome and Restriction of Interventions in Neonates. Pediatrics 1998; 102: e20. 10. Morse SB, Haywood JL, Goldenberg RL, Bronstein J, Nelson KG, Carlo WA. Estimation of Neonatal Outcome and Perinatal Therapy Use. Pediatrics 2000; 105: 1046-1050. 11. Allen SW, Gauvreau, K, Bloom BT, Jenkins KJ. Evidence-Based Referral Results in Significantly Reduced Mortality After Congenital Heart Surgery. Pediatrics 2003; 112 (1): 24-28. 12. AAP Committee on Fetus and Newborn. Policy Statement: Levels of Neonatal Care. Pediatrics 2004; 114 (5): 1341-1347. 13. Institute of Medicine. Crossing the Quality Chasm: a new Health System for the 21st Century, National Academy Press, 2001. 14. Kamath BD, Box TL, Simpson M, Hernandez JA. Infants born at the threshold of viability in relation to neonatal mortality: Colorado, 1991 to 2003. Journal of Perinatology 2008; 28: 354-360. 15. AAP Committee of Fetus and Newborn. Policy Statement: Levels of Neonatal Care. Pediatrics 2012; 130(3): 587-597.

1. Bartels DB, David W, Wenzlaff P, Dammann O, Poets CF. Hospital Volume and Neonatal Mortality Among Very Low Birth Weight Infants. Pediatrics 2006; 117: 2206-2214.

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Tuberculosis Containment among the Homeless in Metropolitan Jackson, Mississippi MARIO J. AZEVEDO, PHD, MPH, MA Dean, College of Liberal Arts and Former Chair, Department of Epidemiology and Biostatistics, Jackson State University DAVID E. CONWILL, MD, MPH Epidemiologist, Office of Tuberculosis and Refugee Health, Mississippi State Department of Health SHONDA LAWRENCE, PHD, MSW, MS Assistant Professor, Social Work, Jackson State University ANN JACKSON, BSN, RN Tuberculosis Nurse Educator, Office of Tuberculosis and Refugee Health, Mississippi State Department of Health AZAD R. BHUIYAN, PHD, MPH Associate Professor, Epidemiology and Biostatistics, Jackson State University DIANNE HALL, BSN, RN Tuberculosis Nurse, Hinds County Health Department BRIAN ANDERSON, PHD, MSW Associate Professor, Social Work, Jackson State University DONALD FRANKLIN, BS, MS Disease Intervention Specialist, Tuberculosis Program, Hinds County Health Department DAVID BROWN, PHD, MPH Assistant Professor, Behavioral and Environmental Health, Jackson State University PATRICIA WILKERSON, PHD, MSW Assistant Professor, Social Work, Jackson State University GLORIA BECKETT, MPH Branch Director, Office of Tuberculosis and Refugee Health, Mississippi State Department of Health AUGUST 2015 â&#x20AC;˘ JOURNAL MSMA

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ABSTRACT Importance: Preventing tuberculosis among the homeless has emerged as an especially difficult challenge. Objectives: We assessed a 2008-2009 tuberculosis (TB) outbreak and subsequent prevention strategies among homeless persons in metropolitan Jackson, Hinds County, Mississippi. Design, Setting and Participants: We compared data about cases and subclinical TB infections (LTBI) among homeless persons during the outbreak and post-outbreak years, interviewed involved homeless persons, compiled observations from visits to Jackson homeless shelters and conducted literature reviews on homelessness and infectious diseases. We reviewed homeless shelter TB prevention methods adopted by other municipalities, guidelines developed by the Centers for Disease Control and Prevention (CDC), and recommendations from other official and ad hoc groups and considered their applicability to metropolitan Jackson. Main Outcomes and Measures: The Mississippi State Department of Health TB Program, assisted by the CDC and other agencies, contained the Jackson-area outbreak by the end of 2009 as reflected by progressively lower TB rates among homeless persons thereafter. However, some follow-up activities and enforcement of shelter preventive measures have not been consistently maintained. Resources to prevent further outbreaks continue to be inadequate, and overreliance on private organizations has continued. In the process, appreciation of the dynamic interaction enhancing TB risk among the homeless and incarcerated persons has emerged.

Introduction One third of the world’s population is infected with tuberculosis (TB) and almost nine million people each year become sick with active TB, still one of the major killer diseases in the developing world, particularly in subSaharan Africa, Southeast Asia, and the Southwest Pacific rim. Globally, an estimated 1.4 million people die from TB annually.1 In the US, from 1953 to 1984, the national prevalence of reported active TB decreased from 84,300 to 22,255 but then rebounded, with 26,673 reported cases in 1992. In 2012, reported U.S. TB cases totaled 9,945, a 63% decline from the 1992 resurgence peak. Foreign-born persons accounted for the majority of reported U.S. TB cases over the past 13 years.2, 3 Mississippi experienced a similar decline of active TB cases over the past several years. In 2007, the state had 137 reported cases and in 2012, 81 reported cases.4 ,5 Nationally, globally, and in Mississippi, homeless people have disproportionately higher TB infection rates as compared to non-homeless persons.4, 5, 6, 7, 8, 9 The 2012 study by Beijer, et al. estimates the prevalence of active TB and closely related diseases among the world’s estimated 100 million homeless persons ranges from 0.2 percent to 7.7 percent for tuberculosis, 3.9 percent to 36.2 percent for hepatitis C virus infection, and 0.3 percent to 21.1 percent for HIV infection.9 Active TB is an important co-morbid infection with HIV/AIDS--at times referred to as Bonnie and Clyde or the Terrible Twins.10, 11 Co-infection with

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Results: Major outbreak contributors were lack of periodic TB screening among homeless shelter clients, preventive treatment compliance and follow-up difficulties among those with subclinical tuberculosis infections, interrupted preventive measures among infected persons incarcerated in local correctional facilities who disproportionately re-join Jackson’s homeless community when released, inadequate attention to shelter environmental preventive strategies such as ultraviolet light germicidal irradiators and proper airexchange/ventilation, costs of isolation housing for homeless people with full-blown tuberculosis (especially those co-infected with HIV and other infections and those with alcohol and/or other chemical dependencies), lack of adequate transportation which impacts access to evaluation and care, lack of mandated ongoing training among shelter and correctional facility staff, and inadequate attention to the societal problem of homelessness itself. Conclusions: Sustained adherence to local shelter and correctional facility TB prevention measures based on standards and policies proved effective in other settings is most crucial. These include requirements for periodic tuberculosis prevention and awareness training for shelter and correctional facility staff, ongoing tuberculosis screening and follow-up among homeless shelter clients and inmates of local correctional facilities, and attention to shelter and correctional facility environmental sanitation, proper ventilation, ultraviolet light fixtures and capacity/bed alignment standards. Key Words: Tuberculosis (TB), Syndemic, HIV, 3HP, Directly Observed Therapy/DOT Homelessness/Homeless, Shelter(s), Correctional Facilities, Alcoholism, Drug Dependency. HIV promotes the activation of old latent TB which, in turn, promotes the progression of further HIV sequelae. Dual HIV and TB infection has been termed “a deadly human ‘syndemic’,” which is defined as “the convergence of two or more diseases that act synergistically to magnify the burden of disease.”12 The stigma attached to both diseases around the globe complicates the difficulty faced in eradicating or controlling TB. Patients with HIV/AIDS must be screened for TB, and TB patients must be screened for HIV. Both are associated with compromised or weakened immunity. People dually-infected with HIV and TB have at least 10 times greater risk of developing active, infectious tuberculosis than do people with inactive (“latent”) TB who are not infected with HIV.13 In the U. S. in 2012 and 2013, about 7% of persons with reported TB were HIV coinfected.3 In Mississippi in 2012, 6 % of reported TB cases were HIV coinfected.5 Among 63 homeless persons with TB statewide since 2009, however, 18 (29%) were HIV-positive (Source: MSDH Office of Tuberculosis and Refugee Health data base). In 2008, a TB outbreak erupted among the 800 to 1,000* homeless persons in the Jackson, Hinds County, Mississippi, area. The outbreak was recognized when a cluster of 5 cases emerged among homeless men at one of the shelters in Jackson, Mississippi. Intense contact investigation around these 5 cases disclosed 24 associated cases over the next year. Significant sites of TB transmission were identified to be area homeless shelters and

the Hinds County Detention Center. By 2009, Jackson-area homeless shelters and correctional facilities had the highest TB rates in Mississippi.4 The high risk of TB transmission in the correctional facility and homeless shelter environments means incarcerated homeless persons may become enmeshed in a dynamic “re-seeding” of TB infection into the jail facilities and then back among homeless shelters and in the community upon release. To contain the outbreak, MSDH and the Hinds County Health Department TB Clinic worked with the cooperation of several Jackson homeless shelters and other organizations and implemented preventive measures patterned after strategies which had proved successful among the homeless in other urban areas. * Number estimated from the accumulated experience of local homeless shelter providers, the Office of Tuberculosis and Refugee Health of the Mississippi State Department of Health (MSDH) and Hinds County Health Department TB Program, other private and government entities who work with the homeless, and from U.S. Department of Housing and Urban Development-mandated annual “Point-in-Time Estimates of Homelessness.”14 Methods TB Program representatives met with the directors of all Jackson homeless facilities, the County Sheriff and staff of the Hinds County Detention Center, the Jackson Chief of Police and staff, the City Council, City Manager, and City Attorney, the City’s Human and Cultural Services Department Homeless Coordinator, the local “Partners to End Homelessness” organization, and other concerned parties to implement necessary measures. These included required periodic tuberculosis testing and pulmonary profile/symptom screening of shelter clients (with a picture ID card provided to document compliance with this requirement), testing and training of shelter staff, intensified follow-up for preventive treatment of persons with identified sub-clinical TB (LTBI), promotion of cough etiquette, assessment and improvement of environmental/engineering preventive measures (UV light placement, improved air-exchange, etc.), and on-site public health personnel visits to bond relationships with shelter clients and staff and to promote directly observed therapy (DOT) for those receiving preventive treatment, and residual treatment of active cases once their DOT under quarantine rendered them smear-negative.15 In one of the shelters, a mass portable chest x-ray screening of over 80 men was done one evening (the first such effort in Mississippi in many years) to ensure no active cases had been overlooked. The Centers for Disease Control and Prevention (CDC) supported these efforts and provided emergency funding assistance. Testing of homeless shelters and correctional facilities clients and staff was done at Health Department expense. During the outbreak, the Mississippi State Department of Health TB Program worked closely with the Hinds County Sheriff ’s Department to reduce the transmission of TB at the Hinds County Detention Center and also worked with the Jackson Police Department to increase TB awareness and to test officers and staff who deal frequently with homeless persons. A few of the preventive measures implemented included: • Mandatory TB screening of all law enforcement personnel and inmates;

• Mandatory prevention training for all law enforcement personnel; • Mandatory TB training for correctional facility medical staff; • Provision of updated information by the MSDH to the Jackson Police Department, Office of the Mayor and Jackson City Council, the Hinds County Sheriff ’s Department, and Hinds County Board of Supervisors. Due to a substantial number of possible exposures in the Hinds County Detention Center in 2009, over 500 staff and 650 inmates were screened for potential new cases of active and latent TB infection. That screening revealed six active cases of TB and 75 persons with LTBI. In addition, the Mississippi State Department of Health screened Jackson Police Department officers who may have come in contact with homeless persons. Of 416 JPD Officers screened with tuberculin skin tests, 20 new reactors were identified and offered preventive treatment. To provide further assessment of these TB outbreak containment measures, the MSDH Office of Tuberculosis and Refugee Health collaborated with a Jackson State University (JSU) faculty team from the Schools of Health Sciences and Social Work, both in the College of Public Service. The JSU team visited homeless shelters in Jackson, interviewed involved parties, and reviewed MSDH records about the outbreak, and assessed these factors in relation to the picture emerging from reported experiences in other locales. Results Ongoing screening and intervention strategies have shown success. The TB case rate and the new infection rate in Hinds County are trending downward over the last several years as reflected in the following tables: TABLE 1.

YEAR

TOTAL HINDS COUNTY TB CASES

HOMELESS

2008 2009 2010 2011 2012 2013

22 49 27 30 27 13

5 24 6 6 2 2

TABLE 2. YEAR TOTAL HINDS COUNTY LTBI CASES HOMELESS 2008 2009 2010 2011 2012 2013

332 563 419 341 298 321

22 98 56 47 30 29

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JSU Study Team Observations Regarding Jackson Community Charitable Organizations and Shelters and Other Involved Agencies Stewpot Community Services, now in its 33rd year, provides shelters, food, clothing, counseling, employment search and other programs for Jackson’s homeless. An average of 200-300 people per day are helped. Stewpot provides a day shelter, the “Opportunity Center,” which serves 125 homeless men and women daily. Stewpot also operates the Billy Brumfield Men’s Shelter, and Sims House and Matt’s House shelters for women and children. Another long-time Jackson charitable group is the Gateway Rescue Mission. In August 2008, when MSDH piloted its efforts for routine TB screening among the homeless, Gateway Rescue Mission was the initial shelter site at which this was accomplished. The James Ivory Homeless Clinic across the street from Gateway Rescue Mission has provided valuable assistance in follow-up and referral as part of these efforts, as has the Jackson-Hinds Comprehensive Health Center by, for example, arranging chest x-rays as part of the clinical evaluation for active TB among homeless clients with positive screening tests or troublesome pulmonary profiles. The Salvation Army also provides shelter and food to Jackson’s homeless. Rather than open-bay barracksstyle sleeping, their facility has 3 or 4 person rooms with state-of-the-art ventilation and UV lighting. It appeared during the visits the JSU team made in Jackson that some of the shelters were too small, old, and in need of renovation. Overcrowding necessitates that beds are in too close proximity, easily facilitating the spread of TB. Ventilation seemed sub-optimal in some cases, and UV lights were not efficiently maintained. In some instances, the homeless go in and out easily or sit idly in front of the premises. It appears that the relative priority given to preventive safeguards employed to combat the 2008-2009 outbreak in some instances has waned over time, and TB transmission in these settings still occurs. Were it not for the private philanthropic organizations and the dedication of volunteers, the plight of the homeless would most likely be much worse and the likelihood of spread of TB and other infectious diseases greater. Other problems identified centered around housing and feeding homeless clients with active TB who require respiratory isolation during early treatment when they still pose an infection risk to others. Transportation of clients for needed follow-up at the local Health Department Tuberculosis Program Clinic for monthly liver profiles and clinical assessments during their months of preventive treatment also proved to be a persistent problem as has consistent enforcement of screening requirements. Interviews among homeless persons by the JSU team indicate that because the homeless often tend to be disenfranchised and wield little political clout, they often feel they are ignored by various authorities. Another problem is that the various charity organizations tend to work independently and, at times, almost in competition with each other for limited resources, rather than sharing resources to fill the gaps that a single organization cannot address. Other mismatches between available funds and programs abound with competing priorities. In this regard, the

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American Lung Association ceased its assistance to the MSDH at the end of 2012 after moving its administrative headquarters to Texas. There has been heightened attention on the plight of homeless veterans from the federal government, which has promised more resources to improve their situation, reflected in $600 million in targeted funding promised in January, 2014.16 In contrast, mental health issues, from which a disproportionate number of homeless people suffer, have received less attention as has been the case of those suffering from alcohol and drug dependency. Discussion Among homeless shelters, the CDC noted: “The absolute number and population density of persons sharing the same breathing space is an important TB transmission factor. If all other factors are constant, the size of the shelter population is directly proportional to the likelihood that someone with infectious TB will be present and that someone else will become infected. Conversely, the smaller and less crowded the shelter, the lower the risk”.17 TB can also be aggravated or triggered by personal behavior such as alcoholism and other drug dependencies and by other illness-related conditions such as diabetes mellitus, silicosis, various cancers, severe kidney disease, low body weight, medical treatment in the form of transplants, Crohn’s disease, and corticosteroid regimens.18 New treatments for rheumatoid conditions (anti-TNF drugs) may also promote activation of latent TB.19 A well-studied outbreak of tuberculosis which peaked in 2011-2012 centered among the homeless in Duval County, Florida (Jacksonville) was contained through similar methods as those employed in the Jackson outbreak, with the assistance of the CDC. This outbreak was genotypically-linked to 99 cases and 13 deaths. Of the cases, 78 were homeless men. Many also had a history of having been incarcerated at some point. African American men were disproportionately represented. 20 It is timely to reinforce emphasis on policies at Jackson’s homeless facilities and local correctional facilities to mitigate TB transmission: • Enforcement of tuberculosis screening requirements among shelter clients; • Properly installed and maintained Ultraviolet germicidal irradiators and HEPA [high efficiency particulate air] filters and service logs; • Attention to sleeping arrangements/layout—adequate square feet per person and improved sanitary standards at the various homeless facilities; • Periodic homeless shelter staff training; • Better-defined Jackson City policy and required standards for operating homeless service facilities; • TB Screening of all correctional facility personnel and inmates at the Hinds County Detention Facility at regular intervals and after any identified TB exposure;

• Prompt notification of the correctional facility about identified and suspected TB infections among current, past, and incoming inmates; • Provision of mandatory TB surveillance and prevention training for all staff in both the Hinds County Sheriff ’s Office and the Jackson Police Department; • Revision of MSDH TB Policy Manual mandates for statewide TB prevention programs among homeless and incarcerated persons. The advent of the newer 3-month 3HP preventive protocol (weekly isoniazid + rifapentine)18 has helped tremendously as has the shift to an Interferon-Gamma Release Assay (IGRA) blood test for TB infection as opposed to the older Tuberculin Skin Test.21 MSDH facilities now screen for TB with IGRA blood tests such as the Quantiferon®-TB Gold Test which have proved more specific than the old Mantoux Tuberculin skin test used for many years. This allows ongoing monitoring of the TB epidemiologic picture among Jackson’s homeless without dependence on the client’s return in 48 to 72 hours for skin test interpretation. The cornerstone and, arguably, the standard of care for public health TB treatment is Directly Observed Therapy (DOT).22 Persons with active TB in Mississippi are usually begun on 4 drugs, typically isoniazid, rifampin, ethambutol, and pyrazinamide; after the first 2 months, treatment is streamlined based on sensitivity found on cultures. Over the past 3 years in Mississippi, persons with sub-clinical (latent) TB infections have been afforded directly observed preventive therapy with 3 months of weekly 3HP (rifpentine + isoniazid) treatment as opposed to the older 9 month regimen of isoniazid alone.18 In addition to greater compliance, DOT and the shorter-duration 3HP preventive treatment promote improved treatment completion and more rapid intervention in the event of side effects, and allow for more “real-time” assessment of efficacy. As a result, MSDH considers DOT an essential part of preventive treatment among the homeless, as their transient lifestyle in many cases mitigates against effective TB containment.5, 23 Based on analyses of successful programs for tuberculosis prevention in urban homeless settings around the country, the Curry International Tuberculosis Center of the San Francisco Department of Public Health and the University of California, San Francisco has published a training guide and list of recommendations for TB prevention in shelter environments with an accompanying training video.24 With appropriate local modifications and updates, including information on the use of IGRA testing and the availability of the new 3HP preventive treatment, these guidelines mirror the measures adopted to contain the Jackson outbreak and form the basis of a sound urban homeless shelter TB prevention strategy. Also helpful in some homeless settings is the use of cost-effective incentives including food or food vouchers, cash, special lodging, transportation vouchers, articles of clothing, priority in food lines, and assistance in filing for benefits.25 Concluding Comments This report discusses effective TB containment activity and follow-up measures employed to counter a TB outbreak among the homeless

and incarcerated persons that took place in Jackson, Mississippi, through collaboration among local homeless shelters, the Hinds County Sheriff ’s Department and the Hinds County Detention Center, the Jackson Police Department, other private and city government entities, the CDC, and the Mississippi State Department of Health and the Hinds County Health Department TB Program. The particular TB strain involved in a given situation impacts the level of resources needed to contain it. The Jackson area was fortunate that the cluster of TB among homeless persons in 2008-2009 did not involve a multi-drug-resistant strain. Otherwise, the cost of emergency screening and containment would have escalated markedly. Multidrug resistant TB strains are difficult to treat and contain, and public health control efforts would require considerable added funding were such a strain to emerge among our homeless. Another issue must be mentioned: when outbreaks erupt, and when recommended preventive measures have not been followed, the question of potential liability arises. To date in Jackson and vicinity, there has been no case where a shelter or a care giver has been found liable stemming from the spread of TB due to non-enforcement of TB guidelines or policies on prevention, treatment, referrals, and isolation of TB infected individuals, or when recommended shelter admissions protocols such as required TB testing of clients are not enforced. This issue must be considered by all who manage shelters or provide care. Finally, to assist the homeless and prevent the spread of TB, our colleges and universities in Jackson, particularly Jackson State University, co-located in this setting and officially designated as the only urban university in the State of Mississippi, should encourage their students, especially those in public health, social work, and public policy and planning, to volunteer with the State Department of Health TB Program and other relevant programs. Important upcoming efforts are papers to be spearheaded by the JSU School of Social Work, in collaboration with the School of Health Sciences, which focus on geopolitical and social advocacy aspects of efforts to reduce or end homelessness. In preparation are additional studies of the root causes of homelessness in Mississippi and strategies to reduce and end homelessness. Also in preparation are analyses of detailed data from HUD-mandated annual homeless “Point-in-Time Count” surveys and ad hoc surveys among participants from the National TB Advisory Council on shelter-associated TB prevention around the country. Requests for reprints can be sent to: David E Conwill, MD, MPH, Office of Tuberculosis and Refugee Health, Mississippi State Department of Health, P. O. Box 1700, Jackson, Mississippi 39215-1700. 1.

Global Tuberculosis Report 2013. Geneva, World Health Organization, 2013.

2. CDC. Reported Tuberculosis in the United States, 2012. Atlanta, GA: U.S. Department of Health and Human Services, CDC, October 2013. 3.

CDC. Trends in tuberculosis – United States, 2013. MMWR 2014; 63:229-233.

4. Mississippi State Dept of Health. Targeted tuberculosis screening in the Jackson, MS homeless population. MS Morb Rep 2010; 26:1-2.

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5. Mississippi State Department of Health. Annual summary of selected reportable diseases Mississippi – 2012. MS Morb Rep 2014; 30:82-6.

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6. Haddad MB, Wilson TW, Ijaz K, et al. Tuberculosis and homelessness in the United States, 1994-2003. JAMA 2005; 293: 2762-6.

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7. Badiaga S, Didier R, Brouqui P. Preventing and controlling emerging and reemerging transmissible diseases in the homeless. Emerg Infect Dis 2008; 14:1353-9. 8. CDC. Tuberculosis outbreak associated with a homeless shelter – Kane County, Illinois, 2007-2011. MMWR 2012; 61:186-9. 9. Beijer U, Wolf A, Fazel S. Prevalence of tuberculosis, hepatitis C virus and HIV in Homeless People: A Systematic Review and Meta-Analysis. Lancet Infect Dis 2012; 12: 859-870. 10. Whiteside A, Sunter C. AIDS: the challenge for South Africa. Cape Town : Human & Rousseau Taufelberg; 2000:25. 11. Azevedo MJ, Prater GS, Hayes SC. Human immunodeficiency virus and tuberculosis co-infections in Kenya: environment, resources and culture. Int J Soc Anthropol 2010; 2:55-65. 12. Kwan CK, Ernst JD. HIV and tuberculosis: a deadly human syndemic. Clin Microbiol Rev 2011; 24:351-376. 13. Daley CL, Hahn JA, Moss AR, et al. Incidence of tuberculosis in injection drug users in San Francisco: impact of anergy. Am J Respir Crit Care Med 1998; 157:19-22.

This 2-story steel frame 21,500 s.f. commercial building contains over 70 offices, several conference rooms, 2 kitchens, and 79 parking spaces.

14. U.S. Department of Housing and Urban Development. The 2011 Point-in-Time Estimates of Homelessness: Supplement to the Annual Homeless Assessment Report. HUD Office of Community Planning and Development, Washington, DC: 2011.

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15. Iseman MD. A Clinician’s Guide to Tuberculosis. Philadelphia: Lippincott Williams & Wilkins; 2000:118-124.

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16. U.S. Department of Veterans Affairs. VA offers $600 million in funding to support services for homeless veteran families. VA Office of Public Affairs News Release, Washington DC: 2014.

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17. CDC. Prevention and control of tuberculosis among homeless persons recommendations of the Advisory Council for the Elimination of Tuberculosis. MMWR 1992; 41 (RR-5):17. 18. CDC. Recommendations for use of an isoniazid-rifapentine regimen with direct observation to treat latent Mycobacterium tuberculosis infection. MMWR 2011; 60:1650-3 with Erratum in MMWR 2012; 61:80. 19. Dixon WG, Hyrich KL, Watson KD, et al. Drug-specific risk of tuberculosis in patients with rheumatoid arthritis treated with anti-TNF therapy: results from the British Society for Rheumatology Biologics Register (BSRBR). Ann Rheum Dis 2010; 69:522-528. 20. CDC. Notes from the field: tuberculosis cluster associated with homelessness – Duval County, Florida, 2004-2012. MMWR 2012; 61:539-540.

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21. Legesse M, Ameni G, Mamo G, et al. Community-based cross-sectional survey of latent tuberculosis infection in Afar pastoralists, Ethiopia, using QuantiFERON-TB Gold In-Tube and tuberculin skin test. BMC Infect Dis 2011; 11:89-97. 22. Iseman, op. cit.:306-315. 23. CDC. Using DOT to improve adherence. Self-Study Modules on Tuberculosis— Module 9: Patient Adherance to Tuberculosis Treatment. Atlanta, GA: U.S. Department of Health and Human Services, CDC, 2013. 24. Curry International Tuberculosis Center. Shelters and TB: What Staff Need to Know, 2nd Ed., San Francisco; 2013. 25. American Lung Association of South Carolina and South Carolina Department of Health and Environmental Control, Division of Tuberculosis Control. Using Incentives and Enablers in the Tuberculosis Control Program. Columbia; 1989.

1600 North State Street Suite 400 Jackson, MS 39202 Telephone: 601.944.1717 WATS: 1.800.355.4231 www.mpsbilling.com AUGUST 2015 • JOURNAL MSMA

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Straight from the Horse’s Mouth ANDREW ADAMS, MD Hancock Medical Center,Bay St. Louis, MS

27-year-old white male presented to the minor care wing of an emergency department with a chief complaint of a 3-week history of progressive swelling in his legs as well as shortness of breath with exercise and when lying flat. In addition, the patient stated that he had gained 35 pounds during the previous month and that his urine had become “darker yellow” than normal. However, he had not noticed any blood in his urine, and he denied pain, including chest pain. He also denied nausea, vomiting and diarrhea. The differential diagnosis for edema is broad. However, the patient’s bilateral pitting edema and orthopnea suggest a systemic and not local cause of his swelling. Congestive heart failure (CHF), pulmonary hypertension, primary kidney disease and primary liver disease are all common causes of these symptoms. Malabsorptive disease and malnutrition are also possible causes but are not supported from the history with the absence of diarrhea and having a Western diet.1

The patient reported no significant medical problems and was taking no medications at the time of presentation. Upon further questioning, the patient reported a significant history of alcohol, tobacco, and drug use during the past 13 years. The patient had consumed alcohol daily for the past 10 years. During the previous year, the patient had consumed 1 quart of liquor daily. In addition, he admitted to use of intravenous and powder cocaine several times per year. He also had smoked 1 pack of cigarettes per day for the past 13 years. One month before presentation, the patient had entered a rehabilitation facility for treatment of his alcohol and drug addiction and was presently living in a group home. He reported abstinence from all substances since entering the rehabilitation facility. CHF secondary to a cardiomyopathy is a concern. Possible causes include alcoholic or cocaine-induced cardiomyopathy, given his extensive history of alcohol and drug abuse, as well as genetic and viral causes.1,2 Hypoalbuminemia and decreased oncotic pressure secondary to cirrhosis of the liver is another concern. The possible causes of cirrhosis include alcohol abuse, viral hepatitis (positive history of

IV drug abuse) or non-alcoholic fatty liver disease.3 Renal disease can decreased albumin concentrations and decreased oncotic pressure as well. A nephrotic or nephritic syndrome is another possible cause.3 His physical examination revealed a young white male, appearing slightly older than stated age and disheveled, sitting on the side of the bed in no acute distress. His vital signs included a temperature of 98.7°F, a heart rate of 89 beats per minute, a blood pressure of 154/99 mmHg and an oxygen saturation of 97% while breathing room air. Carious teeth were noted with no abscess or erythema. Cardiovascular exam revealed a regular rate and rhythm with no murmurs, 2+ peripheral pulses and no jugular venous distention. Rales were auscultated in both lung bases with no increased work of breathing. Abdominal exam revealed a soft abdomen with no distention, ascites, organomegaly,or tenderness. Both lower extremities exhibited 3+ pitting edema circumferentially to the patella. No tenderness was noted in either extremity, and Homan’s sign was negative bilaterally. His skin was non-jaundiced with no rashes. This patient has all of the hallmarks of the classic presentation of CHF with rales auscultated at the bases, a large amount of pitting edema in his lower extremities and symptoms of orthopnea and dyspnea on exertion.1, 2 Patients with cirrhosis also may present with similar symptoms, although some of the other signs and symptoms of cirrhosis are absent (e.g. contracted nodular liver, splenomegaly, ascites, asterixis).3 Nephrotic or nephritic syndrome is also a possibility. Early clinical findings of nephrotic syndrome include weight gain, fatigue and peripheral edema that may worsen to include pleural and pericardial effusions, ascites and anasarca.4 Laboratory results revealed a pro-brain natriuretic peptide (proBNP) concentration of 5362 pg/mL, a blood urea nitrogen concentration of 40 mg/dL and a creatinine concentration of 1.33 mg/dL with a glomerular filtration rate of 66 ml/min. Potassium was 5.1 mmol/L, chloride was 109 mmol/L and bicarbonate was 20 mmol/L. All other electrolytes were within normal limits. Liver function tests showed an albumin of 3g/ dL, a total bilirubin of 0.27 mg/dl and an alkaline phosphatase of 56 U/L. All other indices of the liver function tests were

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within normal limits. A complete blood count revealed a white blood cell count of 12.3 TH/cmm with 74% neutrophils, hemoglobin of 11 g/dL and a normal mean corpuscular volume and platelet count. A hepatitis panel and a human immunodeficiency virus (HIV) antibody screen were negative. An international normalized ratio was within normal limits. A dipstick urinalysis showed > 300 mg/dL of protein with a large amount of blood. Other indices were within normal limits on urinalysis. A urine drug screen was negative. An electrocardiogram showed normal sinus rhythm with no significant abnormality. A chest radiograph showed a right small pleural effusion with bilateral atelectatic changes and no cardiomegaly. The patient was admitted to the family medicine inpatient service for further investigation and management. Shortly after admission, a computed tomographic arteriogram of the chest was obtained that revealed small bilateral pleural effusions with no evidence of pulmonary embolism. The patient had no previous laboratory values for comparison. CHF is primarily a clinical diagnosis based on the common signs and symptoms of heart failure. A proBNP measures strain on the heart and a normal concentration virtually rules out CHF.2 This patient has an elevated proBNP that may indicate CHF. However, the chest radiograph and computed tomographic arteriogram do not show cardiomegaly. An echocardiogram should confirm the diagnosis of heart failure.2 The patient has normal liver enzymes, a negative hepatitis panel and a normal international normalized ratio, which does not indicate liver disease. Derangement of these values would indicate a primary liver cause of the patientâ&#x20AC;&#x2122;s symptoms.1, 3 The modestly decreased albumin is not diagnostic for liver disease. It is possible to have normal liver enzymes with cirrhosis, but this finding is often associated with a later stage of liver injury. Other findings more specific to cirrhosis should be evident on history, physical examination and other laboratory investigations as previously mentioned.3 On the other hand, nephrosis and nephritis are suggested from the urinalysis, blood urea nitrogen, and creatinine. The large amount of protein would indicate nephrotic syndrome; however, the albumin concentration is normally below 2.5 g/L.4,5 The large amount of blood in this clinical scenario in the absence of a urinary tract infection suggests nephritis.5 An echocardiogram demonstrated normal heart function with an ejection fraction of 55%. A lipid panel was within normal limits except for a decreased high density lipoprotein concentration of 30 mg/dL, and the 24 hour urine collection contained 3.124 grams of protein. An erythrocyte sedimentation rate was 40 mm/hr, and a C-reactive protein was 2.5 mg/dL. Antinuclear antibody (ANA) and anti-double stranded deoxyribose nucleic acid (anti-dsDNA) tests were negative. C3 and C4 complement concentrations were low at 16 mg/dL and 13 mg/dL, respectively. A hemoglobin A1c concentration was within normal limits. The patient was treated with a moderate dose of furosemide (Lasix) intravenously and experienced a partial relief of symptoms. Nephrology and rheumatology services were consulted for recommendations. A normal echocardiogram in this setting does not indicate congestive heart failure.1,2 It is possible to have a preserved ejection fraction with heart failure,2 but there are no structural or functional abnormalities to support 250

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this diagnosis. Nephrotic syndrome is characterized by proteinuria (> 3-3.5 grams of protein in a 24 hour urine collection) with edema, hyperlipidemia, hypoalbuminemia (albumin <2.5g/dl) and lipiduria.4, 5 The most common secondary causes of nephrotic syndrome are diabetes mellitus, systemic lupus erythematosus, hepatitis and HIV. A normal hemoglobin A1c, negative hepatitis panel and negative HIV antibody results heavily suggest the absence of diabetes mellitus, hepatitis, and HIV, respectively. The patient has nephrotic range proteinuria but does not meet the other criteria for nephrotic syndrome. Acute glomerulonephritis (GN) is defined as a sudden onset of hematuria, proteinuria and red blood cell casts in the urine.5 The causes of acute GN are usually secondary to either systemic or renal disease, and a serologic evaluation is always warranted.5 The erythrocyte sedimentation rate and C-reactive protein are significantly elevated, which indicates inflammation or infection. The negative ANA and anti-dsDNA argue against lupus, but the hypocomplementemia indicates another autoimmune or infectious cause. GN with nephrotic range proteinuria should be suspected, even in the absence of red blood cell casts in the urine, as these can be difficult to find routinely.5 Rheumatology and nephrology consults are appropriate to evaluate for a systemic or primarily renal cause, and to perform a renal biopsy if clinically indicated. A streptozyme screen was positive with a titer of 1:200. An anti-streptolysin O (ASO) screen was positive with a titer of 1600 IU/ mL. Results of anti-glomerular basement membrane antibodies, cryoglobulin and cold agglutinins screens were negative. His anti-DNase B antibody was elevated at 567 U/mL. Cytoplasmic-antineutrophil cytoplasmic antibody and perinuclear-antineutrophil cytoplasmic antibody results were negative. Upon further questioning, the patient admitted to a recent dental infection approximately 10 days before onset of his current symptoms and was in the process of arranging a tooth extraction with his dentist. The patient was treated with high dose IV methylprednisolone (Solumedrol) and anti-streptococcal antibiotics and responded appropriately with a virtually complete resolution of his symptoms. Acute GN can be arbitrarily divided into those with or without hypocomplementemia. The common causes without hypocomplementemia include Wegener granulomatosis, Goodpastureâ&#x20AC;&#x2122;s syndrome, IgA nephropathy, and anti-glomerular basement membrane disease. Serologic evaluation does not support these diagnoses. The most common causes of acute GN with hypocomplementemia include systemic lupus erythematosus, cryoglobulinemia, subacute endocarditis, acute poststreptococcal GN, and membranoproliferative GN. With a negative ANA and anti-dsDNA, systemic lupus erythematosus is unlikely. Results of a cryoglobulin screen are negative, and the patient does not have a history, physical exam or echocardiogram results that are consistent with a subacute endocarditis. The positive ASO and anti-DNase B screen, along with the clinical history of a recent dental infection, heavily suggest a diagnosis of poststreptococcal glomerulonephritis. Poststreptococcal glomerulonephritis is the leading cause of nephritis with a peak onset at 5-15 years of age. The pathophysiology is not fully understood but is thought to involve antigenic mimicry leading to autoimmunity. It usually presents 2-4 weeks after a group A streptococcal infection with nephritic syndrome and oliguric renal failure.6 Treatment for poststreptococcal glomerulonephritis is primarily with antibiotics active against Group

A strep, diuretics for edema, and immunosuppression with steroids in those cases determined to be refractory or severe. Membranoproliferative GN, along with IgA nephropathy, can present similarly and can only be excluded by renal biopsy. In this particular case, with the response to therapy and positive serologies, a biopsy is not necessary and can be obtained if the patient continues to experience symptoms after treatment. 5, 6 The patient was discharged with a follow-up appointment with his nephrologist, family physician, and rheumatologist for re-evaluation and determination of need for a renal biopsy. He began abusing alcohol shortly after discharge and did not keep his follow-up appointments. He was contacted by telephone, and he stated that he had been without edema since discharge and that his urine had continued to appear normal. Key Words: Glomerulonephritis, Nephrotic Syndrome, Alcohol Abuse, Congestive Heart Failure References 1. 2. 3. 4. 5. 6.

Trayas KP, Studdiford JS, Pickle S, Tully AS. Edema: Diagnosis and Management. Am Fam Physician. 2013; 88(2):102-110. McMurray JJ. Systolic Heart Failure. N Engl J Med. 2010;362:228-238. Starr SP, Raines D. Cirrhosis: Diagnosis, Management, and Prevention. Am Fam Physician. 2011;84(12):1353-1359. Kodner C. Nephrotic Syndrome in Adults: Diagnosis and Management. Am Fam Physician. 2009;80(10):1129-1134, 1136. Madaio MP, Harrington JT. The Diagnosis of Glomerular Diseases. Arch Intern Med. 2001;161:25-34. Hahn RG, Knox LM, Forman TA. Evaluation of Poststreptococcal Illness. Am Fam Physician. 2005; 71:1949-1954.

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DISABILITY DETERMINATION SERVICES 1-800-962-2230 AUGUST 2015 â&#x20AC;˘ JOURNAL MSMA

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Top Ten Facts You Need to Know about the Treatment of Venous Thromboembolism Dominique J Pepper, MBChB MD and J. Michael Brewer, DO

Introduction ver 275,000 cases of new venous thromboembolism (VTE), including acute pulmonary embolism (PE) and deep vein thrombosis (DVT), occur in the United States each year. 1 Acute PE is an important cause of morbidity and mortality. Approximately 25% of patients presenting with sudden death have PE, 2 and approximately 6% of patients with DVT die within one month of diagnosis. 3 The American Heart Association and the American College of Chest Physicians have published management guidelines for the treatment of VTE. 4,5 Here we review treatment that should be performed or that is reasonable to perform based on Level A (multiple randomized trials or meta-analysis) or Level B evidence (single randomized study or strong observational study). 4,5 Clinicians need to be cognizant of the appropriate treatment of venous thromboembolism. Timely therapy is essential to reduce the mortality and morbidity of this critical illness.

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Classification of PE Massive PE is defined as acute PE with sustained hypotension (systolic blood pressure < 90 mm Hg for at least 15 minutes or requiring inotropic support, not due to another cause such as cardiogenic, hypovolemic or distributive shock). Sub-massive PE is acute PE without systemic hypotension but with either right ventricular (RV) dysfunction as defined by the presence of RV dilation on echocardiography or computed tomography, elevated brain natriuretic peptide (BNP) or N-terminal pro-BNP, electrocardiographic changes, or myocardial necrosis (elevated troponin T or I). Low-risk PE is PE without any of these features. 4 Anticoagulation Patients with objectively confirmed PE and no contraindications to anticoagulation should receive initial therapeutic anticoagulation with subcutaneous low molecular weight heparin (LMWH), intravenous or subcutaneous unfractionated heparin, or fondaparinux, with monitoring. 5-7 Warfarin Warfarin therapy can be started on the same day if parenteral therapy (heparin) is used and should be overlapped with initial anticoagulation therapy for a minimum of 5 days and until the INR is >2.0 for at least 24 hours. 5-7 Fibrinolytics Both the American Heart Association (AHA) and American College of Chest Physicians (ACCP) suggest that fibrinolytics be considered in those patients with massive acute PE and a tolerable risk of bleeding complications. The AHA suggests that it is reasonable to perform fibrinolysis while the ACCP gives a weak recommendation based on low quality evidence. 8 Inferior vena caval filters IVC filters should be placed in adult patients with confirmed acute PE (or proximal DVT) who have contraindications to anticoagulation or with active bleeding. 9 Long-term anticoagulation with IVC filters Once contraindications to anticoagulation or active bleeding have resolved, anticoagulation should be resumed in those with IVC filters.10,11

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Author Information Department of Medicine, University of Mississippi Medical Center, Jackson, MS (Dr. Pepper and Dr. Brewer). Corresponding Author Dominique J. Pepper, Email: dominiquepepper@gmail.com

7 8 9 10

Heparin induced thrombocytopenia Direct thrombin inhibitors (such as argatroban or lepirudin) should be given in patients with ileo-femoral DVT who have suspected or proven heparin-induced thrombocytopenia. 12 Duration of therapy Duration of anticoagulation therapy is 3 months if the first episode of DVT is related to a major reversible risk factor and is at least 6 months (with consideration for indefinite anticoagulation) if recurrent or unprovoked. 13,14 Patients with cancer LMWH monotherapy of at least 3 to 6 months duration is indicated in cancer patients with DVT or as long as the cancer and/or chemotherapy is ongoing. 15-17 Pregnant patients LMWH is the preferred treatment for patients who are pregnant and develop VTE or patients receiving warfarin for treatment of VTE who become pregnant. 18 References 10.

Heit JA. The epidemiology of venous thromboembolism in the community: Implications for prevention and management. J Thromb Thrombolysis. 2006; 21(1): 23-9.

Chatterjee S, Chakraborty A, Weinberg I, et al. Thrombolysis for pulmonary embolism 11. and risk of all-cause mortality, major bleeding, and intracranial hemorrhage: a meta-analysis. JAMA. 2014; 311(23): 2414-21.

White RH. The epidemiology of venous thromboembolism. Circulation. 2003; 107(23 12. suppl 1): 14-8.

Jaff MR, McMurtry MS, Archer SL, et al. Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic 13. pulmonary hypertension: a scientific statement from the American Heart Association. Circulation. 2011; 123(16): 1788-830.

Kearon C, Akl EA, Comeroia AJ, et al. Antithrombotic therapy for VTE disease: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012; 141(Suppl 2): e419S-e494S.

14.

Brandjes DP, Heijboer H, Büller HR, et al. Acenocoumarol and heparin compared with acenocoumarol alone in the initial treatment of proximal-vein thrombosis. N Engl 15. J Med. 1992; 327(21): 1485-9.

Barritt DW, Jordan SC. Anticoagulant drugs in the treatment of pulmonary embolism. 16. A controlled trial. Lancet. 1960 Jun; 1(7138): 1309-12.

Wan S, Quinlan DJ, Agnelli G, et al. Thrombolysis compared with heparin for the initial treatment of pulmonary embolism: a meta-analysis of the randomized controlled trials. Circulation. 2004; 110(6): 744-9 .

Kucher N, Rossi E, De Rosa M, et al. Massive pulmonary embolism. Circulation. 2006; 113(4): 577-82.

17.

Decousus H, Leizorovicz A, Parent F, et al. A clinical trial of vena caval filters in the prevention of pulmonary embolism in patients with proximal deep-vein thrombosis. N Engl J Med. 1998; 338: 409–415. White RH, Zhou H, Kim J, et al. A population-based study of the effectiveness of inferior vena cava filter use among patients with venous thromboembolism. Arch Intern Med. 2000; 160: 2033–2041. Lewis BE, Wallis DE, Leya F, et al. Argatroban anticoagulation in patients with heparin induced thrombocytopenia. Arch Intern Med. 2003; 163: 1849 –1856. Hull R, Delmore T, Genton E, et al. Warfarin sodium versus low-dose heparin in the long-term treatment of venous thrombosis. N Engl J Med. 1979; 301: 855–858. Schulman S, Granqvist S, Holmstrom M, et al. The duration of oral anticoagulant therapy after a second episode of venous thromboembolism: N Engl J Med. 1997; 336: 393–398. Meyer G, Marjanovic Z, Valcke J, et al. Comparison of low molecular- weight heparin and warfarin for the secondary prevention of venous thromboembolism in patients with cancer: a randomized controlled study. Arch Intern Med. 2002; 162: 1729 –1735. Hull RD, Pineo GF, Brant RF, et al. Long-term low-molecular-weight heparin versus usual care in proximal-vein thrombosis patients with cancer. Am J Med. 2006; 119: 1062–1072. Lee AY, Levine MN, Baker RI, et al. Low-molecular weight heparin versus a coumarin for the prevention of recurrent venous thromboembolism in patients with cancer. N Engl J Med. 2003; 349: 146–153. Bates SM, Greer IA, Middeldorp S, et al. VTE, thrombophilia, anti-thrombotic therapy, and pregnancy: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012; 141 (Suppl 2): e691S-e736S.

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P R E S I D E N T ’ S

P A G E

The Official Address of the 147th President CLAUDE D. BRUNSON, MD ~ 2014-15 MSMA PRESIDENT August 14, 2015–Jackson Hilton - Madam Speaker, Officers of the Association, members of the Board of Trustees, delegates, members of the Association, staff, ladies and gentlemen, it is an honor and a high privilege for me to address you for the final time as your President. I must say that I found this a difficult speech to start. It seems as though it was only yesterday that I stood at the podium and took that solemn oath to represent you, your patients and the medical profession as your President. And, what a year it has been. When you come to the end of any experience, there is always a mixture of emotions – relief that responsibilities are coming to an end, sadness that what you’ve come to enjoy will to some degree subside. But, there is also excitement; excitement in taking what has been learned in the past year and applying that to what is to come. And I learned a lot this year. And it has made me appreciate beyond expression the work you do and the care you provide to Mississippians and others across this great state. And that experience has made me a better physician and a better person. And, for that I thank you. Let me start by acknowledging some people who have been essential to my success in the role as your President and without whom my tenure would have been certainly less enjoyable and less doable. First, thank you to the lovely Ms. Felicia Anderson who has been a very effective sounding board as I bounced thoughts off of her about approaches to difficult issues that I have had to deal with on your behalf. She has always made sure that I’ve truly heard all sides of a thorny issue and made decisions accordingly. And, for that I thank her. Secondly, I’d like to thank our Executive Director, Mrs. Charmain Kanosky and her extraordinarily capable staff who have made the job of the President and representing the profession of medicine as easily achievable as one could ever imagine. I’d like also to thank the members of our Board of Trustees who serve with distinction and clarity as we tackle tough issues. And, a special thank you to Board Chairman Dr. Lee Voulters who has led us through some very difficult decisions, always with grace, dignity, and a James-Bond-like charm. Thank you, Lee. I would be remiss if I didn’t thank Mrs. Becky Wells, whom I called out in my inaugural address, as being one of the most critical people who helping me navigate this field of organized medicine. From the time I 254

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entered organized medicine as a young physician in the Central Medical Society through my tenure as your President, she has been there encouraging me, guiding me and sometimes leading me to achieve things that I didn’t at first realize I wanted to do or could achieve. Thank you Becky for your long time support and guidance, but most importantly for your friendship. I anxiously await your next assignment for me. Finally, let me thank my colleagues at the University of Mississippi Medical Center. When you elected me as your President, Vice Chancellor Jimmy Keeton called to congratulate me and then said that he and the Medical Center would support me in whatever manner I needed and with whatever time I needed. And, our current Vice Chancellor, Dr. LouAnn Woodward, of whom we should all be so proud, reiterated this same commitment upon taking the reigns as the UMMC Vice Chancellor and Dean of the School of Medicine. Without their commitment, my job would have been nearly impossible. And, let me also say that UMMC’s commitment to the MSMA and to organized medicine has been glaringly evident as demonstrated by their commitment to make all University Physicians members of the Association and by letting us have access to their campus and facilities for our annual meeting for two years at minimal cost and maximal benefit. So, my personal and public thank you to them for their strong support. Let me quickly cover a few of my thoughts as I’ve reminisced about the past year as your President. The challenge before us as an organization is to remain relevant, engaged and indispensable in the evolution of this changing healthcare delivery system. And, we must find ways to make participation in organized medicine from our physician colleagues across the state as second nature to them as tending to an ailing patient; this is especially true for our young physicians. I mentioned in my inaugural address that the solution to all of this upheaval and experimentation in our new and ever changing healthcare delivery world is you. All of us who practice quality medicine and care about our patients and the healthcare they receive. I stated that the physician is the ultimate patient advocate and must be a part of the ultimate solution to this healthcare issue. In an effort to facilitate that we have established a Physician Leadership Academy where we take practicing physicians and formally train them

in healthcare management issues, providing them the needed tools to Some successes that we had during the year on the legislative and be leaders in the administration and management of healthcare delivery. regulatory fronts included defeating legislation designed to weaken our The MSMA Physician Leadership Academy is an in‐depth, nine-month nationally recognized immunization laws. Working with the pediatric long program consisting of six one‐day sessions from 8:30 am to 4:30 association we were also successful in getting texting while driving ban pm. We have enrolled and graduated the inaugural class of physicians legislation through which will make a difference in the lives of many from this academy and I must tell you they are some strong and capable people and their families who could be maimed or killed as a result of physician leaders and will serve our profession and patients well as they texting while driving. We were able finally to get a Medicaid medical continue to advance in leadership at their institutions and in organized director in place -- something that we have been calling on our Medicaid medical leadership. We are in the process of selecting the next class so if Director to do for some years now. Dr. Tami Brooks is the new medical you or one of your colleagues is interested please see Ms. Phyllis director there; and, though only part time, she is making the difference Williams, Director of Practice Strategies and the Leadership Academy that we knew a medical director could. We are still encouraging the and she will get you the particulars of this program. Again, this is just one Medicaid Director to make this a full time position. way your MSMA is providing valuable services to our physicians to help Another success of which I am proud is the collaboration your MSMA us engage and make a difference in provision of quality healthcare did with the Department of Health to address the still problematic issue services for our state; but, again, most importantly we need all our of HIV/AIDS prevalence in the state. We were able through partnering physicians to with UMMC, the engage in medical DOH and leadership. MSMA to launch OUR ELECTED LEADERSHIP FROM CONGRESS, OUR GOVERNOR, AND LEGISLATORS ARE One of the stratean educational ALL VERY INTERESTED IN TELEHEALTH AND WHAT IT CAN MEAN TO OUR STATE AND gic entities that I program to get ACCESS TO CARE ESPECIALLY IN RURAL AREAS. BUT, THEY ALSO ARE AWARE OF THE TIME called for in my our physicians upAND RESOURCES THAT THEY HAVE COMMITTED TO TRAINING PHYSICIANS TO GET THEM inaugural address dated on the new INTO THESE RURAL AREAS AND THAT ANY SOLUTION TO THIS PROBLEM MUST BE ONE was a CommisCDC recommension on Health dations about THAT COMPLEMENTS ALL PARTS OF THE MEDICAL CARE SYSTEM. SO, WE HAVE TO WORK Equity. The premscreening and TOGETHER TO CRAFT A GOOD SOLUTION FOR MISSISSIPPI. THAT MEANS WE HAVE TO ise was that the treatment. One WORK WITH HEALTHCARE PROVIDERS, THE MISSISSIPPI BOARD OF MEDICAL LICENSURE, MSMA should be tool we deployed CORPORATIONS, AND ELECTED LEADERS TO COME UP WITH THE BEST SOLUTION THAT the leader in rewas a special issue viewing and de- MEETS THE NEEDS OF OUR CITIZENS FOR QUALITY, AFFORDABLE HEALTHCARE. WE SHOULD of the Journal veloping strategies MSMA with subNOT AND CANNOT HOLD BACK THE FUTURE; BUT, AS I SAID IN MY INAUGURAL ADDRESS, to address the mission of articles THE FUTURE IS OURS TO CREATE. poor health outfrom experts in comes seen in the field and a speMississippi, devise, and help implement real and measurable solutions. cial guest editor who is also expert in the field. It was well received by The Commission is active and capably lead by Dr. Edward Hill. It is coour physicians and others. I believe this will make a difference in how we chaired by Dr. Bettina Beech, the Associate Vice Chancellor for Populaprevent contraction of the disease and care for the people diagnosed tion Health at UMMC. They have put together a stellar group of exwith this terrible (but, manageable) disease. There is more to come on perts who serve with them and I believe are poised to make a difference this front as this collaboration continues. We plan to do more of these in how healthcare is delivered and illness prevented. Thank you, Dr. kinds of collaborations involving other disease processes that help us all Hill, for your leadership of this Commission. help our patients. We also tried to tackle the daunting issue of a bureaucratic and faltering state mental health system. We had good support from our leaders at the state capitol at the outset. The plan was to establish a mental health task force with MSMA in leadership of a group of statewide stakeholders who would draft a plan for an overhaul of the system and present a model to the legislature of a “best practices” mental health system on which the legislature could act. We did our homework prior to the session meeting with multiple stakeholders who agreed with us. We worked with our legislators during the session and then witnessed an assault on legislators by a bureaucracy that did not want to change. This was during an election year and our bill ultimately died in conference. But, we will not go quietly into the night on this one; it is too important an issue.

Just a couple more topics to touch on that resulted from my experience of visiting you and your practices around the state and listening to your concerns about making the system work better for you and your patients. One such topic of concern was about the encroachment of telehealth services across the state and into your communities where you practice. This was especially a concern to our primary care colleagues who were often caught unaware of a telehealth provider coming to their community or to a business or school in their locale. And, I heard this in every area of the state that I visited. There was concern that these entities would come and take away patients who are important to their practices and for whom they had been caring in their practices. And, with each AUGUST 2015 • JOURNAL MSMA

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passing month it seemed the concern grew. So, two weeks ago, we convened a group of stakeholders to come together and talk about telehealth and what was actually going on in the state as far as telehealth services and companies. The stakeholders included senior leadership from UMMC, the Director of UMMC Center for Telehealth, leadership from the Mississippi Academy of Family Physicians, representatives from the Mississippi Health Solutions Institute and an Associate JMSMA Editor. And, we had some good and frank dialogue about telehealth. I have charged our Council on Medical Service to take the lead to continue examine and gain insight and input from our physicians about their concerns about the growth of telehealth. I have asked them to consider such feedback mechanisms as surveys to the membership to be followed up with a town hall style meeting or something similar and for our Journal leadership to consider a section in our Journal on telehealth to include submissions from all stakeholders on the programs and services they are offering in the state. As many of you know, Mississippi is a national leader in telehealth. Our elected leadership from Congress, our Governor and legislators are all very interested in telehealth and what it can mean to our state and access to care especially in rural areas. But, they also are aware of the time and resources that they have committed to training physicians to get them into these rural areas and that any solution to this problem must be one that complements all parts of the medical care system. So, we have to work together to craft a good solution for Mississippi. That means we have to work with healthcare providers, the Mississippi Board of Medical Licensure, corporations and elected leaders to come up with the best solution that meets the needs of our citizens for quality, affordable healthcare. We should not and cannot hold back the future; but, as I said in my inaugural address, the future is ours to create. One other area to mention is the next phase to follow up on the legislative achievement of Dr. Jim Rish during his Presidential year recognizing Physicians Orders for Sustaining Treatment (POST) for end-of-life decisions. That legislation, in Dr. Rish’s own words “provides for a planning tool that empowers patients and their families to work closely with their physician to clearly define their medical preferences via actionable physician orders when facing a terminal illness.” The next phase, I believe, is for physicians to have these critical conversations with their patients and their families prior to that critical phase when these conversations are forced. In a news release, The Journal Medscape states in part: “The Centers for Medicare & Medicaid Services (CMS) has proposed to pay physicians beginning next year for optional endof-life discussions with Medicare patients,” a subject that helped spark the “death panels” furor during the healthcare reform debate of 2009 and 2010. Organized medicine has long supported making advance-care planning a reimbursable, stand-alone service. Discussions about advance directives, hospice care, and other end-of-life issues can go unpaid in a fee-for-service environment. But, physicians then lack a financial incentive to make time for them. In May, the American Medical Association, the American College of Physicians, and dozens of other medical societies and healthcare organizations - along with AARP -

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urged the US Department of Health and Human Services (HHS) to start paying for two new billing codes for this service. “Published, peerreviewed research shows that [advance-care planning] leads to better care, higher patient and family satisfaction, fewer unwanted hospitalizations, and lower rates of caregiver distress, depression, and lost productivity.” As physicians we know that discussions about end-of-life medical preferences can be the most difficult (but, most important) discussions we ever have with our patients and their families. As a physician who recently lost a loved one, my mother, I appreciated having that discussion along with my siblings with our physician about her wishes long before her death. And, that made our journey along that difficult path easier and more dignified. It is an important discussion and I’m glad that physicians are being encouraged to have these discussions and that reimbursement for the time we spend in this important part of our practices will be recognized and reimbursed accordingly. Our patients deserve nothing less. Finally, as I close, let me again thank you for the honor and privilege to have served as your President. It will forever remain one of the most important endeavors I have ever undertaken and a high point in my life. And, I leave this post with a feeling of fulfillment because I know that the next phase of leadership will carry the torch and bring the Association and the representation of Mississippi medicine to its next heights. Dr. Dan Edney is one of the most talented and committed physician leaders that any of us know. So, I confidently transition to the most coveted position in the Association, that of Past President. Let me leave you with a quote from Dr. Martin Luther King, Jr. that I think apropos to all of us and this Association. Life’s most persistent and urgent question is, “What are you doing for others?” - Martin Luther King, Jr. Thank you for your attention and for the awesome but humbling privilege to have served as your President. May God continue to bless you and bless our Mississippi State Medical Association.

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The Future of Population Health in Mississippi BETTINA M. BEECH, DRPH, MPH AND KEITH NORRIS, MD, PHD UNIVERSITY OF MISSISSIPPI MEDICAL CENTER AND UNIVERSITY OF CALIFORNIA AT LOS ANGELES (UCLA) SCHOOL OF MEDICINE Introduction

Future of Health and Healthcare in the United States

A recent timely article entitled, “There is Power in Numbers”1 by Claude Brunson, MD, President of the Mississippi Medical Association (MSMA), provided a strong and prescient message reinforcing the continued need for Mississippi to play a critical role in preparing healthcare providers, health policy leaders, and other key constituents for the changing healthcare landscape, particularly in the face of increasing health care costs. According to the National Healthcare Expenditure Projections, 2010-2020, the U.S. healthcare system is estimated to account for 20% of the gross domestic product (GDP) by 2020. Simultaneously, the overall quality of health and patient outcomes have not improved commensurate with the expectations from our large national investments.2 Coupling these factors with the growth of evidence-based medicine, outcomes measurement, value-based purchasing, patient-centered care delivery models, and accountable coordinated care, it is clear the healthcare environment is rapidly changing. Policies such as the Affordable Care Act (ACA), as well as the new Medicare and Medicaid payment formulas, commercial third-party payers, and patients each demand increased transparency and accountability as well as continuous clinical performance improvements in a value- rather than a volumedriven market.3

Transformative changes to healthcare delivery systems portend improved patient outcomes. Disruptive technologies have revolutionized the healthcare paradigm through the widespread use of electronic medical records (EMRs), consumer mobile health-related apps, telehealth, home telemonitoring, and wearable devices. The vast amount of data generated (Big Data) through these heterogeneous and secure electronic platforms permits the large-scale integration of data that can be used for real-time decision making and patient management by identifying the ‘right treatment’ for the ‘right individual or subgroups’ providing better predictions and to help target interventions to the ‘right patients’.5 These predictions hold the promise of improving patient outcomes, quality, and efficiency and cost of healthcare; a national objective known as the “triple aim”.6 However, these healthcare advances alone will not have the needed impact on the overall well-being of the population.

While the health care landscape is undergoing massive transformation, the overall health of U.S. citizens substantially lags behind other developed nations. According to a recent scientific article, “US Health in International Perspective: Shorter Lives, Poorer Health,” the health status of Americans is last in comparison to 17 affluent nations.2 The state of Mississippi also faces complex challenges regarding population health. Mississippi often ranks 49th or 50th among the 50 states with respect to many health indicators, chronic diseases, and adult and child morbidity and mortality rates.4 For example, the infant mortality rate of the state is 9.9 deaths per 1,000 live births, compared to the U.S. rate of 6.4.4 This infant death rate would place Mississippi between Botswana and Bahrain in world rankings. On the other end of the age continuum, adults in Mississippi also experience exceptionally high rates of chronic diseases, which place demands on an already strained health care system and reduce the quality of life and productivity for individuals, families, and communities.

The Centers for Medicare and Medicaid (CMS) is testing several different health care payment, service and delivery models aimed to achieve better care for individuals, improve the care and health of communities, and reduce costs through improvement of the health care system.7 Medicare accountable care organizations (ACOs) such as the Medicare Shared Savings Program and the Pioneer ACO model are designed to align financial incentives for providers to engage in care coordination, deliver higher quality medical care, and improve health outcomes for their patients. Eventually such models will move beyond the capitation for a group of disease-specific patients and expand to include entire communities and possibly states. This true “global capitation” will require creative coordination of providers, health care systems, community-based organizations, communityserving agencies and others to infuse a culture of health into our nation, as recently articulated by the Robert Wood Johnson Foundation (RWJF).8 Indeed, RWJF is promoting cross-sector collaboration, including the integration of health services and systems, to improve well-being and to create healthier, more equitable communities.7 In parallel, the NIH is investing in precision medicine, the prevention and treatment strategies that take into account individual variability in the context of their environment, to improve the health of the nation.5 Each of these will require the integration of “big data” and multiple population level inputs to create tangible and relevant outputs.9

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therapy and these continue to evolve and be updated, but the general principles of antiretroviral therapy remain the same: prescribe three The Opportunity for Mississippi active drugs in combination, preferably two NRTIs plus a third drug Unfortunately, the rapid changes prompting integration of health from a different class.² The individual drugs are chosen for each patient and health care at a population level have left a void in the training of based on uniquely previous prepared viral resistance patient comorbidities, and leaders for thispatterns, challenge. The need for developing thepersons potential for drug-drug interactions, and should be tailored for each with the expertise in population health and population health individual patient. Ideally, the the skills chosen would be convenient management, including andregimen understanding of the multiple (once a day), and if possible for the greatest simplicity, one pill once a day. determinants of health (e.g., health care, social environment, health Allbehavior, these factors are taken into account to optimize adherence, which is physical environment, genetics), and the interdependence truly the most important factor in the long-term success of any HAART of the multiple sectors that influence health with the systems of health regimen thanhas preexisting drug resistance. care inother the U.S. never been more critical. Population health is the body of scientific disciplines interested in the study of the distribution When choosing a two-drug NRTI “backbone” as part of an and initialin and determinants of health and disease states in the population HAART combination, emtricitabine or lamivudine (never together as approaches to optimize the performance of the health system through they have the same parentoutcomes nucleoside and identical the improvement of patient and satisfaction, whileresistance reducing 6,10,11 mechanisms) are typically included in the HAART regimen they Thomas Jefferson University has the onlyasSchool health care costs. exhibit minimal side effects and convenient dosing, and the second of Population Health in country; therefore, a substantial opportunity NRTI is usuallytotenofovir or abacavir. Most role FDCinpills include existschosen for Mississippi take a national leadership the training, tenofovir andand emtricitabine, therethe aremanagement also FDCs composed of education, scholarship but around of population abacavir and lamivudine, and zidovudine and lamivudine. health. This will help to create the next generation of new leaders and to augment the education of existing health care providers and health The thirdleaders drug ofprepared the HAART combination from the NNRTI, policy to lead Mississippiis chosen in promoting cross-sector PI,collaboration or INSTI class. NNRTIs the suchhealth as efavirenz rilpivirine may have to optimize status ofand residents of Mississippi CNS effects or exacerbate depression and should be used with and side continue to improve outcomes over time. caution in patients with psychiatric comorbidities. Also, efavirenz is not In addition tointhethose high of prevalence of chronic disease eventually recommended child-bearing potential duewhich to concern for manifests in highPIs costs rehab, neural tube defects. are of notcomplications used by some(e.g., HIV hospitalization, providers as first-line disability, productivegastrointestinal years), Mississippi a relatively therapy duelosstoofcommon sidehaseffects, and stable drug population allowing investments in the state’ s culture of health to interactions may complicate their administration. Integrase inhibitors tangible impactseffective on reducing health careprofile costsand and arehave emerging as highly agentsdownstream with good tolerability productivity andwriting, quality-adjusted areincreasing becomingwork widely-used. As of this the DHHSlife-years. GuidelinesThus, for Mississippi is uniquely poised to take advantage of the the Use of Antiretroviral Agents in HIV-1-Infectedopportunity Adults andto take a leadership role infive the preferred understanding and integration of contain multiple Adolescents recommend regimens, four of which dimensions of health and healthcare through the creation of formalized an integrase inhibitor.² Among the FDC single pill regimens, tenofovir/ training in population health and population management. emtricitabine/efavirenz (Atripla) was the health first available and has demonstrated good tolerability and excellent efficacy a decade. Conclusion Tenofovir/emtricitabine/rilpivirine (Complera) is another NNRTIAs the nation capitated payment of health care outcomes based FDC thatmoves can befrom usedthe in those of child-bearing potential, although for groups of patients to the capitated payment of health and health it is not recommended in those with baseline viral loads >100,000 duecare to outcomes for communities, there will be a critical need for training decreased efficacy. Tenofovir/emtricitabine/cobicistat/elvitegravir leaders in theintegrase management of population In a 6-3 decision, (Stribild) is an inhibitor-based FDChealth. that is well-tolerated and the Supreme Court decision on the ACA rendered June 25,Lastly, 2015, potent, although there may be drug interactions with on cobicistat. 12 Thisinhibitorlandmark upheld the legality of nationwide (Triumeq) health care subsidies. abacavir/lamivudine/dolutegravir is an integrase decision has significant consequences for the context and environment based FDC with excellent tolerability and efficacy. A more detailed, in whichreview healthcare will be delivered the foreseeable future the U.S., thorough of antiretroviral drugintherapy is beyond theinscope of and the downstream implications for population health and population this article. The reader is referred to the DHHS guidelines for a more health review management. detailed of each individual regimen.2 As the state’s only academic medical center (AMC), the University HAART regimensMedical are not Center cheap, and cost is often cited asthea barrier to of Mississippi is currently exploring feasibility therapy. All third party payers in the United States pay for HAART of implementing a novel program in the management of population medications, andofspecial drug assistance programsthearehealth available to help health as part its strategic plan to improve of the state patients highThus, co-pay charges ifwill present. withpoised no insurance and theafford nation. Mississippi soon Patients be uniquely to take at all are eligible to be in enrolled into the Mississippi AIDS Drugof Assistance a leadership role the understanding and integration multiple Program (ADAP). All 50 states have an ADAP program, and are dimensions and sectors of health and healthcare through thethese creation 172 JUNE 2015 • SPECIAL HIV EDITION 258 AUGUST 2015 • JOURNAL MSMA

funded by the federal Ryan White Care Act and administered by the Health Department. ADAP all of the available HAART health meds of formalized training in provides population health and population atmanagement. no cost to HIV-infected who have no insurance, so cost The ability topersons create leaders dedicated to this area and to augment education of health providers,HAART health care and should not be the an insurmountable barriercare to providing therapy policy leaders will inbetter position Mississippi to redistribute its tohealth an HIV-infected person the United States. resources to the multiple sectors that can improve community health, reduce health care costs and to lead the implementation of community Conclusions levelnatural population healthhas carechanged management demonstration The historyhealth of HIVand infection dramatically since the projects as aHAART model forera. theAnation. advent of the once universally fatal infection has become an often easily-managed chronic illness. “Cocktails” consisting of many References pills administered several times a day with significant toxicities have 1. Brunson There is power inregimens numbers. J Miss Med Assoc. 2015;56(4):106-107. made way forCD. contemporary consolidated into single pills 2. Nationalonce Research of Medicine. healtheffective. in international administered dailyCouncil., that areInstitute well-tolerated andU.S. highly Early perspective: Shorter lives, poorer health. Washington, DC: National Academies diagnosis and treatment not only leads to improved immunologic Press; 2013. recovery but also prevents conditions as varied as cardiovascular disease, 3. Rosenbaum S. The patient protection and Affordable Care Act: implications for chronicpublic kidney dementia, andReports. HAART has now been healthdisease, policy andand practice. Public Health 2011;126(1):130-135. demonstrated to markedly decrease person-to-person viral 4. The Henry Kaiser Family Foundation. State Health Facts. 2015;transmission. http://kff.org/ Personsstate-category/health-status/. living with HIV can now live long, productive, healthy lives. Accessed June 23, 2015. 5.

Collins FS, Varmus H. A new initative on precision medicine. New England J Med. 2015;372(9):793-795.

Requests for reprints addressed to Harold Division of cost. 6. Berwick DM,should Nolanbe TW, Whittington J. TheHenderson triple aim: MD, care, health, and Health AffairsUniversity (Millwood). 2008;27(3):759-769. Infectious Diseases, of Mississippi Medical Center, 2500 N. State Street, 7. Centers for Medicare and Medicad Innovation Center. Innovation models. 2015; Jackson, MS 39216.

http://innovation.cms.gov/initiatives/index.html - views=models. Accessed June 21, 2015. 1 Sterne JA, Hernan MA, Ledergerber B, et al. Long-term effectiveness of potent 8. Lavizzo-Mourey R. In it Together—Building a Culture of Health. 2015; http:// antiretroviral therapy on the overall mortality of HIV-infected individuals. Lancet www.rwjf.org/en/library/annual-reports/presidents-message-2015.html. 2005; 366:378. Accessed June 23, 2015. 2. 9. Panel on Antiretroviral Guidelines forCommittee Adults and on Adolescents. Guidelines for the a National Research Council (US) a Framework for Developing use New of antiretroviral agents in HIV-1-infected adults and adolescents. Department Taxonomy of Disease. Toward precision medicine: Building a knowledge network biomedical research and ata http://aidsinfo.nih.gov/contentfiles/ new taxonomy of disease. Washington, of Health andforHuman Services. Available DC: National Academies Press; 2011. lvguidelines/AdultandAdolescentGL.pdf (Accessed on April 22, 2015).

KindigforD,Management Stoddart. G.of Antiretroviral What is population health? Amer Pub Health. 3. 10. Strategies Therapy (SMART) StudyJ Group, 2003;93(3):380-383. El-Sadr WM, Lundgren J, et al. N Engl J Med 2006; 355:2283. Nash DB.Eustace Population health: s theactive beef ? antiretroviral Pop Health Mangt. 2015;18(1):14. 11. Lucas GM, JA, Sozio S, etWhere’ al. Highly therapy and the 3. incidence of HIV-1-associated nephropathy: a 12-year cohort study. AIDS 2004; 12. 18:541. Liptak A. Supreme court allows nationwide health care subsidies. 2015; http:// www.nytimes.com/2015/06/26/us/obamacare-supreme-court.html?_r=0. 5. Grulich AE, van Accessed JuneLeeuwen 26, 2015.MT, Falster MO, Vajdic CM. Incidence of cancers in people with HIV/AIDS compared with immunosuppressed transplant recipients: a meta-analysis. Lancet 2007; 370:59. Author 6. Corresponding Monforte AD, Abrams D, Pradier c, et al. HIV-induced immunodeficiency and mortality from AIDS-defining and non-AIDS-defining malignancies. AIDS 2008; Bettina M. Beech, DrPH, MPH 22:2143. Vice Chancellor for Population Health Associate 7. Professor, Heaton RK, Clifford DB, Franklin DR Jr, etand al. HIV-associated neurocognitive Departments of Pediatrics Family Medicine disorders persist in the era of potent antiretroviral therapy: CHARTER Study. 2500 North Street Neurology 2010; 75:2087. Jackson, Mississippi 39236 8. bbeech@umc.edu Cohen MS, Chen YQ, McCauley M, et al. Prevention of HIV-1 infection with early antiretroviral therapy. (601) 984-1020 (T)N Engl J Med 2011; 365:493. 9. (601) Donnell D, Baeten(F) JM, Kiarie J, et al. Heterosexual HIV-1 transmission after 984-1013 initiation of antiretroviral therapy: a prospective cohort analysis. Lancet 2010; 375:2092. 10. Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission. Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States. http://aidsinfo.nih.gov/guidelines/ html/3/perinatal-guidelines/0/ (Accessed on April 22, 2015).

REFORM Thousands of Mississippi physicians have saved millions in liability premiums since 2002. Most are now paying the rates of 1996. SPECIALTY SOCIETY MANAGEMENT MSMA offers management services to a growing number of state specialty societies. Services include administration, management of membership databases, dues billing, communications and event planning. ADVOCACY MSMA boasts one of the strongest lobbying teams at the Capitol. As a concerted voice for Mississippi physicians, MSMA supports legislation to protect your practice and defeat legislation such as scope of practice and attacks on tort reform. MMPAC The Mississippi Medical Political Action Committee creates relationships with elected officials, making MSMA the voice of physicians at the Capitol and in Washington. OFFICE OF PHYSICIAN WORKFORCE This important office studies the physician population in the state by reviewing geographic disparities as well as specialty disparities.

MSMA Member Benefits: At a Glance Mississippi State Medical Association is proud to be the state’s oldest and largest physician association. We are committed to serving our physician members by offering continuing education opportunities, practice management tools and legislative advocacy. For over 150 years, MSMA has endeavored to serve as an advocate for members, patients and the public health. The association promotes ethical, educational, and clinical standards for the medical profession and the enactment of just medical laws.

LIVE CME EVENTS CME conferences designed for and by medical professionals feature the latest advances in healthcare and networking opportunities. ONLINE CME Online CME allows physicians to obtain CME credits when it is convenient for them, at an affordable cost. RURAL PHYSICIANS SCHOLARSHIP PROGRAM Since implementation of this vital program in 2007, 102 rural physician scholars are in the pipeline and are either practicing, or will soon be practicing in small towns across Mississippi. LEADERSHIP DEVELOPMENT The MSMA Physician Leadership Academy recently completed its first year with 12 scholars soon to be named “Doctors of Distinction.” The program combines mentoring, organizational education, and skills training to prepare MSMA members for future leadership positions. PHYSICIANS’ POSITION Delivered straight to your email inbox each week, Physicians’ Position offers a recap of trending national healthcare news, state medical headlines and the latest development opportunities for members. JOURNAL MSMA Each month, MSMA publishes a scientific Journal, containing submissions from MSMA members. The JMSMA serves as the voice, the face, and the spirit of medicine in Mississippi. It is free to members, an $83 benefit. iPASS SUMMIT The “Insurance Payment Advocacy Solutions Summit” for clinic staff offers information on billing, insurance and claims issues. CAP COMMITTEE The Claims Advocacy for Physicians (CAP) Committee assists MSMA members in resolving claims issues of common concern with insurance companies, HMOs, Medicare, Medicaid, or other third party payers. JOB BANK Members are offered a free, convenient way to post medical job openings and search for employment opportunities. PRACTICE STRATEGIES Answers to regulatory and legal issues, reimbursement, coding/billing and documentation can be overwhelming and time consuming for physicians and their staff. MSMA has a team of experts to assist you in these and many other areas related to your practice. DOCBOOKMD This free, HIPAA-compliant app allows members to share patient files and contains many other benefits.

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L E G A L E S E

Telemedicine and Rural Communities ANDREW CHEVALIER

What is telemedicine and how can it help rural communities?

Insurance Payments and Reimbursements

On July 16, 2015, the Mississippi Board of Medical Licensure voted to postpone its proposed telemedicine regulations in favor of an economic impact statement on the use of telemedicine.1 With the Board’s decision to postpone its regulations, questions about the use of telemedicine remain. Considering the nature of the telemedicine debate, it is important to understand what telemedicine is, how it can be used, and how it can help rural communities.

As of July 1, 2013, all health insurance plans and employee benefit plans in the state of Mississippi “must provide coverage for telemedicine services” to the same extent those plans would provide coverage for in-person consultations.8 These plans may include a deductible, copayment, or coinsurance for health care services provided through telemedicine “so long as it does not exceed the deductible, copayment, or coinsurance applicable to an in-person consultation.”9 Insurers and employee benefit plans have the ability to limit coverage to “health care providers in a telemedicine network approved by the plan,” and coverage is evaluated by a “medically necessary” standard.10

What is Telemedicine? Under the Board of Medical Licensure’s current regulations, telemedicine “is the practice of medicine using electronic communication, information technology or other means between a physician in one location and a patient in another location with or without an intervening health care provider.”2 This definition “does not include the practice of medicine through postal or courier services.”2 Telemedicine, by itself, is not a separate medical specialty or discipline, nor is it the practice of medicine.3 Primarily, telemedicine is a tool to be used by medical professionals to deliver healthcare to patients remotely through “a growing variety of applications and services using two-way video, email, smart phones, wireless tools and other forms of telecommunications technology.”3 Existing Law In Mississippi Currently, the practice of medicine is “deemed to occur in the location of the patient.”4 As such, no physician is allowed to engage in the use of telemedicine unless he/she has first obtained a license to practice medicine within the state from the State Board of Medical Licensure and has met all educational and licensure requirements as determined by the Board.5 This licensure requirement, however, does not apply “where the evaluation, treatment and/or medical opinion to be rendered by a physician outside the state is requested by a physician duly licensed to practice” in Mississippi, and the requesting physician “has already established a doctor/patient relationship with the patient” to be treated or evaluated.6 Furthermore, the physician using telemedicine “should obtain the patient’s informed consent before providing care” through telemedicine.7

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Economic Impact of Telemedicine on Rural Communities In a series of studies conducted by the Oklahoma Cooperative Extension Service (OCES) and the Northeastern Agricultural and Resource Economics Association, the OCES evaluated the economic impact of telemedicine in rural communities by collecting data from 24 hospitals throughout Arkansas, Kansas, Oklahoma, and Texas.11 Specifically, OCES analyzed four categories of benefits associated with the use of teleradiology, teleoncology, and telepsychiatry. The categories include: (1) hospital cost savings outsourcing telemedicine procedures; (2) transportation savings to center patients; (3) missed work income savings to center patients; and (4) lab/pharmacy work performed locally.11 Cost Savings from Outsourcing With the availability of telemedicine, rural hospitals can save money by outsourcing the services conducted by medical specialists. Without the use of telemedicine, these rural hospitals “would have to pay at least a portion of the salaries of individual specialists such as radiologists, psychiatrists, or oncologists to provide those services onsite.”11 According to the OCES study, several of the hospitals involved had either lost its onsite specialist because it was unable to pay for those services, or if the hospital could afford the salaries, it was only for a part time position.11 Another added benefit is an increase in physician productivity by allowing the physician to remain in a single location, as well as the cost saved by limiting travel time.11

Using the “Physician Compensation and Production Survey,” OCES was able to calculate the estimated savings for different specialist employment scenarios after those services were converted to telemedicine.11 In one example, a rural hospital was projected to save $101,600 by switching its onsite radiologist from full time to two days a week and outsourcing the remainder of the annual encounters through telemedicine.11 In another example, one rural hospital was projected to save $61,000 annually by using teleradiology instead of retaining a part time salaried onsite radiologist.11 Transportation Savings Another added benefit of using telemedicine is that the patient saves travel expenses. Accordingly, residents who “take advantage of telemedicine procedures available at their local hospitals do not pay out of their own pocket to travel to the nearest alternative location.”11 Savings varied from location to location and factored in “the driving distance to the nearest location that would offer the same level of service, an average cost per driven mile, and the percentage of telemedicine encounters that would necessitate an immediate response.”11 A certain percentage of teleradiology encounters did not necessitate an immediate response and therefore, did not require traveling. As a result, the patients would not have out-of-pocket traveling expenses. Of the patients whose cases necessitated travel or film transportation, the study found savings on traveling expenses ranging from $2,303-$109,080.11 To calculate these savings, the study multiplied the total round trip miles to the nearest alternative site by the 2008 IRS per mile travel cost assumed and then, multiplied that product by the total number of encounters per year times the percentage of cases needing immediate service.11 One example of travel expenses saved listed by the study occurred in Clinton, Arkansas, population 2,283.11 In this case, the total travel miles to the nearest alternative site were one hundred and sixty miles, with the total mileage cost per trip at $80.80.11 The total number of encounters per year where listed at 14,400, with five percent needing immediate service.11 Using those numbers, the study found that the use of teleradiology saved Clinton’s patients an average of $58,176 annually.11 Missed Work Income Savings The study used the same methodology to calculate missed work income saving, except “instead of driving distance and a per-mile cost, total driving time and an average hourly wage” were used.11 The average hourly wage was taken from the 2006 Bureau of Economic Analysis Wages by County.11 Continuing with Clinton, Arkansas, as the example, the numbers listed were as follows: $11.92 as the average hourly wage, 80 miles as the one-way miles to nearest site, 150 minutes as travel time saved, which was calculated using google maps, $29.81 as the cost saved per trip, 14,400 as the number of potential trips per year, with five prevent of cases needing immediate service.11 Using these numbers, the study found that the community’s patients saved an average of $21,463 annually.11 The study also noted that these costs did not include the additional travel time that “may occur due to paper work requirements for a first time hospital visitor, and thus the missed work savings are likely underestimated.”11

Lab and Pharmacy Work Performed Locally Based on the assumption “that no additional work would have been performed locally in the absence of telemedicine,” the study also calculated the amount of follow-up work that is more likely to find its way into local labs and pharmacies since the patients would not be leaving their communities.11 In order to calculate the use and cost of these procedures, the study multiplied the number of yearly encounters by both a low and high end test cost. For example, in a rural hospital that performed 2,400 CT scans yearly with a low end cost of $2,000 and a high end cost of $48,000, the study found that between $48,000 and $240,000 of services would be kept in that community annually.11 From the information provided by the studies, it seems that the use of telemedicine can limit the cost of healthcare services to patients in rural and underserved communities, as well as provide some benefit to local rural economies. It is important, however, to keep in mind that these studies do not focus on the cost of telemedicine for hospital systems. These costs can include the purchasing and installation of equipment as well as training to operate it. Hopefully, the Board’s economic impact statement can shed more light on overall costs and benefits of telemedicine. References 1.

“Proposed Mississippi Telemedicine rule goes temporarily offline.” MississippiWatchDog.org. http://watchdog.org/229825/proposedmississippi-telemedicine-rule-goes-temporarily-offline/. Accessed July 30, 2015.

Title 30. Part 2635. Chapter 5. R 5.1(b). Miss. Code R. § 73-25-34.

“What is Telemedicine?” American Telemedicine Association.org. http://www. americantelemed.org/about-telemedicine/what-is-telemedicine#.VaQPI_ IViko. Accessed July 30, 2015.

Title 30. Part 2635. Chapter 5. Rule 5.2. Miss. Code R § 73-23-34.

Miss. Code Ann. § 73-25-34(2).

Miss. Code Ann. § 73-25-34(3).

7 .

Title 30. Part 2635. Chapter 5. Rule 5.3. Miss. Code. R § 73-25-34

8 .

Miss. Code Ann. § 83-9-351(2).

9 .

Miss. Code Ann. § 83-9-351(3).

10. Miss. Code Ann. § 83-9-351(4-5). 11. Whitacre, Brian E. “Estimating the Economic Impact of Telemedicine in a Rural Community.” Agricultural and Resources Economic Review. Northeastern Agricultural and Resource Economics Association. (August 2011). Pg.175-79.; Whitacre, Brian E, Hartman PS, Boggs S, Scott V. “Evaluating the Economic Impact of Telemedicine in a Rural Community.” Division of Agricultural Sciences and Natural Resources. Oklahoma State University. (2009).

Author Information Andrew Chevalier is a third year student at Mississippi College School of Law. An Ocean Springs native, Chevalier was a legal extern with MSMA, assisting in both legal and governmental affairs. After he takes the Bar, he hopes to remain in a healthcare-affiliated legal field.

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L et us All Stand and All Sıng — john d. mceachin, md, meridian

I recently heard a song, A song I have heard before. I may have sung it myself, But it could have changed a bit. I think it was a group thing— Seems like we all sang along. Now I remember! We stood, And we were at attention! And did I address the flag? Was my hand over my heart? Yes, we all took off our hats, And we stopped chewing our gum. More and more, it’s coming back. We sang it while the band played. As I got older, things changed. Began to take center stage. Then the tune began to change, It was hard to sing along.

Things really got out of hand! Boy, do I miss the old days When everyone sang that song. Did sports events ruin that song? Did schools stop singing it, too? Anyway, we lost the words And nobody seemed to care. Children do not know the words— Because they’ve never sung it. Parents don’t even know it, Certainly don’t respect it! Yes, I do remember now— There were no solos, just us, Singers were “We the People”! And how we sang that “Anthem”! Sure, the “Star Spangled Banner”! Our own “National Anthem”! You think we could get it back?

his month, we print a poem from Dr. John D. McEachin, MD, a pediatrician of Meridian. He writes, “I have a batch of medical poetry I continue to write, but as a pediatrician, I feel patriotic participation as practiced and that is taught by parents is in serious decline--- specifically, our National Anthem.” Dr. McEachin also provided a copy of U.S. Code 301 regarding the etiquette for the Star Spangled Banner. The code notes that during the playing of the anthem, citizens should stand “straight and rigid and salute (if active military or veteran), or right hand over heart. Hold this position, addressing the flag…until the music is finished.” McEachin adds, “One should not smoke, eat, chew gum, drink, use cell phone, read, or otherwise occupy themselves while the anthem is playing.” He notes further, “The approach for football games (high school and college) is ashamedly simple! PA/announcer: ‘Would you please stand, address our Flag, and, accompanied by the band, join in the singing of our National Anthem!’– Yes, that will omit all the soloists, duets, and self-serving arrangements that no one can possibly accompany!” I join Dr. McEachin in celebrating this patriotic tradition! God bless America! Any physician is invited to submit poems for publication in the journal, attention: Dr. Lampton or email me at lukelampton@cableone.net.)—Ed.

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