VOL. LIX • NO. 9 • 2019

VOLUME LX • ISSUE NO. 9 • 2019

J. Clay Hays, Jr., MD 2019-20 MSMA President

A fabulous gift idea for anyone in medicine!

Pickup in Ridgeland for $49.95 or $57.95 includes shipping.

Order three or more to receive a discount at: http://tinyurl.com/yb7ab974 “Images In Mississippi Medicine by Dr. Luke Lampton and Karen Evers is a handsome and impressive book, filled with stories and scenes ranging from primitive operating rooms and rows of hospitalized tornado victims a century ago to the new teaching complex at the University of Mississippi Medical Center with its modern breakthroughs.

The volume is a piece of our history that every Mississippian can appreciate.”

– Curtis Wilkie, journalist, author, and professor at Ole Miss

Images in Mississippi Medicine: A Photographic History of Medicine in Mississippi; MSMA; Jackson, MS: 2018.

VOL. LX • NO. 9 • SEPTEMBER 2019

SCIENCE ARTICLES

EDITOR Lucius M. Lampton, MD

President J. Clay Hays, Jr., MD

ASSOCIATE EDITORS D. Stanley Hartness, MD Philip T. Merideth, MD, JD

President-Elect W. Mark Horne, MD

MANAGING EDITOR Karen A. Evers PUBLICATIONS COMMITTEE Sheila Bouldin, MD, Chair Dwalia S. South, MD, Chair Emeritus Thomas C. Dobbs, MD Wesley Youngblood, M4 and the Editors

Secretary-Treasurer Joe Austin, MD Speaker Geri Lee Weiland, MD

Early Impact of a Statewide Screening Program for Critical Congenital Heart Disease in Newborns Lily M. Moore, MD; Deani H. McVadon, MD; Ali Dodge-Khatami, MD, PhD; Chad Blackshear, BS; Fazlay S. Faruque, PhD; Mary B. Taylor, MD, MSCI; Sarosh P. Batlivala, MD, MSCI

Major Depression, Chronic Medical Illness, and Access to Mental Health Services among Mississippi Adults Theresa A. Smith, PhD; Grayson S. Norquist, MD, MSPH; Dick Johnson, MS; Ron McAnally, BA; Amy L. Sullivan, MS, PhD, RDH; Ian A. Paul, PhD

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DEPARTMENTS

Vice Speaker Jeffrey A. Morris, MD

From the Editor – There Is No Magic Money Tree Lucius M. Lampton, MD

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Address of the 151st President, Michael Mansour, MD, 2018-19

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Executive Director Claude D. Brunson, MD

MSMA Annual Session Recap

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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.

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332, Email:APatel@MSMAonline.com 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 © 2019 Mississippi State Medical Association.

Official Publication

Top 10 Facts You Need to Know about Achalasia Brannon Harrison, MD; Jacob Moremen, MD

MSMA • Since 1959

President's Page – Inaugural Address of the 152 President 312 J. Clay Hays, Jr., MD nd

New Members

316

Mississippi State Department of Health Reportable Disease Statistics

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Images in Mississippi Medicine – Southern Surigcal Association 318 Meeting, 1936 Lucius M. Lampton, MD Poetry and Medicine – Poems are Stimulants Merrill Moore, MD

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ABOUT THE COVER J. Clay Hays, Jr., MD, Jackson, became the 152nd President of the Mississippi State Medical Association on August 16, 2019,

during an Inaugural Gala Ceremony held at the Old Capitol Inn. Dr. Hays is board-certified in cardiology and interventional cardiology; he practices at Jackson Heart Clinic in Jackson. Dr. Hays graduated cum laude with an undergraduate degree in psychology from the University of Mississippi in Oxford. He earned his medical degree from the University of Mississippi School of Medicine.

He is a fellow of the American College of Cardiology, the American Heart Association, and the Society of Coronary Angiography and Interventions. He is the Chair of the Mississippi Delegation to the American Medical Association. A member of First Baptist Church, he is a deacon and Sunday school teacher. He also serves on the board of Medical Assurance Company of Mississippi and Trustmark Bank. He is past Chairman of the Jackson Preparatory School Board and the Greater Jackson Chamber Partnership. He and his wife, Elizabeth, have two sons.

In his inaugural address, Dr. Hays revealed his focus while president:“Relationships matter.” One can read more about this in his speech on page 312 and future JMSMA issues. r

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There is No Magic Money Tree A

s Britain’s embattled Prime Minister, Theresa May never accomplished a Brexit deal. But she did once assert an enduring truth about government-run health care: “There isn’t a magic money tree that we can shake that suddenly provides for everything that people want.” She’s right, there certainly is no magic money tree, especially for health care. I wish there were. At that June 2017 election special Lucius M. Lampton, MD of BBC Question Time, May seemed Editor almost cold-hearted as she stated this in response to a nurse who simply asked: “My wage slips from 2009 reflect exactly what I’m earning today. How can that be fair, in the light of the job that we do?”

Here in the United States, the demands of the health system have also been outpacing the resources available, and difficult choices have to be made. The Democratic Presidential candidates are embracing Medicare for All, a single, national health insurance program which would pay for every medically necessary service, from routine doctor visits to surgery to mental health to prescription drugs. When fully

enacted, the Bernie Sanders version would replace private insurance, along with Medicaid and Medicare, as well as the Affordable Care Act. The dream of universal coverage is a worthy dream, no doubt, but the desire for universal health care once established is infinite. How would we pay for it? As another Brit, former Prime Minister Margaret Thatcher, so perceptively said: “The problem with socialism is that you eventually run out of other people’s money.” Would Medicare for All eventually become Medicare for None, leaving the program so overstressed that its critical benefits to our older and disabled population would be lost?

All of this said, our health care system is in a mess. Even if the system can’t provide everything everyone wants, our leaders must make health care a funding priority and be smarter with their overall health care vision. Quality health care costs money. Our leaders must demand what little money is available be spent not on bureaucratic bloat but rather on hands-on care delivery and providing access 24/7.

Our limited resources should always be in our focus, but also in our focus should be not letting one penny go to anything unrelated to hands-on patient care. n Contact me at lukelampton@cableone.net.

— Lucius M. Lampton, MD, Editor

JOURNAL EDITORIAL ADVISORY BOARD ADDICTION MEDICINE Scott L. Hambleton, MD

EMERGENCY MEDICINE Philip Levin, MD

ALLERGY/IMMUNOLOGY Stephen B. LeBlanc, MD Patricia H. Stewart, MD

FAMILY MEDICINE Tim J. Alford, MD Diane K. Beebe, MD Jennifer Bryan, MD J. Edward Hill, MD Ben Earl Kitchens, MD

ANESTHESIOLOGY Douglas R. Bacon, MD John W. Bethea, Jr., MD CARDIOVASCULAR DISEASE Thad F. Waites, MD

GASTROENTEROLOGY James Q. Sones, MD GENERAL SURGERY Andrew C. Mallette, MD

CHILD & ADOLESCENT PSYCHIATRY John Elgin Wilkaitis, MD, MBA, FAPA, CPE

HEMATOLOGY Carter Milner, MD

CLINICAL NEUROPHYSIOLOGY Alan R. Moore, MD

INFECTIOUS DISEASE Rathel "Skip" Nolen, III, MD

DERMATOLOGY Robert T. Brodell, MD Adam C. Byrd, MD

INTERNAL MEDICINE Daniel P. Edney, MD Daniel W. Jones, MD Brett C. Lampton, MD Kelly J. Wilkinson, MD

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INTERNAL MEDICINE/ EPIDEMIOLOGY Thomas E. Dobbs, MD MEDICAL STUDENT John F. G. Bobo, M4 NEPHROLOGY Harvey A. Gersh, MD Sohail Abdul Salim, MD OBSTETRICS & GYNECOLOGY Sidney W. Bondurant, MD Sheila Bouldin, MD Darden H. North, MD ORTHOPEDIC SURGERY Chris E. Wiggins, MD OTOLARYNGOLOGY Bradford J. Dye, III, MD PEDIATRIC OTOLARYNGOLOGY Jeffrey D. Carron, MD

PEDIATRICS Michael Artigues, MD Owen B. Evans, MD PLASTIC SURGERY William C. Lineaweaver, MD, Chair PSYCHIATRY Beverly J. Bryant, MD June A. Powell, MD PUBLIC HEALTH Mary Margaret Currier, MD, MPH PULMONARY DISEASE Sharon P. Douglas, MD John R. Spurzem, MD RADIOLOGY P. H. (Hal) Moore, Jr., MD RESIDENT/FELLOW Cesar Cardenas, MD UROLOGY W. Lamar Weems, MD VASCULAR SURGERY Taimur Saleem, MD

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Top 10 Facts You Need to Know about Achalasia BRANNON HARRISON, MD, JACOB MOREMEN, MD

Introduction Achalasia is an uncommon condition affecting the muscles of the esophagus and lower esophageal sphincter (LES). The LES fails to relax during swallowing, pressurizing the esophagus and leading to dilation and, ultimately, loss of peristalsis. Patients typically present with a triad of dysphagia, regurgitation, and weight loss. Dysphagia usually begins with solids and can progress to include liquids. Until recently, treatments have evolved little since the introduction of a laparoscopic technique to the traditional Heller myotomy. In the last decade, a new technique has been developed to perform a myotomy by a less invasive endoscopic approach.1 Per-oral endoscopic myotomy involves entering the submucosal “third” space with an endoscope (Figure 1-4). Early study of this technique has shown similar success and comparable long-term symptomatic relief to traditional therapy.2 Achalasia patients are complex and require life-long follow up even after successful intervention.

length of the esophagus without coordinated peristalsis.

Type 3 – Swallowing results in uncoordinated contractions or spasms.

4

Other diseases masquerading as achalasia are known as pseudoachalasia.

Achalasia symptoms and study findings can be caused by malignancy affecting the esophageal neural plexuses or extrinsic compression at the gastroesophageal junction. Pseudoachalasia has identical manometric and fluoroscopic findings to primary achalasia.

Index of suspicion should be highest in presentation late in life with rapid progression of symptoms, especially weight loss. Approximately 3-5% of cases with achalasia-like symptoms will be secondary to another disease process, most commonly malignancy.13,14

1

5

2

6

What is achalasia?

Achalasia is a benign disorder of the esophagus that causes progressive difficulty with swallowing. It is rare, with an annual incidence of approximately 1.6 cases per 100,000 individuals. Achalasia is typically diagnosed between the ages of 25 to 60 years. Men and women are affected equally.3 How is achalasia diagnosed?

Diagnosis is based on clinical symptoms and high-resolution manometry (HRM). Manometry tells us about the pressurization and contractility of the esophagus across its length.

When the LES fails to relax as food passes and the esophageal wall fails to propagate food forward (failed peristalsis), the diagnosis is made.

Barium swallow and endoscopy are also commonly incorporated in the work-up.4-7

3

Chicago Classification stratifies the disease into three types.

All types of Achalasia have failed relaxation of the LES. Differing pressurization patterns in the distal two-thirds of the esophagus as seen on HRM separate the different types.8-12 Type 1 – No change in esophageal pressurization with swallowing.

No contractility.

Type 2 - Swallowing results in pressurization that spans the entire

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Medical therapy can help in some cases but with limited durability.

Nitrates, calcium channel blockers, and LES Botox injection can be used to relax the smooth muscle of the lower esophageal sphincter.15 Symptomatic relief is inferior to pneumatic dilation and surgical therapy, and medication side effects are commonly problematic.

Dilation is effective therapy when deployed strategically.

Endoscopic balloon dilation is a useful first-line therapy. When utilized multiple times in succession and often in conjunction with Botox, symptomatic relief can be obtained for 92% and 64% of patients over 1 and 5 years, respectively.16 Up to one-third of patients have relief at 10 years. Perforation is a significant concern with rates from 2-16%.17

7

Surgical myotomy is the most durable therapy but also the most morbid.

Even after dilation, 30-50% of patients go on to need surgery.

Younger patients (< 40 years), particularly men, and those with a dilated esophagus or already experiencing complications like aspiration are more likely to proceed to surgery. Laparoscopic myotomy with partial fundoplication is considered the gold standard for treatment of primary achalasia. Surgery should be recommended in those with symptom recurrence after multiple pneumatic dilations or those listed above (< 40, dilated, experiencing complications).18

Figure 1. An incision is made in the mucosa of the distal esophagus with the use of electrocautery.

Figure 2. A submucosal tunnel is created by injecting saline to separate tissue layers and then dissecting with electrocautery.

Figure 4. Mucosal incision is closed with endoscopic clips.

Figure 3. Longitudinal muscle fibers become visible as the circular layer is divided.

8

POEM is becoming established as the standard treatment in centers with experience.

Per-oral endoscopic myotomy (POEM) is a method for performing a myotomy of the LES without having surgery. A submucosal tunnel is created endoscopically to gain access to the circular muscles of the lower esophageal sphincter which are divided with a diathermic scalpel. Two-year follow-up shows >90% symptomatic relief without additional complications.19-21

End-stage achalasia or “burned out esophagus” is a difficult end for some.

Achalasia is a terminal disease of the esophagus that does not have a “cure” but can be palliated in most cases. However, 5% of cases will develop progressive dilation and tortuosity of the esophagus that leads to poor quality of life, malnutrition or both. In most instances, these patients will require esophagectomy.22,23

9

10

Cancer risk and associated disorders must be considered.

The risk of developing esophageal cancer is increased by 15-30% in those diagnosed with achalasia and left untreated.

However, endoscopic surveillance is controversial and not currently recommended.24-26 Other esophageal motility disorders can present with dysphagia to solids and liquids. These are distinguished from achalasia by at least some amount of lower esophageal sphincter relaxation with swallowing.9 n References 1. Inoue H, Minami H, Kobayashi Y, et al. Peroral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy. 2010;42(4):265-271.

2. Inoue H, Sato H, Ikeda H, et al. Per-Oral Endoscopic Myotomy: A series of 500 patients. J Am Coll Surg. 2015;221(2):256-264.

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3.

Sadowski DC, Ackah F, Jiang B, Svenson LW. Achalasia: incidence, prevalence and survival. A population-based study. Neurogastroenterol Motil.

2010;22(9):e256-261.

4. Pandolfino JE, Ghosh SK, Rice J, Clarke JO, Kwiatek MA, Kahrilas PJ. Classifying esophageal motility by pressure topography characteristics: a study of 400 patients and 75 controls. Am J Gastroenterol. 2008;103(1):27-37.

5. Ghosh SK, Pandolfino JE, Rice J, Clarke JO, Kwiatek M, Kahrilas PJ. Impaired deglutitive EGJ relaxation in clinical esophageal manometry: A quantitative analysis of 400 patients and 75 controls. Am J Physiol Gastrointest Liver Physiol.

2007;293(4):G878-885.

6.

Ghosh SK, Pandolfino JE, Zhang Q, Jarosz A, Shah N, Kahrilas PJ. Quantifying esophageal peristalsis with high-resolution manometry: a study of 75 asymptomatic volunteers. Am J Physiol Gastrointest Liver Physiol.

2006;290(5):G988-997.

7. Pandolfino JE, Ghosh SK, Zhang Q, Jarosz A, Shah N, Kahrilas PJ. Quantifying EGJ morphology and relaxation with high-resolution manometry: a study of 75 asymptomatic volunteers. Am J Physiol Gastrointest Liver Physiol.

2006;290(5):G1033-1040.

8. Fox MR, Bredenoord AJ. Oesophageal high-resolution manometry: moving from research into clinical practice. Gut 2008;57(3):405-423.

9. Kahrilas PJ, Ghosh SK, Pandolfino JE. Esophageal motility disorders in terms of pressure topography: the Chicago Classification. J Clin Gastroenterol.

2008;42(5):627-635.

10.

Pandolfino JE, Fox MR, Bredenoord AJ, Kahrilas PJ. High-resolution manometry in clinical practice: utilizing pressure topography to classify oesophageal motility abnormalities. Neurogastroenterol Motil. 2009;21(8):796806.

11. Bredenoord AJ, Fox M, Kahrilas PJ, Pandolfino JE, Schwizer W, Smout AJ. Chicago classification criteria of esophageal motility disorders defined in high-resolution esophageal pressure topography. Neurogastroenterol Motil.

2012;24 Suppl 1:57-65.

12. Kahrilas PJ, Bredenoord AJ, Fox M, et al. The Chicago Classification of esophageal motility disorders, v3.0. Neurogastroenterol Motil. 2015;27(2):160174.

13. Rozman RW, Jr., Achkar E. Features distinguishing secondary achalasia from primary achalasia. Am J Gastroenterol. 1990;85(10):1327-1330.

14. Kahrilas PJ, Kishk SM, Helm JF, Dodds WJ, Harig JM, Hogan WJ. Comparison of pseudoachalasia and achalasia. Am J Med. 1987;82(3):439-446.

15. Gelfond M, Rozen P, Gilat T. Isosorbide dinitrate and nifedipine treatment of achalasia: a clinical, manometric and radionuclide evaluation. Gastroenterology.

1982;83(5):963-969.

16. Katzka DA, Castell DO. Review article: an analysis of the efficacy, perforation

HELP YOURSELF TO SOME

rates and methods used in pneumatic dilation for achalasia. Aliment Pharmacol Ther. 2011;34(8):832-839.

17. J Gupta S, R Gaikwad N, R Samarth A, R Gattewar S. pneumatic balloon dilatation for achalasia cardia: outcome, complications, success, and longterm follow-up. Euroasian J Hepatogastroenterol. 2017;7(2):138-141.

18. Vaezi MF, Pandolfino JE, Vela MF. ACG clinical guideline: diagnosis and management of achalasia. Am J Gastroenterol. 2013;108(8):1238-1249; quiz 1250.

19. Talukdar R, Inoue H, Nageshwar Reddy D. Efficacy of peroral endoscopic myotomy (POEM) in the treatment of achalasia: a systematic review and meta-analysis. Surg Endosc. 2015;29(11):3030-3046.

20. Teitelbaum EN, Dunst CM, Reavis KM, et al. Clinical outcomes five years after POEM for treatment of primary esophageal motility disorders. Surg Endosc. 2018;32(1):421-427.

21. Li QL, Wu QN, Zhang XC, et al. Outcomes of per-oral endoscopic myotomy for treatment of esophageal achalasia with a median follow-up of 49 months.

Gastrointest Endosc. 2018;87(6):1405-1412.e1403.

22. Vela MF, Richter JE, Wachsberger D, Connor J, Rice TW. Complexities of managing achalasia at a tertiary referral center: use of pneumatic dilatation, Heller myotomy, and botulinum toxin injection. Gastrointest Endosc.

2004;99(6):1029-1036.

23. Aiolfi A, Asti E, Bonitta G, Bonavina L. Esophagectomy for end-stage achalasia: Systematic review and meta-analysis. World J Surg. 2018;42(5):1469-1476.

24. Sandler RS, Nyren O, Ekbom A, Eisen GM, Yuen J, Josefsson S. The risk of esophageal cancer in patients with achalasia. A population-based study. JAMA. 1995;274(17):1359-1362.

25. Leeuwenburgh I, Scholten P, Alderliesten J, et al. Long-term esophageal cancer risk in patients with primary achalasia: a prospective study. Am J Gastroenterol.

2010;105(10):2144-2149.

26. Zendehdel K, Nyren O, Edberg A, Ye W. Risk of esophageal adenocarcinoma in achalasia patients, a retrospective cohort study in Sweden. Am J Gastroenterol.

2011;106(1):57-61.

Author information Brannon Harrison, MD, Administrative Chief Resident, General Surgery, University of Mississippi Medical Center, 2500 North State St., Jackson, MS 39216.

Corresponding author: Jacob Moremen, MD, Assistant Professor of Thoracic Surgery, UMMC Department of Surgery, 2500 North State St., Jackson, MS 39216.

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Early Impact of a Statewide Screening Program for Critical Congenital Heart Disease in Newborns LILY M. MOORE, MD; DEANI H. MCVADON, MD; ALI DODGE-KHATAMI, MD, PHD; CHAD BLACKSHEAR, BS; FAZLAY S. FARUQUE, PHD; MARY B. TAYLOR, MD, MSCI; SAROSH P. BATLIVALA, MD, MSCI Abstract Background: Critical congenital heart disease is life-threatening and delayed diagnoses increase morbidity and mortality. Pulse oximetry is a useful screening tool for these diseases. Screening outcomes in Mississippi, an underserved state, were evaluated.

Methods: A single-center, retrospective study of all infants treated for critical congenital heart disease before and after screen implementation is described. Measures of interest included age, mortality, total interventions, length of stay, and complications. Outcome measures of the pre- and post-screen eras were compared.

Results: 75,760 infants were born in the pre-screen era, of whom 121 were treated for critical congenital heart defects; 75,154 were born postscreen, of whom 103 were treated for critical congenital heart defects. 23 deaths occurred pre-screen and 9 post-screen, a significant decrease by era (0.3 per 1000 live births vs. 0.12 per 1000 live births, p 0.03). Length of stay and total interventions were also significantly lower post-screen.

Discussion. Screening was associated with the improved outcomes above, though the study design limits generalizability. There were trends toward fewer delayed diagnoses and complications. Further work can improve screening reliability and availability in resource-poor regions.

Keywords: critical congenital heart disease, newborn screening program Background The incidence of congenital heart disease (CHD) is approximately 9 per 1000 live births, with an estimated quarter of those patients with critical CHD, defined as being dependent on a patent ductus arteriosus to survive or requiring intervention within the first month of life (Table 1).1,2 Critical CHD has the highest mortality rate of all birth defects in the developed world.3,4 Most infants with critical CHD can be diagnosed by echocardiography, palliated with prostaglandin in any health care setting, and ultimately transported to a tertiary care center.

Thus, early recognition of critical CHD is a key factor in optimizing outcomes as morbidity and mortality rates increase if treatment is delayed.5–7 Pulse oximetry is a useful tool in screening for critical CHD.8-10 In 2009, the American Academy of Pediatrics, partnered with the American College of Cardiology and American Heart Association, recommended that all infants be screened for critical CHD.11 Screening programs can aid in earlier detection which improves outcomes, decreases mortality, and lowers medical costs.11-13 In 2015, the Director of the Mississippi Department of Health (MSDOH) mandated that Mississippi

1 Table Forms of Critical Congenital Heart Disease Mahle et al) (1) Table1.1.Specific Specific forms of critical congenital heart disease (adapted from(adapted Mahle et al) from

Tetralogy of Fallot

Truncus arteriosus

D-transposition of the great arteries

Totally anomalous pulmonary venous return

Double-outlet right ventricle

Pulmonic valve stenosis (critical) & atresia

Ebstein anomaly

Pulmonary atresia with intact septum

Tricuspid atresia

Aortic valve stenosis (critical) & atresia

Hypoplastic left heart syndrome

Aortic arch coarctation, hypoplasia, & interruption

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Figure 1. Screening algorithm for critical congenital heart disease

The screen is performed by obtaining pulse oximetry readings on the right hand and either foot between 24 and 48 hours of life.

hospitals with infant delivery services screen all newborns for critical CHD before discharge.14 Figure 1 outlines the screening protocol recommended by professional medical societies and MSDOH.

Methods

The Children’s Heart Center (CHC) at the University of Mississippi Medical Center (UMMC) was well positioned to evaluate this new program, as the CHC was developed prior to the screening mandate, with data to compare pre- and post-critical CHD screening to investigate the program’s impact. More information on the utility of screening initiatives can be beneficial given the short time these programs have been in place to identify improved detection methods and cost savings. These reports are also helpful for communities contemplating developing similar screening programs.15-18

A retrospective analysis of the clinical records all children treated at the CHC was performed. The incidence of delayed diagnoses of critical CHD pre- and post-implementation of the statewide screening program was compared. Our specific criteria for inclusion were infants (<1 year of age) diagnosed with critical CHD and cared for at the CHC between 7/1/2013 and 6/30/2017 who underwent a cardiac intervention (either surgery or catheterization) during the first year of life. Screenings for the congenital cardiac lesions listed were also an inclusion criterion (Figure 1, Table 1).11 Since it was the intention to investigate outcomes for all infants with critical CHD, there were no specific exclusion criteria.

It was hypothesized that our new screening program would result in lower infant mortality related to critical CHD. It was hypothesized that median cardiac interventions, hospital lengths of stay (LOS) for the initial cardiac hospitalization, complications, and persistent cardiovascular symptoms would decrease after screen implementation.

Study Design & Patient Selection

Recruitment, Study Procedures, and Approval No patients were recruited given the retrospective design. Neither participants nor cardiologists were contacted for this study. All data were

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Table Demographics and Cardiac Diagnostics Cohort Table 2.2.Demographics and cardiac diagnostics of the cohortof andthe by screen eraand by Screen Era

Age at Diagnosis (days) Sex Male Female Diagnosis† Tetralogy of Fallot HLHS Pulmonary Stenosis/Atresia D-TGA Aortic Coarctation Aortic Arch Hypoplasia DORV Truncus arteriosus PA/IVS TAPVR Tricuspid atresia PA/VSD Aortic Valve Stenosis/Atresia Ebstein anomaly Other# Genetic Anomaly Congenital Heart Block

All (N=224) 0.5 [0-220]

Pre-Screen (N=121) 0 [0-192]

Post-Screen (N=103) 1 [0-220]

115 (51%) 109 (49%)

60 (49.5%) 61 (50.5%)

55 (53%) 48 (47%)

50 (22%) 34 (15%) 37 (17%) 29 (13%) 28 (13%) 26 (12%) 19 (8.5%) 11 (5%) 10 (4.5%) 10 (4.5%) 5 (2%) 4 (2%) 3 (1%) 1 (0.5%) 18 (8%) 35 (15%) 9 (4%)

28 (23%) 18 (15%) 29 (23%) 18 (15%) 10 (8%) 14 (12%) 13 (11%) 3 (2.5%) 6 (5%) 7 (6%) 3 (2.5%) 4 (3%) 2 (1.5%) 0 (0%) 11 (9%) 23 (19%) 5 (4%)

22 (21%) 16 (15.5%) 8 (8%) 11 (10.5%) 18 (17.5%) 12 (12%) 6 (6%) 8 (9%) 4 (4%) 3 (3%) 2 (2%) 0 (0%) 1 (1%) 1 (1%) 7 (7%) 12 (12%) 4 (4%)

p 0.63 0.57

0.75 0.89 0.001* 0.35 0.04* 0.98 0.19 0.07 0.7 0.3 0.79 0.06 0.66 0.28 0.31 0.92 0.13

Data presented as median [range] or count (percentage of appropriate subset) † Percentages exceed 100% given patients with multiple diagnoses * Indicates a statistically significant difference between groups # Other includes patients with multiple, complex diagnoses (see text for examples) Abbreviations: D-TGA = D-transposition of the great arteries DORV = Double-outlet right ventricle PA/VSD = Pulmonary atresia with ventricular septal defect PA/IVS = Pulmonary atresia with intact septum TAPVR = Totally anomalous pulmonary venous return HLHS = Hypoplastic left heart syndrome

obtained from existing medical records, and the UMMC Institutional Review Board approved the study.

Outcome Measures Records were reviewed to determine the total number of infants diagnosed and treated with critical CHD before (7/1/2013 through 6/30/2015) and after (7/1/2015 through 6/30/2017) statewide screen implementation. Infants with a delayed diagnosis of critical CHD, defined as a diagnosis on or after day 10 of life, were counted.

The delayed diagnosis group was subcategorized into mildly delayed (10-27 days of age) and severely delayed (≥28 days of age). To calculate the incidence of critical CHD, the total number of births in each era (which was provided by MSDOH) was used. The total cases in each

284 VOL. 60 • NO. 9 • 2019

era were divided by the total births and then multiplied by 1000 to arrive at a case per 1000 live births (LB) incidence rate. ICU and total hospital LOS for the initial intervention were collected. The number of subsequent hospitalizations related to on-going cardiac morbidity was also determined, including ICU admissions. These indications included admissions for worsening cyanosis/hypoxemia, heart failure management, pulmonary hypertension exacerbation, concern for shunt occlusion, recurrent cardiac anatomic pathology (e.g. re-coarctation), and cardiac arrest. Total cardiac interventions, including surgery and catheterization, were counted for each participant. Major adverse events were counted and included occurrence of a stroke (related to a cardiac procedure or the critical CHD lesion), as well as unplanned, and emergent cardiac re-interventions. Death was recorded as a separate

Figure 2. All Infants with Delayed CHD Diagnosis in the A) Pre-Screen (N=18) and B) Postscreen (N=13) Eras by MS county. Counties in which children with critical CHD were born are

Figure 2. All infants withwith delayed CHD diagnosis in the A) and B)the Post-screen (N=13) eras by MS county shaded, the numeral representing thePre-Screen number of (N=18) cases during era.

Counties in which children with critical CHD were born are shaded, with the numeral representing the number of cases during the era.

measure. The presence of cardiovascular symptoms at most recent follow-up was also recorded.

Statistical Analyses The demographics, cardiac diagnostics, interventions, and outcomes were characterized with the screening era. As a secondary analysis, summaries related to the timing of the diagnosis were presented.

Associations between categorical outcome measures and screening were tested using a chi-square test for differences, whereas continuous outcome measures were tested using a nonparametric (Kruskal-Wallis/ Mann-Whitney U) t-test. The threshold for statistical significance was 0.05. Statistical testing was performed using SAS version 9.4 (SAS Institute Inc., North Carolina USA) and IBM SPSS Statistics version 24 (IBM, Armonk, NY).

Results In the pre-screen era (7/1/2013 to 6/30/2015), 75,760 infants were born in the state of Mississippi, and 74,154 infants were born in the post-screen era (7/1/2015 to 6/30/2017). During the post-screen era, 66,159 infants were screened with 80 positive screens.

Era: Pre- and Post-Screen There were 121 infants diagnosed and treated for critical CHD during

the pre-screen period and 103 post-screen. The incidence of critical CHD was 1.59 cases per 1000 LB pre-screen and 1.39 cases per 1000 LB post-screen (p 0.33). Table 2 outlines the demographic characteristics of the entire cohort as well as by screen era. The “other” category included complex lesions (e.g. cardiac heterotaxy, unbalanced atrioventricular canal defects, complex venous abnormalities, and obstructive outflow lesions). The frequency of most diagnoses was consistent between eras, though there was a statistically significant decrease in patients with pulmonary valve stenosis/atresia and an increase in aortic coarctation from eras 1 to 2.

Table 3 outlines cardiac interventions and outcomes for the entire cohort and by era. There was a statistically significant difference in mortality by era, with 0.3 deaths per 1000 LB pre-screen and 0.12 deaths per 1000 LB post-screen (p 0.03). There were also significant decreases in total cardiac interventions and LOS—both ICU and total—in the postscreen era. The proportion of first intervention types (i.e., operation vs. catheterization) was similar by era.

Timely vs. Delayed Diagnosis Thirty-one infants—inclusive of both cohorts—had a delayed diagnosis.

Eighteen were in the pre-screen era, and 13 were post-screen (Figure 2), with an incidence of 0.24 delayed-diagnoses per 1000 LB pre-screen and 0.18 delayed-diagnoses per 1000 LB post-screen (p 0.63).

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Table Cardiac Interventions and Outcomes forand the Table 3.3.Cardiac interventions and outcomes for the cohort

by Cohort screen eraand by Screen Era

Delayed Diagnosis Age at First Intervention (days) First Intervention Type Operation Catheterization Total Interventions per patient Operations Catheterizations Hemodynamic Interventional st 1 Intervention ICU LOS 1st Intervention Total LOS Ever on ECMO? Post-intervention Hospitalization Post-intervention ICU Current CV Symptoms# Any Major Complication Death

All (N=224) 31 (13.8%) 9 [0-310]

Pre-Screen (N=121) 18 (14.9%) 8 [0-288]

Post-Screen (N=103) 13 (12.6%) 12 [0-310]

183 (82%) 41 (18%) 2 [1-16] 1 [0-7] 1 [0-9] 0 [0-4] 1 [0-9] 6 [0-104] 12 [1-104] 39 (17.4%) 72 (32%) 47 (21%) 23 (12%) 28 (12.5%) 32 (14%)

95 (79%) 26 (21%) 3 [1-16] 2 [0-7] 1 [0-9] 0 [0-4] 1 [0-9] 6 [1-104] 14 [3-104] 23 (19%) 38 (31%) 28 (23%) 13 (13%) 19 (16%) 23 (19%)

88 (85%) 15 (15%) 2 [1-10] 1 [0-6] 1 [0-5] 0 [0-2] 1 [0-4] 5 [0-51] 11 [1-91] 16 (15.2%) 34 (33%) 19 (18%) 10 (11%) 9 (9%) 9 (9%)

Data presented as median [range] or count (percentage of appropriate subset) * Denotes a statistically significant result # Proportion based on living patients Abbreviations: ECMO = Extracorporeal membrane oxygenation ICU = Intensive care unit CV = Cardiovascular

Of note, two patients with moderate aortic coarctation both had severely delayed diagnoses in the post-screen era, and both required only one catheterization. Though coarctation is included as a critical CHD lesion, moderate coarctation may not be immediately life-threatening and it can elude detection by pulse oximetry screen (i.e. false negative). No other patients had lesions that could plausibly have false-negative screens.

Excluding these two, 29 patients had a delayed diagnosis (18 pre-screen and 11 post-screen), translating to an incidence of 0.15 per 1000 LB post-screen with fewer severely delayed diagnosis after screening (10 pre-and 4 post-screening).

Table 4 outlines the demographic characteristics based on the timeliness of diagnosis. As expected, patients with delayed diagnoses were older.

The frequency of various diagnoses was relatively consistent with prior years. As expected, none of the severely delayed diagnosed patients had congenital heart block or other hemodynamically significant rhythm issues at birth.

Table 5 outlines cardiac interventions and outcomes based on the timeliness of diagnosis. As expected, patients with delayed diagnoses were older at the time of first intervention. The proportion of first intervention types (i.e., operation vs. catheterization) was relatively

286 VOL. 60 • NO. 9 • 2019

p 0.63 0.36

<0.001*

0.001* 0.001* 0.49 0.79 0.39 0.58 0.12 0.03*

similar, though there was a slightly higher number of operations as the first intervention in the mildly delayed diagnosis group. There were no statistically significant differences in interventions between the timely and delayed diagnosis groups. There was a significant difference in current CV symptoms and major complications, and a trend toward longer initial ICU LOS (p 0.06).

Discussion One major goal of critical CHD screening is to reduce cardiac-related deaths.19,20 Another important goal is to prevent delayed diagnoses.

While the most severe lesions typically lead to emergencies, other forms of critical CHD may allow infants to survive some time, though not without consequence. Those who present late (≥10 days of age) may develop significant co-morbidities, including irreversible lung disease, neurologic, gastrointestinal, renal, and other significant system problems.

Further, children with a delayed diagnosis may require unique treatment strategies because they are too ill to survive typical operations.21 They may also have prolonged hospital stays with greater re-interventions and subsequent hospitalizations; others may not survive. Finally, recent studies of newly implemented screening programs have demonstrated

region-specific challenges and opportunities for improvement.22–25 Data demonstrated a significant reduction in post-screen era mortality.

Though a statistically significant decrease in delayed diagnoses was not detected, there was a trend towards significance after removing the two severely delayed coarctation patients. Surgeons were the same in both eras, so the decrease in deaths was unrelated to individual surgeon outcomes. It is posited that the decline in mortality may be partly related to greater diagnostic/referral vigilance after the screening program’s launch. Similar effects have been suspected in other states.26

Nevertheless, the decrease in mortality is welcome though the data highlight an ongoing need to support the program and ensure birthing hospitals are performing the screening appropriately.

The sample sizes for sub-analysis of mildly and severely delayed patients were small, and no significant outcome differences were detected.

Though severely delayed diagnosis is likely associated with worse outcomes prima facie, the heterogeneity of critical CHD, small sample sizes, and interplay of other factors may preclude detection of significant differences.

Table Demographics and Cardiac Diagnostics

by Time of Diagnosis Table 4.4.Demographics and cardiac diagnostics by time of diagnosis

Age at Diagnosis (days) Sex Male Female Diagnosis† Tetralogy of Fallot HLHS D-TGA Pulmonary Stenosis/Atresia Aortic coarctation Aortic Arch Hypoplasia DORV Truncus arteriosus PA/IVS TAPVR PA/VSD Tricuspid atresia Aortic Valve Stenosis/Atresia Ebstein anomaly Other# Genetic Anomaly Congenital Heart Block Pre-Screen Era Post-Screen Era

On-Time (N=193) 0 [0-9]

All Delayed (N=31) 42 [10-220]

103 (53%) 90 (47%)

12 (39%) 19 (61%)

43 (22%) 31 (16%) 29 (15%) 29 (15%) 24 (12%) 23 (12%) 17 (9%) 11 (6%) 10 (5%) 7 (4%) 4 (2%) 5 (3%) 2 (1%)

7 (23%) 3 (9.5%) 0 (0%) 8 (26%) 4 (13%) 3 (9.5%) 2 (6%) 0 (0%) 0 (0%) 3 (10%) 0 (0%) 0 (0%) 1 (3%)

1 (0.5%) 15 (8%) 27 (14%) 9 (5%) 103 (53%) 90 (47%)

0 (0%) 4 (13%) 8 (26%) 0 (0%) 18 (58%) 13 (42%)

p

Mildly Delayed (N=15) 16 [10-24]

Severely Delayed (N=16) 77 [42-220]

6 (40%) 9 (60%)

6 (38%) 10 (62%)

0.97 0.36 0.02* 0.14 0.94 0.72 0.66 0.17 0.19 0.13 0.42 0.37 0.33

3 (20%) 1 (6.5%) 0 (0%) 2 (13%) 2 (13%) 2 (13%) 1 (6.5%) 0 (0%) 0 (0%) 2 (13%) 0 (0%) 0 (%) 1 (6.5%)

4 (25%) 2 (12.5%) 0 (0%) 6 (4%) 2 (12.5%) 1 (6%) 1 (6%) 0 (0%) 0 (0%) 1 (6%) 0 (0%) 0 (%) 0 (%)

0.69 0.22 0.09 0.22

0 (%) 2 (13%) 5 (33%) 0 (%) 8 (53%) 7 (47%)

0 (%) 2 (12.5%) 3 (19%) 0 (%) 10 (62.5%) 6 (37.5%)

0.13

0.2

Data presented as median [range] or count (percentage of appropriate subset) † Percentages exceed 100% given patients with multiple diagnoses * Indicates a statistically significant difference between groups # Other includes patients with multiple, complex diagnoses (see text for examples) Abbreviations: D-TGA = D-transposition of the great arteries DORV = Double-outlet right ventricle PA/VSD = Pulmonary atresia with ventricular septal defect PA/IVS = Pulmonary atresia with intact septum TAPVR = Totally anomalous pulmonary venous return HLHS = Hypoplastic left heart syndrome

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Table Cardiac Interventions and Outcomes Time of Diagnosis Table 5.5.Cardiac interventions and outcomes by time ofby diagnosis

Age at First Intervention (days) First Intervention Type Operation Catheterization Total Interventions Operations Catheterizations Hemodynamic Interventional 1st Intervention ICU LOS 1st Intervention Total LOS Ever on ECMO Post-intervention Hospitalization Post-intervention ICU Current CV symptoms# Major Complication?

Death?

On-Time (N=193)

All Delayed (N=31)

p

Mildly Delayed (N=15) 39 [10-223]

Severely Delayed (N=16)

p

8 [0-310]

96 [10-288]

<0.001*

152 [47-288]

0.04*

156 (81%) 37 (19%) 2 [1-16] 1 [0-7] 1 [0-9] 0 [0-4] 1 [0-8] 5 [2-39] 12 [3-44] 31 (16%) 58 (30%)

27 (87%) 4 (13%) 2 [1-12] 1 [0-6] 1 [0-9] 0 [0-2] 1 [0-9] 6 [0-104] 12 [1-104] 8 (26%) 14 (45%)

0.56

0.06 0.12 0.25 0.13

14 (93%) 1 (7%) 2 [1-12] 1 [1-5] 1 [0-9] 0 [0-2] 1 [0-9] 7 [0-41] 13 [2-84] 4 (27%) 6 (40%)

13 (81%) 3 (19%) 2 [1-10] 1 [0-6] 1 [0-4] 0 [0-2] 1 [0-3] 4 [0-104] 8 [1-104] 4 (16%) 8 (50%)

38 (20%) 14 (8%) 19 (10%) 26 (13%)

9 (29%) 8 (32%) 9 (29%) 6 (19%)

0.29 0.05* 0.03* 0.45

4 (27%) 5 (42%) 4 (27%) 3 (20%)

5 (31%) 3 (23%) 5 (31%) 3 (19%)

0.49

Data presented as median [range] or count (percentage of appropriate subset) * Denotes a statistically significant result # Proportion based on living patients Abbreviations: ECMO = Extracorporeal membrane oxygenation ICU = Intensive care unit CV = Cardiovascular

No statistically significant differences based on the era were identified in our secondary analyses. Though patients with delayed diagnoses had more complications (10% on-time vs. 29% delayed, p 0.03), there were no differences in these outcomes among the delayed-diagnosis subcategories, suggesting that timely diagnosis is the primary factor.

Comparing total intervention rates is a common surrogate for overall medical complexity in studies of CHD.27 That complexity is related to anatomical and physiologic disturbances, so sequelae from delayed diagnoses may require more interventions. Alternate strategies to treat infants with delayed CHD diagnoses were adopted as the patients were unlikely to survive standard therapies.21 The decrease in postscreen interventions, in conjunction with the slight decrease in delayed diagnoses, may suggest that the screening program had a positive impact on overall quality of care.

Length of stay is another common marker for overall disease burden.

Children presenting in extremis may require longer hospitalizations and ICU stays. As with total interventions, other factors may be related, including post-operative wound healing and nutrition. A statistically significant decrease in initial ICU and total LOS was noted, though this association may not be entirely related to timeliness of diagnosis. For instance, the severely delayed patients had shorter LOS compared to mildly delayed patients.

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Extracorporeal membrane oxygenation (ECMO) can be life-saving but requires massive resources and is among the most costly and burdensome treatment strategies in modern healthcare.28 Myriad factors play a role in ECMO utilization, including anatomic complexity and co-morbidities that developed from delayed diagnosis, among others. Sample sizes for the ECMO subset were inadequate to power a robust statistical analysis, but, notably, patients with a delayed diagnosis had greater ECMO utilization, especially after censoring the two severely delayed coarctation patients (16% ECMO pre-screen vs. 28% post-screen). Further data are needed to determine if this difference is significant.

Inpatient stay data are especially important given the overall costs of hospitalization. Costs are compounded in pediatrics because multiple caregivers may miss work thereby with resultant loss of productivity.29 Subsequent hospitalizations also have significant economic impact, especially in Mississippi with an underfunded healthcare system.

Minimal differences were noted per screening era, with more postintervention hospitalizations and ICU admissions for the late-diagnosed patients, further highlighting the importance of timely diagnosis.

Limitations This is a retrospective analysis, with inherent limitations precluding the ability to determine causality and associated biases. Some sub-

comparisons had limited sample sizes, so those data may be affected by Type I error. Though we are the only pediatric CHD center in Mississippi, it is possible that some children received cardiac care out-of-state and were screened but not treated in Mississippi. Our study is also unable to identify patients who died suddenly from CHD at home; that stated, there is no reason to believe these events would disproportionately occur in one era to skew the results. Another issue is that the eras are distinct time periods which limit the statistical analyses that can be utilized. That is, “typical” survival analyses cannot be calculated because the cohorts existed at two distinct times. These limitations highlight the need for ongoing investigation to improve our understanding of the screening program’s impact.

Conclusion There has been a decrease in mortality for infants with critical CHD since the implementation of a newborn screening program in Mississippi.

Similarly, there have been fewer total cardiac interventions per patient and initial hospital lengths of stay in the era of screening. However, delayed diagnoses are still occurring despite screening, most notably in the 10-28 day age range. Further investigation is warranted into multiple facets of the program, including rationale/reasons for lack of screening, institutions with ineffective screening algorithms and practices, and resource limitations to effective screening. n References 1. Botto LD, Correa A, Erickson JD. Racial and temporal variations in the prevalence of heart defects. Pediatrics. 2001;107(3):E32.

2. Talner CN. Report of the New England Regional Infant Cardiac Program, by Donald C. Fyler, MD, Pediatrics, 1980;65(suppl):375-461. Pediatrics. 1998;102(1 Pt 2):258259.

3. Heron MP, Smith BL. Deaths: Leading causes for 2003. Natl Vital Stat Rep Cent Dis Control Prev Natl Cent Health Stat Natl Vital Stat Syst. 2007;55(10):1-92.

4. Rosano A, Botto LD, Botting B, Mastroiacovo P. Infant mortality and congenital anomalies from 1950 to 1994: an international perspective. J Epidemiol Community Health. 2000;54(9):660-666.

5. Liberman RF, Getz KD, Lin AE, et al. Delayed diagnosis of critical congenital heart defects: trends and associated factors. Pediatrics. 2014;134(2):e373-381. doi:10.1542/ peds.2013-3949 6. Peterson C, Ailes E, Riehle-Colarusso T, et al. Late detection of critical congenital heart disease among US infants: estimation of the potential impact of proposed universal screening using pulse oximetry. JAMA Pediatr. 2014;168(4):361-370. doi:10.1001/ jamapediatrics.2013.4779 7. Chang R-KR, Gurvitz M, Rodriguez S. Missed diagnosis of critical congenital heart disease. Arch Pediatr Adolesc Med. 2008;162(10):969-974. doi:10.1001/ archpedi.162.10.969 8. Oster ME, Kochilas L. Screening for critical congenital heart disease. Clin Perinatol.

2016;43(1):73-80. doi:10.1016/j.clp.2015.11.005 9. Martin GR, Beekman RH, Mikula EB, et al. Implementing recommended screening for critical congenital heart disease. Pediatrics. 2013;132(1):e185-192. doi:10.1542/ peds.2012-3926 10. de-Wahl Granelli A, Wennergren M, Sandberg K, et al. Impact of pulse oximetry screening on the detection of duct dependent congenital heart disease: A Swedish prospective screening study in 39,821 newborns. BMJ. 2009;338:a3037.

11. Mahle WT, Newburger JW, Matherne GP, et al. Role of pulse oximetry in examining newborns for congenital heart disease: A scientific statement from the AHA and AAP. Pediatrics. 2009;124(2):823-836. doi:10.1542/peds.2009-1397 12. Boneva RS, Botto LD, Moore CA, Yang Q, Correa A, Erickson JD. Mortality associated with congenital heart defects in the United States: Trends and racial disparities, 1979-

1997. Circulation. 2001;103(19):2376-2381.

13. Abouk R, Grosse SD, Ailes EC, Oster ME. Association of US state implementation of newborn screening policies for critical congenital heart disease with early infant cardiac deaths. JAMA. 2017;318(21):2111. doi:10.1001/jama.2017.17627 14. MS Department of Health. Mississippi Newborn Screening and Birth Defects Registry. http://www.sos.ms.gov/ACProposed/00020841b.pdf.

15. Costich JF, Durst AL. The Impact of the Affordable Care Act on funding for newborn screening services. Public Health Rep Wash DC 1974. 2016;131(1):160-166. doi:10.1177/003335491613100123 16. Andrea J. Implications of using pulse oximetry to screen for critical congenital heart disease in newborns. Nurs Womens Health. 2015;19(4):314-323. doi:10.1111/1751486X.12217 17. Cloete E, Gentles TL, Alsweiler JM, et al. Should New Zealand introduce nationwide pulse oximetry screening for the detection of critical congenital heart disease in newborn infants? N Z Med J. 2017;130(1448):64-69.

18. Reeder MR, Kim J, Nance A, et al. Evaluating cost and resource use associated with pulse oximetry screening for critical congenital heart disease: Empiric estimates and sources of variation. Birt Defects Res A Clin Mol Teratol. 2015;103(11):962-971. doi:10.1002/bdra.23414 19. Peterson C, Dawson A, Grosse SD, et al. Hospitalizations, costs, and mortality among infants with critical congenital heart disease: how important is timely detection? Birt Defects Res A Clin Mol Teratol. 2013;97(10):664-672. doi:10.1002/bdra.23165 20. Dobbenga-Rhodes Y. Critical congenital heart disease screening tools may reduce neonatal deaths. AORN J. 2014;100(5):C7-8.

21. Dodge-Khatami J, Dodge-Khatami A, Knudson JD, et al. Alternative strategies in newborns and infants with major co-morbidities to improve congenital heart surgery outcomes at an emerging programme. Cardiol Young. 2016;26(3):485-492. doi:10.1017/S1047951115000463 22. Singh A, Rasiah SV, Ewer AK. The impact of routine predischarge pulse oximetry screening in a regional neonatal unit. Arch Dis Child Fetal Neonatal Ed. 2014;99(4):F297302. doi:10.1136/archdischild-2013-305657 23. Oster ME, Aucott SW, Glidewell J, et al. Lessons learned from newborn screening for critical congenital heart defects. Pediatrics. 2016;137(5). doi:10.1542/peds.2015-4573 24. Klausner R, Shapiro ED, Elder RW, Colson E, Loyal J. Evaluation of a screening program to detect critical congenital heart defects in newborns. Hosp Pediatr. 2017;7(4):214218. doi:10.1542/hpeds.2016-0176 25. Mouledoux J, Guerra S, Ballweg J, Li Y, Walsh W. A novel, more efficient, staged approach for critical congenital heart disease screening. J Perinatol Off J Calif Perinat Assoc. 2017;37(3):288-290. doi:10.1038/jp.2016.204 26. Bradshaw EA, Martin GR. Screening for critical congenital heart disease: advancing detection in the newborn. Curr Opin Pediatr. 2012;24(5):603-608. doi:10.1097/ MOP.0b013e328357a843 27.

Triedman JK, Newburger JW. Trends in congenital heart disease: The next decade.

Circulation.

2016;133(25):2716-2733. doi:10.1161/ CIRCULATIONAHA.116.023544 28. Faraoni D, Nasr VG, DiNardo JA. Thiagarajan RR. Hospital costs for neonates and children supported with extracorporeal membrane oxygenation. J Pediatr.

2016;169:69-75.e1. doi:10.1016/j.jpeds.2015.10.002 29. Gerber AU, Torre AH, Büscher G, et al. Direct non-medical and indirect costs for families with children with congenital cardiac defects in Germany: A survey from a university centre. Cardiol Young. 2010;20(2):178-185. doi:10.1017/S1047951109991995

Author Information Department of Pediatrics, University of Mississippi Medical Center (Moore, McVadon, Taylor, Batlivala). Division of Pediatric and Congenital Heart Surgery, University of Mississippi Medical Center (Dodge-Khatami). Department of Data Science, University of Mississippi Medical Center (Blackshear). Geographic Information Systems and Remote Sensing Program, University of Mississippi Medical Center (Faruque).

Corresponding Author: Sarosh P. Batlivala, MD, MSCI; Associate Professor of Pediatrics, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave, MLC 2003, Cincinnati, OH 45229. Ph: (513)636-7072 (sarosh.batlivala@cchmc.org).

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Major Depression, Chronic Medical Illness, and Access to Mental Health Services among Mississippi Adults THERESA A. SMITH, PHD; GRAYSON S. NORQUIST, MD, MSPH; DICK JOHNSON, MS; RON MCANALLY, BA; AMY L. SULLIVAN, MS, PHD, RDH; IAN A. PAUL, PHD Abstract This study used Mississippi’s Behavioral Risk Factor Surveillance System data to examine the prevalence of depression, service access by adults with depression and a history of selected chronic non-psychiatric illnesses and factors that influence mental health service use. Results indicated a higher prevalence of depression among adults with a history of selected medical conditions, compared to those without. Although they had depression symptoms, one-third with a chronic illness history reported not ever being told they had a depressive disorder, and just over half reported not currently receiving mental health treatment.

Adults without a personal healthcare provider were significantly less likely than those with a usual healthcare provider to report mental health service use. Black adults and adults aged ≥ 70 were half as likely to report service use as white adults and adults aged 18-34, respectively.

Adults with healthcare coverage were twice as likely to report service use as those without coverage.

Keywords: Depression, Chronic disease, Comorbidity; Health services accessibility Introduction Recommendations by the United States Preventive Services Task Force support screening adults for depression within the context of appropriate follow-up diagnosis and treatment,1 highlighting the need for information on the prevalence of major depression, as well as access to and utilization of services for mental health conditions. Depression is a major contributor to chronic disability and disease burden;2 therefore, it is important to more routinely assess depression as part of overall population health, especially in Mississippi with its high poverty, population health risks and chronic disease burden.3-5 High poverty and unemployment and low levels of educational attainment and household income are among “social determinants of health” that not only influence individuals’ health status but also complicate strategies to address health problems.4,6 Depression is a potential problem among adults with chronic illnesses since depressed individuals are less likely to adhere to prescribed medical or behavioral treatment7-9 or to engage in effective self-care management, including healthy behaviors 290 VOL. 60 • NO. 9 • 2019

that might help them cope with their chronic illness and improve their quality of life.7,8,10,11 Mississippi’s 2011 Behavioral Risk Factor Surveillance System (BRFSS) data was used to assess recent symptoms of major depression in the state’s adult population, and among adults who reported a history of selected medical conditions, including heart attack, coronary heart disease, stroke, diabetes or hypertension. To examine service access among those with recent depression symptoms and a history of chronic non-psychiatric conditions, self-reported history of a depressive disorder or current treatment for any mental health condition was assessed. The contribution of selected individual and system factors in predicting adults’ receipt of mental health treatment was also examined to provide more specific information that can facilitate the development of public health outreach strategies.12,13 Because methodological changes to the BRFSS instituted in 2011 prevent comparison to BRFSS data from previous years, this analysis establishes a new state-level baseline for monitoring depression as part of overall population health.14 Methods Data This cross-sectional study was a secondary analysis of data from Mississippi’s 2011 Behavioral Risk Factor Surveillance System (BRFSS), a population-based telephone survey of non-institutionalized U.S. adults (≥ 18 years of age), administered annually through collaboration between the Centers for Disease Control and Prevention (CDC) and state public health agencies. The Mississippi BRFSS utilizes a disproportionate random sample design, stratifying by nine public health districts; the CDC further stratifies the landline sample by listed and unlisted numbers. Data were weighted for race, age, gender, education, marital status, renter/owner (of dwelling) status, telephone source and public health district. Further details about the survey, including response rates, design, the raking weighting methodology and the addition of cellphone respondents in sampling, can be found on CDC’s website.14 Study variables were based on responses to selected questions on demographics, service access, health risk behaviors and chronic conditions, as well as to questions in an optional module on Anxiety and Depression that included the Patient Health

Questionnaire-8 (PHQ-8).15,16, 17,18 (Contact corresponding author for study variable descriptions.)

A total of 8907 adults responded to Mississippi’s 2011 BRFSS, including 7,226 landline and 1681 cellphone respondents.14 Because Mississippi administered the Anxiety and Depression optional module only to landline respondents in 2011, the final sample included 6,186 (85.6%) of 7,226 landline respondents who answered all eight questions on the PHQ-8; cellphone respondents were excluded. Non-responses, refusals, unknown, unsure or not asked/blank responses to individual questions were also excluded from analysis. The Institutional Review Boards of the Mississippi State Department of Health and the University of Mississippi Medical Center approved the protocol containing this analysis.

Statistical analysis Given the complex sample design of the BRFSS, data were analyzed using SURVEYFREQ and SURVEYLOGISTIC procedures in SAS® (v 9.4). 14,19,20 PROC SURVEYFREQ yielded un-weighted frequencies and weighted percentages to characterize the study sample, to estimate the prevalence of recent symptoms of major depression, and to examine associations between depression and other study variables using the Rao-Scott F adjusted Chi-square statistic. 21-23 PROC SURVEYFREQ was also used to analyze access to mental health services by adults with recent symptoms of major depression and a previous diagnosis of any of the selected chronic non-psychiatric illnesses, which was determined using two questions. The first assessed whether a health professional had ever recognized their depression, indicated by a positive response to the question asking if they had ever been told they had a depressive disorder. The second question assessed if they were currently receiving mental health treatment. Positive responses to questions indicating having been diagnosed with a chronic non-psychiatric medical illness were used as a proxy for having received some type of healthcare in the past.15 Variables were set up as potential predictors of adults’ mental health service use. Similar to another analysis of 2007 BRFSS data, selected factors were grouped into four categories of Andersen’s Behavioral Model of Health Services Use: (1) predisposing factors, (2) enabling (or limiting) factors, (3) perceived need and (4) evaluated need.12,13 PROC SURVEYLOGISTIC was used to conduct multiple logistic regression analyses of four models of the association between selected individual and system factors and self-reported current receipt of mental health treatment, yielding adjusted odds ratios with 95% confidence intervals (rounded).19-23 A base model (Model 1) that included only predisposing factors was progressively adjusted by adding enabling (or limiting) factors in Model 2, the perceived need factor in Model 3, and the evaluated need factor in the final adjusted Model 4.12,13 Results Characteristics of the study sample Approximately two-thirds of adults in the study sample were in the 18-55-year-old age range, and approximately half were female and were

in a committed relationship (Table 1). Just over two-thirds (64.1%) were in the white racial group, approximately one-third (33.7%) was in the black racial group, and only 2.2% were in the “other” racial group. The proportion that had completed some college or technical school and the proportion that graduated high school were similar (approximately 30%), as were the proportion that graduated from college or technical school and the proportion that had less than a high school education (approximately 19%). Almost half were employed, approximately 16% were retired, approximately 12% were unable to work or were student/homemakers, and approximately 11% were unemployed. Approximately one-third reported income ≥$50,000, one-fourth at the $25,000 - <$50,000 level, and one-fifth at each of the lowest income levels.

Prevalence of recent symptoms of major depression

The prevalence of self-reported recent symptoms of major depression among adult Mississippians who answered all eight questions on the PHQ-8 in the 2011 BRFSS was 8.4% (Table 2). Prevalence was highest within the 35-54-year age group (10.8%), among women (10.0%), and previously married respondents (11.4%). The prevalence of recent symptoms of major depression increased as education level decreased, ranging from 3.6% among adults who had graduated from college or technical school to 15.4% among adults with less than a high school education. Considering self-reported employment status, adult Mississippians who were unable to work had the highest prevalence of major depression (26.7%), followed by unemployed adults (16.0%).

Prevalence increased as self-reported income level decreased, being over twice as high within the two lowest income groups (11.3% in the $15,000 - <$25,000 group and 19.8% in the < $15,000 group) compared to the 2 higher-income groups (5.3% in the $25,000 to <$50,000 group and 3.4% in the ≥ $50,000 group).

Of the health risk factors examined in this study, current smoking, lack of physical exercise, and obesity had a statistically significant association with self-reported recent symptoms of major depression.

The percentage of adults with recent symptoms of major depression among current smokers (17.1%) was over 3 times higher than among non-smokers (5.2%). Prevalence of self-reported recent depression symptoms among adults who reported a lack of physical activity or exercise (12.3%) was almost twice as high as prevalence among adults who reported recent physical activity (6.3%). Adults who were obese (BMI ≥ 30) had a higher prevalence of recent depression symptoms (10.6%) than individuals who were not obese (7.0%).

Both lack of healthcare coverage and inability to see a doctor because of cost had a statistically significant association with self-reported recent symptoms of major depression. The prevalence of major depression among adults who reported that there was a time in the last 12 months when they were unable to see a doctor because of cost (20.5%) was approximately 4 times higher than among those who did not report this access-to-care barrier (4.9%), and prevalence among adults who reported that they lacked healthcare coverage (13.0%) was almost twice as high as among adults with coverage (7.0%). Associations between self-reported recent symptoms of major depression and race, public health district, excessive drinking, and status regarding having SEPTEMBER • JOURNAL MSMA

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Table 1. Characteristics of study sample Table 1. Characteristics of Study Sample Total n a Total study sample 6186 Variables Age group 6156 18-34 522 35-54 1696 55-69 2257 ≥70 1681 Gender 6186 Men 2000 Women 4186 Race 6164 Black 1888 White 4179 Other 97 Marital status 6177 Committed relationship 3117 Previously married 2337 Never married 723 Educational level 6179 < High school 918 Graduated high school 2024 Some college/technical 1610 school Graduated college/ 1627 technical school Employment status 6183 Employed 2360 Not employed 372 Student/homemaker 548 Retired 2073 Unable to work 830 Income group 5326 < $15,000 1166 $15,000 - < $25,000 1185 $25,000 - < $50,000 1373 ≥ $50,000 1602 Public Health District 6186 I (Northwest) 618 II (Northeast) 701 III (Delta/Hills) 592 IV (Tombigbee) 684 V (West Central) 678 VI (East Central) 689 VII (Southwest) 832 VIII (Southeast) 717 IX (Coastal Plains) 675 Health risk factors Current smoking 6164 Yes 1090 No 5074 Obesity 5971 Yes 2078 No 3893 Excessive drinking 6112 Yes 441 No 5671

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Percentage (%)a 85.6

95% CI

32.5 34.6 20.8 12.1

30.0-35.0 32.6-36.6 19.6-22.1 11.2-12.9

47.6 52.4

45.4-49.8 50.2-54.6

33.7 64.1 2.2

31.6-35.8 62.0-66.2 1.4-2.9

50.0 22.2 27.8

47.8-52.2 20.7-23.7 25.4-30.1

19.0 30.1 32.2

17.2-20.8 28.1-32.1 30.1-34.3

18.7

17.2-20.2

48.5 10.8 12.4 15.7 12.5

46.3-50.7 9.2-12.5 10.7-14.0 14.7-16.7 11.2-13.8

20.2 20.1 25.5 34.3

18.4-22.0 18.3-21.9 23.5-27.5 32.1-36.5

10.4 11.9 7.0 8.5 22.2 7.9 5.9 10.1 16.0

9.4-11.3 10.9-13.0 6.3-7.8 7.6-9.5 20.6-23.7 7.1-8.7 5.3-6.5 9.1-11.1 14.7-17.3

26.5 73.5

24.4-28.6 71.4-75.6

36.3 63.7

34.2-38.5 61.5-65.8

13.4 86.6

11.6-15.2 84.8-88.4

Table 1 continued. Characteristics of study sample Table 1. Characteristics of Study Sample Total n a Percentage (%)a 95% CI Total study sample 6186 85.6 Variables Lack of physical 6182 activity/exercise Yes 2197 34.2 32.2-36.2 No 3985 65.8 63.8-67.8 Access to care factors Have personal 6175 doctor/healthcare provider Yes 5392 77.8 75.7-79.8 No 782 22.2 20.2-24.3 Healthcare coverage 6175 Yes 5355 76.9 74.8-79.0 No 820 23.1 21.0-25.2 Unable to see doctor 6170 because of cost Yes 1030 22.0 20.1-24.0 No 5140 78.0 76.1-80.0 Frequent mental distress b 6120 Yes 756 13.6 12.1-15.1 No 5364 86.4 84.9-87.9 Recent symptoms of 6186 major depression c Yes 447 8.4 7.1-9.6 No 5739 91.6 90.4-92.9 Currently taking 6171 medicine/receiving other mental health treatment Yes 812 12.1 10.7-13.4 No 5359 87.9 86.6-89.3 Previous Diagnosis of Chronic Illnesses Depressive disorder 6151 Yes 1181 18.9 17.3-20.6 No 4970 81.1 79.4-82.7 Heart attack/myocardial 6136 infarction Yes 454 5.0 4.3-5.7 No 5682 95.0 94.3-95.7 Angina/coronary heart 6101 disease Yes 449 4.8 4.1-5.4 No 5652 95.2 94.6-95.9 Stroke 6166 Yes 367 3.7 3.1-4.3 No 5799 96.3 95.7-96.9 Diabetes 6177 Yes 1155 12.2 11.2-13.3 No 5022 87.8 86.7-88.8 Hypertension 6169 Yes 3303 39.8 37.8-41.8 No 2866 60.2 58.2-62.2 a Frequencies (n) are un-weighted, and percentages (%) are weighted. b “Frequent mental distress,” was self-report of ≥14 of the last 30 days when mental health was “not good.” 40 c “Recent symptoms of major depression,” based on results of the PHQ-8, a shortened version of the PHQ-9, which is a validated depression screening instrument, found to be appropriate for general population studies.16,17,18 In this study, the PHQ-8 was scored using the days approach, as defined by Dhingra, Kroenke, Zack, Strine and Balluz (2011). 41

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Table 2. Prevalence of recent symptoms of major depressiona

Table 2. Prevalence of Recent Symptoms of Major Depression a Recent Major Depression Symptoms nb Total study sample (N = 6186) 447 Variables Age group (n= 6156) 18-34 37 35-54 186 55-69 172 ≥70 50 Gender (n=6186) Men 120 Women 327 Race (n=6164) Black 150 White 781 Other 14 Marital status (n=6177) Committed relationship 182 Previously married 205 Never married 58 Educational level (n=6179) < High school 109 Graduated high school 165 Some college/technical school 112 Graduated college/technical school 60 Employment status (n=6183) Employed 89 Not employed 61 Student/homemaker 24 Retired 69 Unable to work 204 Income group (n=5326) < $15,000 169 $15,000-< $25,000 108 $25,000-< $50,000 64 ≥ $50,000 50 Public Health District (n=6186) I (Northwest) 42 II (Northeast) 52 III (Delta/Hills) 38 IV (Tombigbee) 55 V (West Central) 49 VI (East Central) 45 VII (Southwest) 72 VIII (Southeast) 49 IX (Coastal Plains) 45 Health risk factors Current smoking (n=6164) Yes 190 No 255 Obesity (n=5971) Yes 208 No 221 Excessive drinking (n=6112) Yes 42 No 402

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Percentage (%)b 8.4

95% CI

P Value c

7.1-9.6

7.4 10.8 8.6 3.4

4.6-10.2 8.6-13.0 6.8-10.3 2.2-4.6

6.5 10.0

4.7-8.3 8.3-11.7

8.8 7.9 10.6

6.6-11.0 6.4-9.5 3.3-17.9

6.3 11.4 9.6

4.9-7.7 9.0-13.8 6.3-12.8

15.4 9.1 6.2 3.6

11.4-19.4 6.8-11.5 4.3-8.2 2.2-4.9

4.7 16.0 2.7 4.3 26.7

3.1-6.3 10.1-21.8 1.3-4.0 2.8-5.7 21.8-31.6

19.8 11.3 5.3 3.4

15.4-24.2 8.1-14.5 3.1-7.6 2.0-4.8

7.4 8.4 9.4 9.6 8.2 8.7 7.6 7.2 8.9

4.2-10.5 4.8-12.0 5.0-13.9 5.2-14.0 5.2-11.1 5.3-12.1 5.1-10.1 3.8-10.7 5.1-12.8

17.1 5.2

13.4-20.8 4.2-6.2

10.6 7.0

8.3-12.9 5.5-8.5

10.8 8.1

6.0-15.6 6.8-9.3

.0007

.0085 .6433

.0041

< .0001

< .0001

< .0001

.9914

< .0001 .0066 .2181

Table 2 continued. Prevalence of recent symptoms of major depressiona Table 2. Prevalence of Recent Symptoms of Major Depression a Recent Major Percentage 95% CI P Value c b Depression Symptoms (%) nb Total study sample (N = 6186) 447 8.4 7.1-9.6 Variables Lack of physical activity/exercise (n=6182) < .0001 Yes 262 12.3 10.0-14.6 No 185 6.3 4.8-7.8 Access to care factors Have personal doctor/health care provider .8816 (n= 6175) Yes 377 8.4 7.0-9.8 No 70 8.2 5.3-11.1 Healthcare coverage (n=6175) .0003 Yes 344 7.0 5.9-8.2 No 102 13.0 9.2-16.8 Unable to see doctor because < .0001 of cost (n=6170) Yes 202 20.5 16.3-24.7 No 243 4.9 3.9-5.9 Frequent mental distress d (n=6120) < .0001 Yes 308 44.8 38.8-50.7 No 134 2.6 1.9-3.4 Currently taking medicine or receiving other < .0001 mental health treatment Yes 215 27.3 22.3-32.3 No 231 5.7 4.5-7.0 Chronic illnesses Depressive disorder (n=6151) < .0001 Yes 295 26.9 22.5-31.3 No 147 3.8 2.8-4.9 Heart attack/myocardial infarction (n=6136) .0005 Yes 59 15.4 10.3-20.5 No 380 7.9 6.7-9.2 Angina/coronary heart disease (n=6102) .0014 Yes 61 14.5 9.7-19.4 No 373 7.9 6.6-9.2 Stroke (n=6166) < .0001 Yes 53 22.2 13.0-31.5 No 392 7.8 6.6-9.1 Diabetes (n=6177) .0264 Yes 119 11.1 8.4-13.8 No 324 7.9 6.6-9.3 Hypertension (n=6169) < .0001 Yes 273 11.4 9.3-13.6 No 172 6.2 4.7-7.7 a “Recent symptoms of major depression,” based on results of the PHQ-8, a shortened version of the PHQ-9, which is a validated depression screening instrument, found to be appropriate for general population studies.16,17,18 In this study, the PHQ-8 was scored using the days approach, as defined by Dhingra, Kroenke, Zack, Strine and Balluz (2011). 41 b Frequencies (n) are un-weighted, and percentages (%) are weighted. c Statistical test results at level 0.05 were interpreted as significant; p-values were based on the Rao-Scott F adjusted Chi-square statistic, recommended to provide a conservative interpretation of data from a survey with a complex sample design. 21-23 d “Frequent mental distress,” was self-report of ≥14 of the last 30 days when mental health was “not good.” 40

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a personal doctor or healthcare provider(s) were not statistically significant.

When the prevalence of recent symptoms of major depression in those who reported a history of the selected chronic non-psychiatric illnesses was examined, it was found that the prevalence was 11.1 % in those with diabetes, 11.4% in those with hypertension, 14.5% in those with angina/coronary heart disease, 15.4% in those who had had a heart attack, and 22.2% in those who reported having had a stroke.

The prevalence of major depression was highest among adults who reported frequent mental distress (44.8%), which was not surprising; however, it was also high among those who reported ever having been told they had a depressive disorder (26.9%) and among those taking medication or receiving other treatment for a mental health condition (27.3%), which might be indicative of inadequate treatment.

Access to services by adults with recent depressive symptoms

A history of any of the selected chronic non-psychiatric medical illnesses was used as a proxy for having received some type of healthcare in the past. Among those who had received such healthcare and who had symptoms consistent with recent depression, 67.4% (CI 58.6-76.3) reported that they had ever been told they had a depressive disorder, but only 44.1% (CI 35.1-53.2) reported that they were currently taking medication or receiving treatment for a mental health condition.

Predictors of self-reported receipt of treatment for a mental health condition Progressively adjusted logistic regression models were developed to examine predictors of current mental health treatment among adults in the study sample. In Model 1, which included only predisposing factors proposed in our study, women, adults who were previously married or never married, and adults aged 35-54 and aged 55-69, were significantly more likely to self-report mental health treatment compared to men, adults in a committed relationship and adults aged 18-34 years, respectively. Black adults were only 60% as likely as white adults to self-report receiving mental health treatment. Educational level overall had a significant association with current treatment (p = .0358); however, compared to college/technical school graduation, lower educational levels were not significant predictors.

Results from adding enabling factors in Model 2 indicated that adults who were unable to work followed by adults who were unemployed or retired were significantly more likely to report receiving treatment compared to employed adults. Adults who had no personal health care provider were only 20% as likely as those who did to self-report receipt of mental health treatment. Adults with healthcare coverage were just over twice as likely to report receipt of treatment as those who lacked coverage. The association between the inability to see a doctor because of cost and receipt of mental health treatment was not statistically significant. The association with the 35-69 age group was no longer significant while being ≥ 70 years of age became a significant factor; adults who were aged ≥ 70 years were 40% as likely as adults aged 1834 years to report receiving mental health treatment. The association 296 VOL. 60 • NO. 9 • 2019

between being black and receiving treatment remained significant, increasing slightly, while significant associations between being female, previously married or never married and receipt of treatment were attenuated. The educational level was no longer significant.

Model 3 added perceived need indicated by frequent mental distress (≥14 days when mental health was “not good”). Results indicated that adults who reported frequent mental distress were 4.9 times more likely to report receiving treatment than those who did not. Adjusted odds of self-reported mental health treatment and being black, previously married and having no personal health care provider remained the same and statistically significant. The associations between having never been married and having healthcare coverage and receipt of treatment remained significant, increasing slightly, while significant associations between being ≥70 years old, being female, being retired or unable to work and receiving treatment were attenuated. Being unemployed was no longer a significant predictor of self-reported treatment.

Evaluated need, indicated by meeting criteria for recent symptoms of major depression, was added in the final adjusted Model 4 (Table 3). Results showed that adults who reported not having a personal healthcare provider remained only 20% as likely as those who had a usual healthcare provider to report receiving mental health treatment, making it the strongest predictor of all the factors selected for this study. Adults who reported frequent mental distress (compared to those who did not), who were unable to work (compared to those who were employed), and who met criteria for recent symptoms of major depression (compared to those who did not) were about three times more likely to report receiving mental health treatment. Compared to adults without healthcare coverage, those with coverage were just over twice as likely to self-report mental health treatment. Black adults and adults who were aged ≥ 70 years remained 50% as likely to have selfreported mental health treatment as white adults and adults aged 18-34 years respectively. Significant associations between being retired and between being previously married and receipt of treatment remained the same while having never been married was no longer a significant predictor. The association between receipt of treatment and being female remained significant but was attenuated.

Discussion

The estimated prevalence of recent symptoms of major depression among adult Mississippians of 8.4% in this study was higher than the estimate of approximately 7% based on the National Survey of Drug Use and Health from 2010-2011.24 This study provides a new baseline for the prevalence of major depression among Mississippi adults, and in particular, among adults who reported previous diagnoses of five major chronic illnesses, all of which had a significant association with major depression. The need for depression screening among adults with any of the selected chronic medical illnesses, especially stroke, is compelling as the prevalence of major depression was high, ranging from 11.1% for diabetes to 22.2% for stroke.

Among adults with recent depression and a history of any of the selected chronic non-psychiatric medical illnesses, a third (32.6%)

Table 3. Predictors of Self-reported Current Treatment for a Mental Health Condition among Adult

Table 3. Predictors of self-reported current treatment for a mental health condition among adult Mississippians Mississippians Variable (1) Predisposing factors Age group 18-34 35-54 55-69 ≥ 70 Gender Men Women Race Black White Other Educational level < High school Graduated high school Some college/technical school Graduated college/technical school Marital status Committed relationship Previously married Never married (2) Enabling factors Employment status Employed Not employed Student/homemaker Retired Unable to work Lack of personal health care provider Had healthcare coverage Unable to see doctor because of cost (3) Perceived need Met criteria for frequent mental distress b (4) Evaluated need Met criteria for major depression c

Final Adjusted Model 4 Odds ratio (95% CI) P value a Referent 1.4 (.9-2.4) .9 (.5-1.5) .5 (.3-.9) Referent 1.6 (1.2-2.2) .5 (.4-.8) Referent 1.3 (.2-9.9) .8 (.4-1.4) 1.0 (.7-1.4) .7 (.5-1.0) Referent Referent 1.5 (1.2-2.0) 1.7 (1.0-2.8)

< .0001 .1703 .6823 .0149 .0023 .0023 .0074 .0018 .8044 .1702 .3979 .8925 .0686 .0055 .0024 .0686 .0001

Referent 1.7 (.8-3.6) 1.3 (.8-2.4) 1.8 (1.3-2.6) 3.0 (1.9-4.7) .2 (.1-.3) 2.3 (1.1-4.9) .8 (.5-1.3)

.1330 .3186 .0016 < .0001 < .0001 .0236 .4091

3.3 (2.2-5.1)

< .0001

2.9 (1.8-4.8)

< .0001

a Statistical

test results at level 0.05 were interpreted as significant. PROC SURVEYLOGISTIC yielded Type 3 analysis of effects (p value) for independent variable categories (e.g., gender) and maximum likelihood estimates (MLE p-value) for sub-groups of independent variables (e.g., men, women). 23 b “Frequent mental distress,” was self-report of ≥14 of the last 30 days when mental health was “not good.” 40 c “Recent symptoms of major depression,” based on results of the PHQ-8, a shortened version of the PHQ-9, which is a validated depression screening instrument, found to be appropriate for general population studies.16,17,18 In this study, the PHQ-8 was scored using the days approach, as defined by Dhingra, Kroenke, Zack, Strine and Balluz (2011). 41

reported they had never been told they had a depressive disorder, and more than half (55.9%) reported that they were not currently taking medication or receiving treatment for a mental health condition.

Additionally, adults who reported they did not have someone they considered their personal doctor or healthcare provider were not as likely to report receiving services for a mental health condition, compared to adults who reported they did. Together, these findings indicate the need to improve identification and treatment of depression

in those with chronic non-psychiatric illnesses and reinforce the importance of efforts to increase the availability, accessibility, and continuity of treatment services, as well as the integration of behavioral health services in primary care settings. Such initiatives are particularly important in poor resource areas like Mississippi, which has limited availability and/or accessibility of physicians, and in particular, mental health professionals. 25,26

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We found that black adults and adults aged ≥70 years were half as likely to report receiving services for mental health conditions compared to white adults and 18-34-year-olds, respectively, even after controlling for employment and healthcare coverage status. Stigma, particularly among elderly adults27,28 and racial/ethnic differences in beliefs about the acceptability of different types of treatment and treatment provider preferences29, are factors warranting further study to inform outreach initiatives better.

Both evaluated need, as indicated by meeting criteria on the PHQ-8 for recent depression, and perceived need, as indicated by frequent mental distress, were significant predictors of receipt of treatment for a mental health condition. This indication of the significant role of perceived need and/or evaluated need in predicting mental health service use is consistent with other studies that used Andersen’s Behavioral Model of Health Services Use.13,30,31 Limitations of this study include different recall periods for recent depression symptoms and chronic medical illnesses. Both were also based on self-reported data which are subject to recall bias rather than on clinical confirmation.32,33 Responses to questions asking respondents if they had ever been told they had selected chronic illnesses might be more indicative of previous access to services than current conditions.34 The cross-sectional design did not permit analysis of the time of onset or severity of chronic non-psychiatric medical illnesses,34 the timing of associations between chronic non-psychiatric conditions and recent depressive symptoms,34,35 or conclusions about causation between variables.33,36 Additionally, the prevalence of depression and other chronic health conditions might be underestimated due to the exclusion of institutionalized adults.33,36 Depressive symptoms and mental health treatment might have been underreported because of stigma,32 and a telephone survey might not have reached all people with and without mental illness and persons in lower socio-economic groups, including homeless individuals.33,36 The optional Anxiety and Depression module was not administered to cellphone respondents in Mississippi’s 2011 BRFSS; therefore, this analysis was limited to landline respondents. Although telephone source was included among weighting variables, significant differences between cellphone and landline respondents on study variables was not included in the weighting methodology; therefore, responses to some questions might have been subject to mode effects.37

In summary, study results indicated that adults with chronic nonpsychiatric medical illnesses should be screened for depression with special outreach to adults with poor continuity of care, adults without healthcare coverage, black adults and elderly adults who appear at risk for not receiving mental health treatment. The prevalence of depression in those with selected medical illnesses also emphasizes the need to integrate behavioral health services into primary care settings further as individuals are less likely to go to specialty mental health service centers.38,39 Acknowledgments The authors declare no conflicts of interest and received no financial support for the research, authorship, and/or publication of this article.

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11. Kravitz RL, Ford DE. Introduction: chronic medical conditions and depression--the view from primary care. Am J Med. 2008;121(11 Suppl 2):S1-7.

12. Andersen RM. Revisiting the behavioral model and access to medical care: does it matter? J Health Soc Behav. Mar 1995;36(1):1-10.

13. Dhingra SS, Zack M, Strine T, Pearson WS, Balluz L. Determining prevalence and correlates of psychiatric treatment with Andersen’s Behavioral Model of Health Services Use. Psychiatr Serv. 2010;61(5):524-528.

14.

Centers for Disease Control and Prevention. BRFSS 2011 Survey Data and Documentation. 2013; http://www.cdc.gov/brfss/annual_data/annual_2011.htm.

Accessed July 17, 2016.

15. Centers for Disease Control and Prevention. 2011 Behavioral Risk Factor Surveillance System Questionnaire. January 27, 2011; http://www.cdc.gov/brfss/questionnaires/ pdf-ques/2011brfss.pdf.

16. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606-613.

17. Kroenke K, Spitzer RL. The PHQ-9: a new depression diagnostic and severity measure.

Psychiatric Annals. 2002;32(9):509-521.

18. Kroenke K, Strine TW, Spitzer RL, Williams JB, Berry JT, Mokdad AH. The PHQ-8 as a measure of current depression in the general population. J Affect Disord. 2009 Apr;114(1-3):163-73. doi: 10.1016/j.jad.2008.06.026. Epub 2008 Aug 27.

19. Allison PD. Logistic regression using SAS®: theory and application, second edition. Cary, NC: SAS Institute, Inc.; 2012.

20. Berglund PA. Analysis of survey data using the SAS® survey procedures: a primer. June 25, 2014; http://www.isr.umich.edu/src/smp/Berglund%20 Survey%20Data%20 Analysis%20WIILL%20June%202014.pdf. Accessed April 20, 2016.

21. Centers for Disease Control and Prevention. Task 3b: how to perform chi-square test using SAS®. NHANES dietary web tutorial: test hypotheses: task 3b 2016; http://www. cdc.gov/nchs/tutorials/Dietary/Basic/TestHypotheses/Task3b.htm. Accessed April 5, 2016.

22. SAS®. The SURVEYFREQ procedure, Rao-Scott chi-square test. SAS /STAT® 9.3 User’s Guide 2016; http://support.sas.com/documentation/cdl/en/statug/63962/HTML/ default/statug_surveyfreq_a0000000259.htm. Accessed April 5, 2016.

23. SAS® Institute Inc. 2015. SAS/STAT® 14.1 User's Guide. Cary, NC: SAS Institute, Inc. http://support.sas.com/documentation/onlinedoc/stat/141/statug.pdf. Accessed March 12, 2016.

24. Substance Abuse and Mental Health Services Administration. National Survey on Drug

Use and Health: comparison of 2009-2010 and 2010-2011 model-based prevalence estimates for adults aged 18 or older (50 states and the District of Columbia). 2016; http://www.samhsa.gov/data/sites/default/files/NSDUHStateEst2010-2011_ v2/279/AdultTabs/NSDUHsaeAdultTabs2011.pdf. Accessed May 23, 2016.

25. Health Resources and Services Administration. HRSA data warehouse. Data portal 2016; http://datawarehouse.hrsa.gov/tools/DataPortal.aspx. Accessed March 21, 2016.

26. Health Resources and Services Administration. Mental health HPSA designation criteria. 2013; http://bhpr.hrsa.gov/shortage/hpsas/designationcriteria/ mentalhealthhpsacriteria.html Accessed September 23, 2013.

27. Choi NG, Kimbell K. Depression care need among low-income older adults: views from aging service providers and family caregivers.Clin Gerontol. 2009;32:60-76.

28. Conner KO, Copeland VC, Grote NK, et al. Mental health treatment seeking among older adults with depression: the impact of stigma and race. Am J Geriatr Psychiatry.

2010;18(6):531-543.

29. Cooper LA, Gonzales JJ, Gallo JJ, et al. The acceptability of treatment for depression among African-American, Hispanic, and white primary care patients. Med Care.

2003;41(4):479-489.

30. Vasiliadis HM, Lesage, A., Adair, C. Wang, P.S., & Kessler, R.C. Do Canada and the United States differ in prevalence of depression and utilization of services. Psychiatr Serv.

2007;58: 63-71. doi:10.1176/appi.ps.58.1.63. Accessed September 23, 2013.

31. Fleury MJ, Grenier G, Bamvita JM, Perreault M, Kestens Y, Caron J. Comprehensive determinants of health service utilisation for mental health reasons in a Canadian catchment area. Int J Equity Health. 2012;11:20.

32. Norquist GS, Magruder K. Mental health epidemiology (psychiatric epidemiology). In: Heggenhougan K, ed. International Encyclopedia of Public Health. Oxford: Elsevier, Ltd.; 2008:97-106.

33. Fan AZ, Strine TW, Huang Y, et al. Self-rated depression and physician-diagnosed depression and anxiety in Florida adults: Behavioral Risk Factor Surveillance System, 2006. Prev Chronic Dis. 2009;6(1):A10.

34. Farr SL, Hayes DK, Bitsko RH, Bansil P, Dietz PM. Depression, diabetes, and chronic disease risk factors among U.S. women of reproductive age. Prev Chronic Dis. 2011;8(6):A119.

35. Fan AZ, Strine TW, Jiles R, Mokdad AH. Depression and anxiety associated with cardiovascular disease among persons aged 45 years and older in 38 states of the United States, 2006. Prev Med. 2008;46(5):445-450. doi: 10.1016/j.ypmed.2008.02.016. Epub 2008 Feb 20.

36. Strine TW, Mokdad AH, Balluz LS, et al. Depression and anxiety in the United States: findings from the 2006 Behavioral Risk Factor Surveillance System. Psychiatr Serv.

2008;59(12):1383-1390.

37. Link MW, Battaglia MP, Frankel MR, Osborn L, Mokdad AH. Reaching the U.S. cell phone generation: comparison of cell phone survey results with an ongoing landline telephone survey. Public Opin Q. 2007;71(5):814-839.

38. Regier DA, Narrow WE, Rae DS, Manderscheid RW, Locke BZ, Goodwin FK. The de facto US mental and addictive disorders service system. Epidemiologic catchment area prospective 1-year prevalence rates of disorders and services. Arch Gen Psychiatry.

1993;50(2):85-94.

39. Wang PS, Demler O, Olfson M, Pincus HA, Wells KB, Kessler RC. Changing profiles of service sectors used for mental health care in the United States. Am J Psychiatry.

2006;163(7):1187-1198.

40. Centers for Disease Control and Prevention. Self-reported frequent mental distress among adults--United States 1993-1996. MMWR Morb Mortal Wkly Rep. 1998 May 1;47(16):325-331. PMID: 9583900.

41. Dhingra SS, Kroenke K, Zack MM, Strine TW, Balluz LS. PHQ-8 Days: a measurement option for DSM-5 Major Depressive Disorder (MDD) severity. Popul Health Metr. 2011 Apr 28;9:11. doi: 10.1186/1478-7954-9-11. n

Author Information Retired from Mississippi Department of Mental Health. Board member, Mississippi Public Health Institute, and Magnolia Health Plan (Smith). Professor, Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta.

Chair, Patient-Centered Outcomes Research Institute (PCORI) Board of Governors (Norquist). Systems Manager, Office of Public Health Statistics, Vital Statistics Bureau, Mississippi State Department of Health, Jackson, at the time of writing; he has since retired (Johnson). BRFSS Coordinator, Office of Public Health Statistics, Vital Statistics Bureau, Mississippi State Department of Health, Jackson, at the time of writing; he has since retired (McAnally). Professor, Dental Hygiene, School of Dentistry, University of Mississippi Medical Center, Jackson (Sullivan). Professor and Director, Medical Student Education, Department of Psychiatry and Human Behavior, University of Mississippi Medical Center, Jackson (Paul).

Corresponding Author: Theresa A. Smith, MS, MEd, PhD; 5306 Kaywood Drive; Jackson, MS 39211. Ph: (601) 953-5002 (tessiehome@comcast.net).

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Immediate Past President Dr. Michael Mansour and 2019-2020 MSMA President Dr. J. Clay Hays, Jr.

Increasing Access to Health Care in Mississippi â&#x20AC;&#x201C; Understanding the Challenges and Possible Solutions Address of the President Michael Mansour, MD 2018-19 MSMA President

M

ississippi has the lowest life expectancy of all the states.

Many factors contribute to this statistic. The overall rate of death in Mississippians improved significantly in the past 20 years but remains lower than all the other states that have shown more progress. Mississippi leads the U.S. with the highest incidence per capita of non-communicable diseases. The social determinants of health play a significant role in the relative low life expectancy. Twentythree percent of the population smokes cigarettes contributing to the high incidence of heart attacks, strokes, lung disease, and cancer. The Mississippi Legislature has been unable to pass a tobacco tax of $1.50/ pack known to deter smoking. Many people are uninsured and do not qualify for Medicaid, lack adequate transportation to seek care outside

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their home community, and lack adequate access to proper nutrition and areas for physical activity. Mississippi has been unable to find a way to expand health care coverage to the working poor, considered to be those people making just above 138% of the Federal Poverty Level. This lack of expansion of access to health care has created many challenges for Mississippi. Many people continue to work to develop ways to improve health care coverage and outcomes for the most disadvantaged.

Medicaid has generally been a low-cost means of providing health care coverage. Risk-adjusted expenditures for adult and Medicaid beneficiaries are approximately 22% lower than expenditures for adults covered by private insurance.

The Affordable Care Act (ACA) ended Disproportionate Share Payments to rural hospitals intending for this difference in government subsidy to hospitals caring for the poorest patients to

be replaced by greater reimbursements with the expansion of health insurance through Medicaid.

Rural hospitals are facing a confluence of pressures. Rural hospitals see a higher percentage of self-pay patients. These hospitals and physicians have the same cost of electronic medical records, supplies and staff.

Many rural patients with insurance have high deductibles that they are unable to pay, resulting in an increase in severe debt for rural hospitals and physicians.

Uncompensated care exceeds hundreds of millions of dollars annually in Mississippi. Mississippi is among the states with the highest medical debt in the country due to the extensive need for healthcare services in a population without the ability to meet these financial obligations.1 Thirty-one of Mississippi’s 64 rural hospitals or 48% are at financial risk. There are 430 rural hospitals nationwide at high financial risk.

Many of these rural hospitals are essential to their communities.

Considering factors like the level of trauma care they can provide, geographic isolation, and hospital employee to county population, Mississippi has 19 of the 64 rural hospitals that are either moderately essential or critically essential to their areas.2 Flexibility that facilitates payment approaches designed to slow overall spending and improve outcomes may be an opportunity for bipartisan efforts that could benefit patients and taxpayers.

Discussions about Medicaid have often overlooked the role of chronic disease management, preventive health, and the role of long-term services. Almost half of Medicaid spending has misaligned with care and spending goals tending to favor nursing facilities and institutionalbased care over home and community-based services.

Integrated care models that allow patients to receive primary care and treatment for behavioral health conditions have improved patient outcomes, especially important for Medicaid populations who have a higher prevalence of mental health and substance abuse conditions than the general population. The greatest benefits to public health and the largest returns on the taxpayer dollar will come from an honest acknowledgment of the successes and weaknesses of the program and the pursuit of policies tailored to the realities of Medicaid and the populations it covers.

Medicaid spending on prescription drugs increased by 24% in 2014.

The Medicaid Drug Rebate Program designed to guarantee Medicaid a “best price” for prescription drugs has left states vulnerable to the excessive cost of brand-name drugs with little competition. The Rebate Program limits states’ flexibility to exclude low value drugs from formularies and provides no mechanism for states to negotiate lower prices.3 Medicaid expansion is a cornerstone of the Affordable Care Act (ACA). Arkansas enacted legislation to adopt a model whereby Medicaid funds could be used to buy private health plans sold through the new health insurance exchanges made possible by the ACA. Since 1965 Medicaid has authorized the Secretary of Health and Human

Services to use federal funds to pay insurance premiums in States that elect such an approach. Most states have developed Medicaid managed care systems that now cover 75% of beneficiaries.4 Thirty-seven states and the District of Columbia expanded Medicaid under the Affordable Care Act. Indiana was one of eight states that used Section 1115 waivers to modify the terms of expansion.

The Social Security Act Section 1115 waivers allow providers to experiment with approaches that do not adhere to Federal Medicaid guidelines. Indiana won approval from CMMS for its Healthy Indiana Plan (HIP 2.0) which expanded Medicaid eligibility to non-elderly non-disabled adults but with State-specific variations.5 As of February 2017, 16 states led by Republican governors had expanded Medicaid. Then-Governor of Indiana Mike Pence took his own approach to Medicaid expansion using private insurance, health savings accounts, and increased cost-sharing, among other policies.

The Healthy Indiana Plan (HIP) allows access to substance-abuse treatment and additional incentives for members to quit smoking, use chronic disease management programs and take part in voluntary job referral and training programs. Beneficiaries pay premiums as low as one dollar per month, get health savings accounts, and can lose their benefits if they miss payments. Seema Verma, the current Administrator of the Centers for Medicare and Medicaid Services, was the architect of the Indiana plan.

Medicaid expansion in Indiana is estimated to cost $1.5 billion but bring $8.6 billion in federal funding from 2018 to 2020.

If Indiana had not expanded coverage at all, the state would have missed out on $17.3 billion in federal funding in a decade from 2013 to 2022.6 Enrollees in the HIP 2.0 Plan can pay premiums to receive more generous benefits called HIP plus. The premiums are as low as one dollar per month for people with income in the 0% to 5% of the federal poverty level range, or in the form of contributions to a ”Personal Wellness and Responsibility” (POWER) health savings account.

Those who don’t pay premiums receive lesser benefit packages.

For enrollees with incomes between 101% and 138% of the federal poverty level, premiums are required to enroll in HIP 2.0. These premiums are capped at 2% of income. For enrollees at or below the poverty level, HIP Basic offers an alternative that does not require premiums.5 The HIP can include vision and dental coverage if members make monthly contributions of $1 to $28 to Personal Wellness and Responsibility or (POWER) accounts. This money is used for the first $2500 of medical expenses each year. Indiana pays the bulk of that $2500.

Anthem is one of three private insurers providing coverage under the Healthy Indiana Plan. Nearly 75% of Anthem’s Healthy Indiana members visited a dentist, and 65% sought vision care in the first three months of coverage.

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Recipients who make their contributions face no other healthcare costs. They can also lower their future contributions by getting recommended preventive care such as cancer screenings and checkups. State figures showed a 42% drop in emergency room use in 2015 among people who changed from traditional Medicaid to the HIP. Eighty percent of HIP members have used primary care at least once.7 States are responsible for covering 10% of the cost associated with Medicaid expansion beginning in 2020. A drafting mistake in the ACA allows people between 100% and 138% of the federal poverty level to receive subsidies to purchase private health insurance on insurance exchanges if they are ineligible for Medicaid. For these people the Federal government pays the entire cost of subsidizing private coverage. As a result, states save money for every beneficiary whom they can move from Medicaid into their expansion and subsidized health plans.8 Nearly 75,000,000 U.S. residents have health insurance through Medicaid. Benefits and programs vary by state in part due to Section 1115 waiver projects that are likely to assist in promoting the objectives of the Medicaid statute.

States wishing to implement experimental policies in their Medicaid programs must apply to the Centers for Medicare and Medicaid Services (CMMS) for a Section 1115 waiver, which lifts certain federal regulations for five years. Thirty-seven states had active Section 1115 waivers as of October 2018.

Foremost among these policies are community engagement requirements, which mandate that non-disabled, non-pregnant adults meet monthly quotas for time engaged in work, volunteer activities, or school to maintain Medicaid coverage.

Other proposed waiver terms include beneficiary premiums with coverage lockouts for people who do not pay premium surcharges for tobacco use, drug screening and asset testing for beneficiaries, expansion of substance use treatment, elimination of non-emergency medical transportation services, and incentives or benefits tied to engagement in healthy behaviors.

Many new Section 1115 waiver policies are controversial, but waiver policies are diffusing rapidly as states exchange ideas that should establish a knowledge base for Medicaid policy choices.9 Primary care companies around the country have demonstrated the ability to cut costs by managing chronic disease with team-based care with a focus on keeping chronically ill patients out of emergency rooms and hospitals. By having more frequent visits with these patients who average five chronic conditions, one primary care company has seen 50% fewer hospital admissions compared with standard primary care practice, 28% lower per member cost, and significantly higher use of evidence-based medicine. 10 Another model of providing and expanding health to disadvantaged patients has been through Community Health Centers (CHCs).

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to help gain control overgrowth and cost and help to preserve access to care for Medicaid recipients in view of many cash strapped states at that time contemplating deep Medicaid cuts.

To sustain CHCs and thereby preserve access to care for Medicaid beneficiaries and other low-income patients while gaining control over cost, CHCs and Academic Medical Partnerships were proposed.

The Community Health Center Academic Medical Partnerships or CHAMPS combines the subspecialistsâ&#x20AC;&#x2122; expertise, medical technology, and inpatient care of local Academic Medical Centers with the primary care expertise of CHCs. 11 The Mississippi Hospital Association is leading a more recent innovation. Mississippi Cares is a proposed public-private partnership between the State of Mississippi, Mississippi hospitals, Mississippi True and its plan members to reform the Medicaid payment and delivery models. Premiums for Mississippi True, a hospital-owned health plan, would be funded by plan members at $20 per member per month and by hospital investments. No state general funds would be needed to fund the premiums.

Mississippi Cares proposes to cover almost 300,000 adults who are not currently eligible for Medicaid. The proposed plan would be a public-private partnership between the State of Mississippi, Mississippi hospitals, Mississippi True and its plan members to reform the Medicaid payment and delivery models.

Under a special Medicaid waiver request, Mississippi hospitals would make an additional investment in the premiums needed to fund the insurance coverage through a hospital-owned provider-sponsored health plan, Mississippi True. Due to hospital and participant investment funding the needed 10% state share to match the 90% federal share, this plan will not cost the state any additional dollars.

Other leaders continue to propose innovative ways to increase access to health care. Congressman Michael Guest is sponsoring the physician pro bono care act of 2019. HR 856 would encourage physicians to provide pro bono healthcare to Medicaid and CHIP eligible individuals as well as allow physicians to take a single charitable tax deduction (32%) in place of administratively costly and complex Medicaid and CHIP reimbursement processes. The deduction would be based upon the value of the services based on Medicare rates or usual and customary fees in the state. The bill additionally provides liability coverage.

A Deloitte Survey 2018 of US Healthcare Consumers shows that most adult Medicaid beneficiaries own mobile technologies, use them for a variety of health purposes, and are interested in trying new digital health applications. One in five people in the United States is enrolled in Medicaid, and a number of mobile apps on the market are designed to meet diverse needs such as prescription refills, measure fitness, and health improvement goals, monitor glucose or mood, or receive reminders to take prescriptions. Fourteen percent of Medicaid patients lack digital technology, however, emphasizing the importance of maintaining non-digital tools and resources that keep the physicianpatient relationship at the center of healthcare delivery.12

Health care in Mississippi is at a crossroads. Mississippi is the only state with statewide networks providing rapid and lifesaving treatments for patients suffering trauma, heart attacks, or strokes. Many patients will be unable to rapidly access these services if Mississippi is unable to maintain its rural hospital network. Hospitals, physicians and the entire health care community are facing many challenges in the evolution of health care delivery. Shouldering the burden of caring for the uninsured and the underinsured is a responsibility that must be shared by Mississippi as a whole.

Many opportunities exist for Mississippi to do a better job of improving health care delivery and for improving the cost of health care while also improving the health of Mississippians.

The greatest benefit for patients and taxpayers will come from honest discussions of the problems Mississippi health care faces and the opportunities available to adequately address these problems. Those who put Mississippi’s interest first will address these health care issues with the highest sense of urgency. n References 1.

Mississippi Hospital Association. Mississippi Cares press release.

Mississippi Hospitals Offer Proposal, Mississippi Cares, to Reform Medicaid in State. https://mycarematters811958087.files.wordpress. com/2019/05/ms-cares-press-release.docx 2. Mississippi Today website: https://mississippitoday.org/2019/02/halfof-mississippians-rural-hospitals-at-risk-of-closing-report-says/.

3. McConnell KJ, Chernew ME. Controlling the cost of Medicaid. N Engl J Med. 2017;377(3):201-203.

4. Rosenbaum S, Somers BD. Using Medicaid to buy private health insurance – The great new experiment? N Engl J Med. 2013;369(1):7-9.

5. Indiana and the ACA’s Medicaid Expansion. Norris, L. Healthinsurance. org website. https://www.healthinsurance.org/indiana-medicaid/ 6. Sommers BD, Epstein AM. Red-State Medicaid expansion – Achilles’ heel of ACA repeal? N Engl J Med. 2017 Feb 9;376(6):e7. doi: 10.1056/ NEJMp1700156. Epub 2017 Jan 25.

7. “Indiana’s Medicaid Expansion Makes Poorest Pay - WebMD.” 24 Mar. 2016, https://www.webmd.com/health-insurance/news/20160324/ in-conservative-indiana-medicaid-expansion-makes-poorest-pay.

8. McIntyre A, Joseph AM, Bagley N. Small change, big consequences – partial Medicaid expansions under the ACA. N Engl J Med. 2017;377:1004-1006.

9. Underhill K, Venkataramani A, Volpp KG. Fulfilling states duty to evaluate Medicaid waivers. N Engl J Med. 2018;379:1985-1988.

10. https://www.ajmc.com/press-release/increasing-patient-contact-withdoctors-cut-medicare-advantage-costs-28-percent-iajmcisupreqsup-s 11. Community Health Centers: Opportunities and Challenges of Health Reform – issue brief. Menlo Park, CA: Kaiser Family Foundation, August 2010. Hackbarth G, Boccuti C. Transforming graduate medical to improve health care value. N Engl J Med. 2011;364:693-5.

12. Medicaid and Digital Health: Findings from the Deloitte 2018 Survey of U.S. Health Care Consumers. Mayerol M, Carroll W. www.deloitte. com/centerforhealthsolutions. n

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House of Delegates Board of Trustees Dr. W. Mark Horne (internal medicine, Laurel) was voted president-elect; he will take office in 2020. Dr. Joseph Austin (obgyn, Vicksburg) was named secretary/treasurer of the Association.

The elections were part of MSMA's 151st Annual Session held August 16-17 at the Westin in Jackson. Dr. Amy Woods (internal medicine, Byhalia) was elected to represent District 2 on the Board of Trustees. Drs. Jennifer Bryan (family medicine, Flowood)

and Lee Valentine (family medicine, Meridian) were re-elected to another three-year term as trustees for districts 4 and 5, respectively. Kandice Bailey was elected student trustee, and Dr. Chelsea Rick resident trustee. The 17-member Board of Trustees re-elected Dr. Jennifer Bryan as Chair. Dr. John Cross (internal medicine, Brandon) was elected Vice-Chair, and Dr. Steven Stogner (pulmonary medicine, Hattiesburg) was re-elected Secretary of the Board. n

2019-20 MSMA BOARD OF TRUSTEES – Seated l. to r. Mark Horne, MD, PRESIDENT-ELECT, Laurel; John Cross, MD, YPS, VICE CHAIR Board of Trustees; Jennifer Bryan, MD, District 4, CHAIR Board of Trustees; J. Clay Hays, Jr., MD, PRESIDENT, Jackson; and Steven Stogner, MD, District 6, SECRETARY, Board of Trustees. Standing l. to r.: Michael Mansour, MD, IMMEDIATE PAST PRESIDENT, Greenville; Rod Givens, MD, District 1 TRUSTEE, Greenville; Geri Weiland, MD, SPEAKER OF THE HOUSE, Vicksburg; Katherine Pannel, DO, District 3 TRUSTEE, Oxford; John Pappas, MD, District 8 TRUSTEE, Gulfport; Joseph Austin, MD, MSMA SECRETARY/TREASURER, Vicksburg; Kandice Bailey, STUDENT TRUSTEE, Jackson; Chelsea Rick, DO, RESIDENT/ FELLOW TRUSTEE, Tupelo; and Amy Woods, District 2 TRUSTEE, Holly Springs. Not pictured: J. Lee Valentine, DO, District 5 TRUSTEE, Meridian; Loretta Jackson-Williams, MD, District 4 TRUSTEE, Jackson.

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MSMA Annual Session Recap Summaries of the resolutions from the 151st Meeting of the MSMA House of Delegates are below: Ban Smoking in Public Places MSMAsupports legislation to ban smoking in public places, including vaping and e-cigarettes.

Raising the Minimum Legal Age for the sale and possession of Nicotine products to age 21 MSMA will advocate with the Mississippi legislature to raise the age to purchase nicotine products to 21 years.

Truth in Advertising and Transparency in Medical ID Badges MSMAwillsupport legislation and other avenues to strengthen Truth in Advertising laws and obtain standards for all medical personnel regarding medical ID badges.

Banning the Sale of Kratom MSMAwill advocate banning Kratom, a substance not currently illegal in Mississippi, but otherwise being abused for its opioid-like properties.

Maintaining the Board of Health Oversight of the Department of Health MSMAsupports the current structure of the Board of Health and the Department of Health and will work to maintain the process by which the State Health Officer and the Board members are selected and appointed.

Limitation on Sales of E-Cigarettes The Association will recommend the adoption of legislation to equate e-cigarettes with traditional cigarettes, including a prohibition on sales to minors and taxing such products as cigarettes.

Postpartum Medical Coverage MSMAwill work with the Medicaid Advisory Committee to recommend to Medicaid that the program be extended to women following delivery or involuntary miscarriage to facilitate healthy pregnancy spacing and reduce other risk factors.

Shortage of Graduate Medical Education (GME) Training Positions in Mississippi The Association will advocate for increased federal and state support for residency training in Mississippi and will work with the Office of Mississippi Physician Workforce to increase the number of residency positions in Mississippi.

Medical Marijuana The Board of Trusteeswill evaluate various policy positions on medical marijuana, including increasing medical research, adult-use marijuana, and standards of products.

Malpractice Insurance Coverage for Physicians Providing Medical Care to Athletes Outside of the US The Board of Trustees will study whether malpractice insurance carriers can insure physicians caring for athletes on foreign soil and across state lines and how to obtain such coverage.

Maintenance of Tort Reform The Board of Trustees will study the current language of tort reform laws to determine such lawsâ&#x20AC;&#x2122; effectiveness and relevance related to malpractice claims and decisions in Mississippi.

Ex Post Facto Laws The Board of Trustees will study private and public insurer practices of adopting rules and regulations that retroactively impact physician practice and reimbursement.

Doubling the Fine for Not Wearing a Seatbelt The Board of Trustees will study the impact of raising the fine for not wearing a seatbelt in Mississippi, including potential fine amounts and allocation of collected fines.

Initial Assessment and Treatment Recommendations by Specialists The Board of Trustees will ask a Committee to study the significance of the physician developing the diagnosis and treatment as the best practice of patient care, that ER patients should not be discharged without direct physician oversight, and how MSMA can work with the State Board of Medical Licensure to enforce this.

Climate Control in Prisons and Jails MSMA supports providing climate control to inmates in prisons and jails and will ask the AMA to study the same.

Financial Penalties for Delay of Reimbursement to Physicians The Board of Trustees will study timely payments for service of all insurance carriers in Mississippi and consider additional financial penalties for all insurance providers for delayed payments.

Early MMPAC Endorsements in Competitive Primaries MSMA will encourage MMPAC to delay endorsement of a candidate in a party primary when other candidates are significantly supported by physicians.

Rural Hospital and Rural Medical Practice Task Force MSMA will form a task force to study federal and state solutions to help physicians in private practice and hospitals in rural areas and report to the Board of Trustees for Action.

Remove Limit on Number of Reference Committee Members The MSMA Bylaws are amended to remove the cap on the number of MSMA members who can serve on a reference committee at the House of Delegates. n

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James C. Waites, MD, Leadership Award L to R below: Dr. Carlos Latorre received the Dr. James C. Waites Leadership Award presented by MSMA Board Chair Dr. Jennifer Bryan. The Dr. James C. Waites Leadership Award was instituted in 2001 to recognize the many contributions Dr. Waites made to his community and organized medicine. Each year the Board of Trustees selects one physician under the age of 50 who is an outstanding leader in organized medicine and community affairs.

A member of MSMA since 2011, Dr. Latorre is President of West Mississippi Medical Society. He also has served on multiple occasions as a delegate to MSMA’s Annual Session and is a graduate of MSMA’s Physician Leadership Academy.

Dr. Latorre is a board-certified family physician who lives in Vicksburg. He earned his medical degree at the University of Puerto Rico School of Medicine in 2008 and completed his residency at the University of Mississippi Medical Center in 2011 while serving as chief resident for the Department of Family Medicine.

He has a B.S. and M.S. in Geology from the University of Southern Mississippi and is a registered professional geologist in the state of Mississippi. n

MSMA Excellence in Health Promotion Award The Mississippi State Medical Association presented the Excellence in Health Promotion Award to Michaela Gibson Morris (above). This award recognizes an individual or entity for promoting public health and wellness through media or another unique and effective program.

Ms. Morris is a health care reporter with the Northeast Mississippi Daily Journal. She grew up in Louisiana and studied at Drake University.

In her series, “Will the Doctor Be In?” Ms. Morris examined the shortage of primary care physicians in the northeast region of rural Mississippi and focused on efforts to rebuild the primary care infrastructure. The Council on Public Information noted Ms. Gibson’s innovative reporting on health care helps the public understand important and complicated issues. From covering Medicaid to exposing air ambulance schemes, she keeps the public informed of local health promotions and keeps the pulse of medical professionals and doctors' directions, whether it is a new service or a new practice. She often explores medical topics in a personal manner like her features on recognizing BMI shortcomings, relating health paradoxes, and discovering alpha-gal syndrome.

As a health reporter, Ms. Morris has been diligent in covering healthrelated and medical communications to help move Mississippi in a healthier direction. n 306 VOL. 60 • NO. 9 • 2019

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Doctors of Distinction These physicians were honored as Doctors of Distinction as they completed training in the MSMA

Physician Leadership Academy. The MSMA Physician Leadership Academy was established as part of MSMAâ&#x20AC;&#x2122;s effort to ensure strong and sustainable physician leadership with organized medicine and to fill this gap by training physicians to become leaders in the healthcare team, in their profession, and in their communities. L to R: Kristen Crawford, MD; Katherine Pannel, DO; Sara Ball Robertson, MD; Geri Weiland, MD; Jennifer Bryan, MD; Michael Mansour, MD.

STAT Scholars The MSMA Student Advocacy Training (STAT) program was designed to encourage medical students to become

involved with organized medicine through advocacy, professional networking, and leadership training. Students completed six eligible activities during their medical school career and were recognized as STAT Scholars at the Annual Session of the Mississippi State Medical Association House of Delegates. L to R: William Buck, Bobby May, Ashley Noblin, Sara Parker, Kirby Parker, Candise Johnson, Elliott Taylor, Kaylie Bradshaw, Amanda Walker, Anna Bailey Britt, Niki Patel, Danielle Block, Josh Irby, Priyanka Parajuli.

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2019 MSMA Annual Session Election Results MSMA Officers

Associate Editor, Journal MSMA

President-Elect 2019-2020 W. Mark Horne

Philip Merideth 2019-2022

Secretary/Treasurer Joseph Austin Trustee, Dist. 2 2019-2022 Amy Woods

AMA Delegates

Trustee, Dist. 4 2019-2022 Jennifer Bryan

Jennifer Bryan

Trustee, Dist. 5 2019-2022 Lee Valentine

Sharon Douglas

Trustee, Resident 2019-2020 Chelsea Rick

J. Clay Hays, Jr.

Trustee, Student 2019-2020 Kandice Bailey Council on Accreditation 2019-2022 J.Anthony Cloy

AMA Alternate Delegates

Council on Accreditation 2019-2022 Jeremy Erwin

Randy Easterling

Council on Budget & Finance 2019-2022 Carlos Latorre

Katherine Pannel

Council on Budget & Finance 2019-2022 Chip Holbrook

Lee Voulters

Council on Constitution & Bylaws 2019-2022 Melissa Stephens Council on Constitution & Bylaws 2019-2022 Amanda Daho-Habeeb

AMA Work Team

Council on Constitution & Bylaws 2019-2022 Jon Corey Jackson

Thomas Joiner

Council on Constitution & Bylaws 2019-2022 Angela Wingfield

Lucius Lampton

Council on Ethical & Judicial Affairs 2019-2022 Jason Stacy

Jeffrey Morris

Council on Legislation, Dist. 1 2019-2022 Katherine Patterson

Jaleen Sims

Council on Legislation, Dist. 2 2019-2022 Ann C. Roberson

Christopher Wyatt

Council on Legislation, Dist. 3 2019-2022 Katherine Pannel Council on Legislation, Resident 2019-2020 Craig Moffett

MSMA Alliance Officers 2019-2020

Council on Legislation, Student 2019-2020 Elizabeth Wicks

President - Teresa Floyd, Hattiesburg

Council on Medical Education, Dist. 2 2019-2022 June Powell

President-Elect - Lauren Reed, Belden

Council on Medical Education, Dist. 4 2019-2022 John Vanderloo

Treasurer - Shannon Warnock, Ridgeland

Council on Medical Education, Dist. 5 2019-2022 Sarah Grabmiller

Secretary - Michele Mahaffey, Prentiss

Council on Medical Service, Dist. 4 2019-2022 Amy Hollman

VP Scholarship - Lisa Lippincott, Tupelo

Council on Medical Service, Dist. 5 2019-2022 Dee Dee Price

VP Legislation - Nancy Smith, McComb

Council on Medical Service, Resident 2019-2020 Johnny Lippincott

VP Heath Promotions - Mary Elizabeth Monaghan,

Council on Medical Service, Student 2019-2020 Hannah Wikoff

Council on Public Information, Dist. 1 2019-2022 Renia Dotson

VP Membership - Rebecca Martin, Madison

Council on Public Information, Dist. 2 2019-2022 Troy Cappleman

Immediate Past President - Joseph "Bo" Zimmerman,

Council on Public Information, Dist. 3 2019-2022 John R. Mitchell

308 VOL. 60 â&#x20AC;˘ NO. 9 â&#x20AC;˘ 2019

Tupelo

Jackson

Shine bright like a diamond with MMPAC’s newest exclusive diamond level.

These diamond level MMPAC members were pinned at annul session. L to R: Joe Austin, MD; Katherine Pannel, DO; Scott Hambleton, MD; Lee Voulters, MD; Randy Easterling, MD; Dan Edney, MD; Roderick Givens, MD; Claude Brunson, MD; Veronica Tassin, MD; Angela Wingfield, MD; Seger Morris, DO; J. Clay Hays, MD; and Patrice Harris, MD, AMA President- not a diamond member. If you have further questions about MMPAC's I.V. League or if you would like to be a part of this premium donor club, please contact David Roberts at 601-853-6733, ext. 310 or via email DRoberts@MMPAConline.com. Join or donate today at MMPAConline.com 2009 to 2019, helping to oversee the creation of the Two Mississippi Museums project, which included the creation of the Mississippi Civil Rights Museum and the new Museum of Mississippi History in Jackson.

Dr. Lampton Awarded MSMA Community Service Award Lucius “Luke” Lampton, MD, FAAFP of Magnolia, was awarded the prestigious MSMA Community Service Award. The MSMA Community Service Award recognizes a physician for significant participation in civic activities that improve the community. The award, presented by Council on Public Information Chair Dr. Stephen Beam (right), recognizes a physician who actively engages both in the practice of medicine and in community service.

As President of the South Pike Hospital Association since 2015, he has led the survival of his rural hospital Beacham Memorial Hospital of Magnolia, which remains open and operating. Dr. Lampton was named Citizen of the Year in 2017 by the McComb Enterprise-Journal for his work to save his local hospital. Dr. Lampton is leading the restoration of downtown Magnolia and Osyka. He restored the old Osyka bank building to serve as the public library of Osyka. He also led the preservation and restoration of the historic 1893 Magnolia Depot, which now serves as the city hall of Magnolia. Dr. Lampton recently served on the Mississippi Guardianship and Conservatorship Commission, which has updated and revised the state’s conservatorship laws. He serves on the Mississippi Rural Physician Scholarship Commission and the Office of the Mississippi Physician Workforce Commission.

Dr. Lampton also was the primary author and creator of “Images in Mississippi Medicine: A Photographic History of Medicine in Mississippi,” a 266-page book published in 2018 for the 150th Anniversary of the MSMA House of Delegates. He has been an editor of the Journal MSMA for the past twenty years and has published hundreds of articles on medicine and health care. Dr. Lampton has saved two prominent rural newspapers from closure, the Magnolia Gazette, established in 1872 in Magnolia, and the Hinds County Gazette, Dr. Lampton served as Chairman of the Board of Health from 2007established in 1843 in Raymond. He publishes both newspapers 2017 and was recently reappointed to another six-year term on the through his “Magnolia Gazette Publishing Company” as well as many board by Governor Bryant. For more than a decade, he served as President and Chairman of the Foundation of Mississippi History, from books with local, state, and regional interest. n

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U M M C

H O N O R S

D A Y

A W A R D S

Carl G. Evers, MD Award - Named for the former MSMA President elected to the AMA Council on Medical Education and UMMC Associate Dean of Academic Affairs, this award is given to medical students who excel in MSMA and AMA activities. MSMA President Dr. J. Clay Hays, Jr. presented the Evers awards to Mary Elizabeth Butts, William Madison Ross and Avani Kishor Patel.

Virginia Stansel Tolbert, MD Award – Awarded to medical students who have demonstrated superior scholarship and leadership in campus activities. MSMA President Dr. J. Clay Hays, Jr. presented the Tolbert Awards to Andrew Desrosiers and Kandice Bailey (not pictured).

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UMMC-SOM Honors Day Awards Additional awards given by MSMA and MACM were presented at the University of Mississippi School of Medicine 2019 Honors Day program held May 2, 2019.

Mockbee Named 2019 Robert S. Caldwell, MD Award Winner - Chelsea S. Mockbee, MD, a senior resident in the Department of Dermatology at the University of Mississippi Medical Center, was recognized recently with the Robert S. Caldwell, MD Award. Medical Assurance Company of Mississippi presents this award each year to the “top” resident at UMMC. Nominated by the faculty of the Department of Dermatology at UMMC, Dr. Mockbee was acknowledged for her knowledge of medicine and excellence in care as well as record documentation and leadership. Given each year in memory of the late Dr. Caldwell, a general surgeon from Tupelo, this award also recognizes those individuals that are considered to be an avid teacher of medical students and fellow residents.

Dr. Caldwell was instrumental in the founding of Medical Assurance Company of Mississippi and served on the Company’s first Board of Directors. n

L to R: Eric A. McVey, III, MD, Chairman of the MACM Board of Directors; Chelsea S. Mockbee, award recipient; Gerry Ann Houston, MD, Medical Director of MACM; and Robert T. Brodell, MD, Professor and Chair of the UMMC Department of Dermatology.

2018-19 Dr. Wallace Conerly Community Service Award – Given to medical students who exemplify the leadership qualities of the former Vice-Chancellor and Dean of the School of Medicine. Dr. Helen R. Turner presented the UMMC-SOM Award to Caitlin Renee Kutz.

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P R E S I D E N T ’ S

P A G E

Inaugural Address of the 152nd President

J. Clay Hays, Jr., MD Friday, August 16, 2019, Old Capitol Inn

G

ood evening ladies and gentlemen, and thank you for coming out tonight to be part of this celebration. It is quite an honor to serve as the 152nd President of the Mississippi State Medical Association. I look forward to representing the physicians of this great association, and hopefully I can continue the strong work of those who have gone before me.

So what’s my story? Well, it’s all about relationships.

Many of you have heard the term “gym rat” when a child has followed in their father’s footsteps as a coach, so I guess I would be considered a medicine mouse since I was born into a family of physicians.

My life started in Rochester, Minnesota, when my father was an internal medicine resident at the Mayo Clinic. We moved to Athens, Greece, where he served in the Air Force but ultimately landed back home here in Jackson, where I had a great childhood. My sister, Mary Preston Dubberly, and I had a loving and supportive home with two wonderful parents as great examples. My mother, the late Preston Hays, was a spitfire and was always into something. She would never take no for an answer whether it was in the Junior League of Jackson, bringing professional tennis to Jackson, publishing a newspaper that spotlighted SEC football games at Memorial Stadium, or making sure we had a wonderful Children’s Museum in our state. She was a very driven lady who expected nothing but success. Obviously, I still miss her, but many of her life lessons live on.

My mother’s father, Dr. Onnie P. Myers, was a urologist here in town. I don’t remember him very well as he died when I was young. However, I knew that my mother was very proud of him, and I knew that he worked hard. I’ve had the pleasure of seeing some of his patients, and it’s neat to hear their stories about how he treated them. I’m still reminded of him as I walk by his picture on the wall at St. Dominic’s, where he was chief of staff. I often wonder about what it must’ve been like when he started his practice of medicine.

Then there is my father, Dr. James C. Hays. He was one of the founding members of the Jackson Heart Clinic and is affectionately known by his friends and family, including grandchildren as Jimmy. Jimmy has influenced my life more than any other person in the world. I can still remember going on rounds with him at the hospital when I was very young. I would watch his every move. –How he would talk to

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J. Clay Hays, Jr., MD

the patients and their families. –How he would laugh with them and listen to their concerns. –How he would bark at the nurses but later apologize when he felt guilty for being so forceful! –How he would interact with other physicians and tell me that no other profession had more honorable people. He would give me advice and tell me what I should do and what I should not do. Basically, he was my hero and still is. You know I love you, Dad.

Like any other kid, I got to interact with other kids in my neighborhood. My best friends growing up were the Dye boys on Cherokee Drive. Hamp, Ford, and I were inseparable. Yes, this is the same Dr. Ford Dye in Oxford. We played the usual cowboys and indians, traded army men figures, and debated whether the Steelers were better than the Raiders. To me, Franco Harris is still one of the alltime greats after making the immaculate reception to beat the Raiders to go into the playoffs!

One of our favorite topics was to discuss our fathers and whose dad was better. The late Lt Governor Brad Dye was a very formidable figure. His ability to spit Red Man tobacco way across the room and hit a spittoon perfectly was a sight to be seen. Of course, my buddies and I had to try it when nobody was looking, but after getting sick for a few days, I decided tobacco was not for me.

As I mentioned, the Dye boys and I would enter into the “My Dad was better than your Dad” debate on multiple occasions. It would start off with something like Hamp saying, “My Dad’s from Coffeeville where they have the tallest trees and the greatest hills.” I would respond with “Well, my Dad’s from Hollandale where they have the greatest soil called sand loam. It comes from Deer Creek and is the finest soil in the whole wide world.” They would respond with “my Dad knows the Governor” to whit, and I would say “my Dad knows Archie Manning.

You know he’s from Drew,”(like Drew was some sort of metropolis akin to New York City).

“Well, my Dad is THE Lieutenant Governor, and he is the head of all of the Mississippi Senators.” This one always stumped me as I thought he must have been a professional baseball player until we went to his office at the Capitol, and then I knew the truth. Once I had that key piece of knowledge, I responded: “my Dad would bring people back to life after

Dr. J. Clay Hays, Jr., MD takes the oath of office as the 152nd MSMA President with his wife, Elizabeth, holding the Bible.

your Dad gave them a heart attack with all of those taxes.” Checkmate!

My family then moved to Honeysuckle Lane to live next door to my mother’s sister, Carlene Scanlon, and her family. My cousin, now surgeon Pat Scanlon, and I would spend many an afternoon playing sports, including football, basketball, and golf. Pat and I are still very close and actually practice together at St. Dominic. I am sure his uncle Jimmy played a role in shaping his career choice.

Next, I was off to college at Ole Miss, where I met my wife, Elizabeth.

I studied psychology and entered UMMC in 1987. We had a tremendous medical school class with multiple leaders including LouAnn Woodward, Mike McMullan, Mary Barazza Taylor and Rick Guynes, just to name a few. I will come back to them in a minute.

At the encouragement of my father, I started looking around at different medical centers in the country. I was able to spend time at the NIH in Bethesda, Maryland; the Brigham and Women’s Hospital in Boston, and residency in internal medicine at Mayo in Rochester. These are all great places, but just like the slogan at Ole Miss says, you may graduate from the University, but you never leave Ole Miss.

Pat Lehan was the Chief of Cardiology when I started my fellowship in 1994. He was the consummate fireball with a very, shall we say, colorful vocabulary. As many of you know, he believed in proper physical diagnosis and stressed to all the residents and fellows the importance

of looking at everything, including their fingernails, eyeballs, and earlobes. The man was intense, and everybody loved him. I can vividly remember having to make him walk up six flights of stairs to see the next consult so he would get winded and quit asking me so many questions! The guy was a legend and one of my heroes of the past.

Why did I tell you all of these stories and talk about all of these people?

Because relationships matter. I have told you my past to give you some idea who has shaped my life and the importance of family, friends, coworkers, and teachers. I am indebted to all of them.

So let’s talk about the present. Who are my role models in medicine today?

Let’s start with one of my partners, Dr. Rick Guynes. He is a man who believes in excellence. Rick and I began medical school together and have worked on various projects over the years. After going on a site visit to the Minneapolis Heart Institute, Rick championed the idea of creating our own Level 1 STEMI program, which reduced the time it took to properly treat a heart attack from 120 minutes to our current rate of 56 minutes. Rick, along with Dr. Harper Stone, worked with other cardiologists around the state including Dr. Thad Waites in Hattiesburg, Dr. Barry Bertolet in Tupelo, and Dr. Mike Mansour in Greenville to create the Mississippi Health Care Alliance, the 2nd STEMI Statewide network in the country. For years Rick has been the medical director for the Blues Marathon and actually treated patients

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on-site at the Boston Marathon bombing. He started the Magnolia Meltdown half marathon that occurs each spring and was the main driver in getting the Ornish cardiac rehab program to Mississippi. This guy bleeds health and wellness and is a tremendous role model for our community. To use one of his favorite words, Cheers!

Dr. Mike McMullan is no stranger to challenges. After literally breaking his neck after a mountain bike accident in Utah, Mike has come back stronger than ever. Now the Chief of Cardiology, Mike developed one of the first of its kind adult congenital heart programs in the country.

He also managed to finish multiple marathons, lead annual medical mission trips to Haiti, and mentor numerous medical students in his role as an advisor to the house of Evers. I believe Mike working with Dr. Mary Taylor, a pediatric cardiologist from our class and now Pediatrics chair, will build one of the finest comprehensive congenital heart programs in the nation. To quote Philippians 4:13, Mike and I both believe “I can do all things through him who strengthens me.” To Mike, I say, “Please be careful.”

Has anyone heard of Dr. LouAnn Woodward? LouAnn started with me, Rick, and Mike as M1s in 1987. I never in a million years would have thought that girl from Carroll County would have ever become the Vice-Chancellor at UMMC. But let me tell you, don’t ever underestimate her. She is absolutely driven to make all Mississippians healthier. I could not think of a better person to lead that institution.

Last week I had the pleasure of listening to her talk to the parents of all incoming M1s. Under her leadership, the M1 class boasts 170 students, making it the largest medical school class in the history of our state.

Students come from 95% of the underserved communities, and many are enrolled in the Rural Scholars program. The goal of this program promoted by MSMA will put primary care physicians back in all 82 counties. By the way, the Phil Bryant School of Medicine building is state of the art. UMMC is doing an outstanding job of training the next generation of physicians. Way to go, LouAnn! I am also excited about the job Dr. Jim Turner is doing down at William Carey in Hattiesburg. Dr. Turner has been a visionary in partnering with medical organizations around the state and nation. The Tradition Medical Center in south Mississippi, where William Carey University has partnered with the Cleveland Clinic, should be one of the best diabetes research centers in the country.

So why have I highlighted all of these people? Because of their leadership and ability to foster relationships has yielded tremendous results, sort of like a family. I consider them part of my family. The family of Medicine. The family of Mississippi Medicine. The family of Mississippi Medicine on a mission. Relationships matter.

So what is the mission of the Mississippi State Medical Association? I believe the mission of MSMA is to take care of the physicians who take care of Mississippi.

So how do we do that? Is it with education? Is it through advocacy? Is it through wellness? Is it by having a place to connect with each other? I think it is all of the above.

314 VOL. 60 • NO. 9 • 2019

In the area of education, MSMA continues to find ways to provide CME with programs like CME in the Sand, CME With the Saints, prescribing hours online and in person. We are also the accrediting body for many other statewide CME programs. Our staff of Becky Wells and Kim Mathis has done a tremendous job making sure everything is done just right.

In the area of Advocacy, MSMA is down at the Capitol every year, working with our legislature and elected officials on key pieces of legislation that are important to us. The Council on Legislation meets weekly during the legislative session and sends out regular updates to our members. The Doctor of the Day program provides you an opportunity to be in contact not only with your local legislators but also statewide officials. MSMA COO, David Roberts, is everywhere and continues to do a terrific job with our legislative agenda. We also meet with our national Senators and Representatives both at home and in Washington. This year we have worked with the AMA and other state organizations to develop our state scope of practice program, which you will hear more about. We believe that taking care of patients is now team-based, but like any team, there must be a leader. That leader needs to be a physician. There is no substitute for knowledge and experience, and no one has more knowledge and experience in the field of healthcare than a physician. Period.

If you have any interest in being Doctor of the Day, please see David. I also want to send a shout out to Garrett McInnis and Dr. Hugh Gamble and the work that they have done to build up our PAC. I understand that we may have set a record for funds raised this year. If you have not made your donation to MMPAC this year, please see Garrett.

What about physician wellness and taking care of each other? Dr. Scott Hambleton has done a masterful job with the Mississippi Physicians Health Program. It is one of the best in the nation, and we should be grateful to him and his staff as they work to help physicians get back on their feet when they are in need.

Mississippi is often mentioned in the national statistics as having some of the worst healthcare in the country. I would wholeheartedly disagree.

I think we have some of the best healthcare in the country. I think the public’s wellness is the problem. Mississippi is the only state that has a combined statewide network of STEMI, stroke, and trauma care in the country. This is something we should be proud of. This system was put together by dedicated physicians who put their health organizations aside so that lifesaving care could be provided to the patients.

Relationships matter.

So what about the general public’s wellness? What can we do to make the 2.9 million Mississippians healthier? First, we need to set an example.

We need to exercise, eat right, keep our weight in check, get our vaccines, don’t use tobacco products, don’t text and drive, and wear your seatbelt.

These things need to be visible to our patients and families. Just like our children, our patients watch us and see what we do. How many times have friends, family members, and patients said to you, “are you really going to eat that? “ I thought you said that wasn’t healthy.

I would also like to challenge you to get out and exercise in your community. Whether it’s in the health club, your neighborhood, or on one of the numerous multipurpose trail systems in our state, it’s important for the public to see you out and moving. To that end, I would like to encourage you. We will be putting together special technical running shirts and bike shirts for you to purchase soon. The front of the shirt will say #MSMA4Fitness and on the back will be our logo. Please wear these shirts when you exercise and tag them in a picture so we can post them on our social media.

Speaking of social media, we are definitely out there building relationships. Under the leadership of our board chair, Dr. Jennifer Bryan, the Physicians for Mississippi Facebook page is alive and well.

Jill Gordon has done a wonderful job marketing our association and all that it has to offer. As an example, the Women in Medicine program last night was a big hit.

So what about the future? What would I like to see? I want to see more engagement from physicians and the further development of relationships.

I would like us to continue the work of Dr. Michael Mansour and Dr. Ed Hill as we fight non-communicable diseases in our state. This will need to be done through our relationships with our elected officials, healthcare systems, public health department, insurance companies, media, and the public. I would also like us to engage our members at the local level better. Please invite your colleagues to the component society meetings. Don’t expect them to show up because a notice or an email was sent out. Call or text them and encourage them to be part of the conversation. Also, encourage your local members to send in articles to the Journal. Dr. Luke Lampton, Karen Evers, and the publications committee have updated the Journal to make it efficient and effective. I look forward to reading the next issues.

In closing, I would like to thank several organizations, friends, and family who have helped me tremendously in my life and career. First, I would like to thank the Lord for blessing me and giving me the opportunity to serve him and the people of Mississippi. Thank you Lord for my family and friends. Thank you, Lord, for Pastor Chip Stevens and First Baptist Church Jackson.

I would next like to thank the folks of Medical Assurance Company of Mississippi (MACM) for being a sponsor tonight and covering my malpractice insurance. Rob Jones and his staff do a wonderful job supporting the physicians of our state.

I would also like to thank MPCN, the American College of Cardiology, Central Medical Society, Origin Bank, and Blue Cross Blue Shield for sponsoring tonight’s event.

Next I would like to thank all of the people I have met over the many years at State Medical. There are so many to name, and if I leave someone out, please forgive me. I want to thank Dr. Jim Fuller for getting me into the organization and starting the YPS CME in the Sand. I want to thank Charmain Kanosky for her help when I was

board chair. -All of the past presidents who inspired me when I was just getting started in the organization, including but not limited to Dr. Ed Hill, Dr. Steve Parvin, Dr. Mike Carter, Dr. Eric Lindstrom, Dr. Tom Joiner and Dr. Jim Rish. I would like to thank Dr. Dan Edney for being a mentor and always pushing me forward. -Dr. Tim Alford for inspiring me, challenging me, and debating me on numerous topics related to medicine, education, and fitness. -Dr. Randy Easterling for providing me with words of encouragement, support, and how to deal with Paul Gallo on the radio. -Dr. Steve Demetropoulos for his dedication and determination to fight tobacco and all the ill effects of tobacco. -Dr. Lee Voulters and Dr. Bill Grantham for their wise counsel during times of stress, and of course, Dr. Michael Mansour for being such a great statesman for our organization.

Next I would like to thank Dr. Jennifer Bryan and all of the trustees of the Board, both past and present, the Mississippi AMA delegation, both past and present, as well as all of the staff at MSMA, both past and present. Without you, this organization would be nothing. I want to thank Dr. Claude Brunson. You are doing a great job leading the association forward!

I want to thank the folks at St Dominic Hospital. The physicians, nurses, staff, and administration have been a pleasure to work with.

Next, I want to thank my Jackson Heart Family. My medical assistant, Rosie Allen, and my nurse, Tina Morgan, for keeping me straight and focused. Our CEO, Stephanie Carr, for keeping us all in line. Our marketing director, Lizzy Lacoste, with promoting our crazy ideas. I definitely want to thank all of my partners and staff both past and present for your support. You do a tremendous job taking care of our patients and helping me with my call schedule. Just one more year, guys!

Finally, I want to thank my family. I want to thank my in-laws, Gale and Bob Drummond, and my sister in law, Kathleen May. Thanks go out to my extended family for being here tonight- cousin, Cissy Scanlon, aunt, Carlene Scanlon, cousin and his wife, Pat, and Mary Schiele Scanlon.

Thank you to my parents, Jimmy Hays and Margaret Hays. My son, Tyler, and his fiancée, Catherine. My son, Wilson, and finally, my beautiful wife, Elizabeth. I love you all.

May God continue to bless our Association, our patients, Mississippi, and the United States of America!

Thank you. n

J. Clay Hays, MD President, Mississippi State Medical Association

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HALL, JAMES, Oxford, Cardiovascular Disease ISIKALU, OLUSOLA, Pascagoula, Nephrology JOHNSON, WILLIAM, Jackson, Orthopedic Surgery KOURY, MICHAEL, Oxford, Emergency Medicine LAMAR, DAVID, Jackson, Diagnostic Radiology

Welcoming our Newest Members

MILLER, VANESSA, Amory, Obstetrics & Gynecology

ALLRED, LINDSEY, Jackson, Radiology

NICHOLAS, KATHRYN, Jackson, Radiology

ATCHLEY, LANCE, Starkville, Anesthesiology ATKINS, JENNIFER, Lucedale, Pediatrics

MA, JING-YUAN, Jackson, Cardiovascular Disease MYERS, PHILIP, Gulfport, Orthopedic Surgery PAINE, ELIZABETH, Jackson, Gastroenterology PATIL, SACHIN, Laurel, General Surgery PAYNE, ANGELA, Starkville, Family Medicine

BESSA CAMPELO BRAGA FIALHO, ANDREA, Laurel, Gastroenterology

PHILLIPS, EARL, Southaven, Orthopedic Surgery

BROWNING, JOHN, West Point, Emergency Medicine

SMITHHART, WILLIAM, Flowood, Neonatology

BUTLER, JAVED, Jackson, Cardiovascular Disease

SPEED, JULIUS, Hattiesburg, Family Medicine

CARDEN, NICOLE, Petal, Pediatrics

STEELE, JANEE, West Point, Family Medicine

CLARK, BARRY, Tupelo, Orthopedic Surgery

SWANSON, CHARLES, Corinth, Internal Medicine

FAGAN, BRYAN, Tupelo, Orthopedic Surgery

TASAN, EDIZ, Ocean Springs, Cardiovascular Disease

FERGUSON, JAMES, Hattiesburg, Obstetrics & Gynecology

WEILAND, DAVID, Jackson, Pediatric Cardiology

GLENN, CLYDE, Madison, Psychiatry

WILLIAMS, NILDA, Laurel, Diagnostic Radiology

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• HR • Payroll • Benefits Phone Toll Free 877-759-5765 www.MWGEmployerServices.com Offices in Jackson and Oxford, MS, and Madisonville, LA

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M I S S I S S I P P I

S T A T E

D E P A R T M E N T

O F

H E A L T H

Mississippi Mississippi

Mississippi Provisional ReportableDisease Disease Statistics* Provisional Reportable Statistics Provisional Reportable Disease Statistics* February 2018 August 2019 August 2019 *Monthly statistics are provisional. Disease totals may change depending on additional reporting from healthcare providers and public health investigation. These numbers do not reflect the final case *Monthly statistics arecounts. provisional. Disease totals may change depending on additional reporting

from healthcare providers and public health investigation. These numbers do not reflect the final case Public State Health District Totals* counts.

I

Sexually Transmitted Diseases

Primary & Secondary Syphilis

Gonorrhea Chlamydia

10

Vaccine Preventable Diseases

Mycobacterial Diseases

Pulmonary Tuberculosis (TB)

8

3

6

6

Pertussis

3

0

0

0

0

0

2

1

3

0

0

0

Tetanus

Poliomyelitis

Hepatitis B (acute)

0

2

0

Invasive H. influenzae disease

Tetanus

0 0 0 Invasive Meningococcal disease

Poliomyelitis

Hepatitis A (acute)

Measles

Salmonellosis

0

Enteric Diseases

0

0

6

0

0

Campylobacteriosis

362 3 8

0

3

4

3

6

50

YTD

50

72

YTD

37

34

95

5

1

9

99

739

77

616

9572 1

2221 117 6

209 0

0 305 4

2,340 2,041 16,94445 14,947 3 44 81 24

0 11 0

04

0

00

0 0

0

0

0

01

0

00

0

0

0

1

2

1

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3

6

0

0

0

0 0

1 0

00

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9

0

40

40

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0 1

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2 0

0

0

0

410

00

0

4

4

0

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9

08

2

0

450 00

0

0

0

0

0

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2 2

2

3

846 0 052 5 0

3

03

07,7720

3

6,521 0

0 333 0

3610

34

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8 0

80

023

0 219 0

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6

37

5 1

2

40

0

160

33

5

0

13

40

7 31

0 6 21

01

10

30

14

0

01

0

7

00

0

38

078

44

20 75

24

3

57

0

0

0

0

2

1

0

01

0

0

0

00

00

00

0

0

0

20

02

0

47

0

490

0

00

0

0

0

00

00

00

0

0

0

00

01

0

3

0

10

0

0

0

5

14

1

00

Rocky Mountain spotted fever

0

0

West Nile virus

0

0

0

0

0 0

0 0

0 0

00

0

0

0

0

4

0 0

0 0

4 6of Corrections 19 and8 those not 3 reported 10 from11 Totals include 9 reports36 from Department a specific106 District.

*

39

05

40

0

7

August

603 954 2018 52720191274 2018 1,529 859 2,842 1,633 42 387 289

171 0 0

0

2

16

4

August

304

Invasive Meningococcal disease

2

0

29

Lyme disease

3

4

56 82 VIII 21 IX 60 2019 133 68 175 196 10 10 59

43

60

Animal Rabies (bats)

0

0

3 131 VII

31

1

Invasive H. influenzae disease

0

0

11

0 2 0 E. coli O157:H7/STEC/HUS 1

1

YTD 2017

2

Hepatitis B (acute)

0

5

YTD 2018

1,222 0

2

0

2

1

Feb 2017

State 13 Totals* 20

0 203 0

0

0

1

Feb 2018

1

0

1

IX

1

0

0

4

3

VIII

135 0

10

0

14

2

VII

590

00

0

2

VI

1020

0

Shigellosis

1

V

0265 0

286

Mumps

Salmonellosis

1

256 202

Diphtheria

Mumps

5

93 0

2

1

69 V 66 VI57 175 139 3 12 155 4126

119

Diphtheria

IV

61 IV

137 109

Measles

Zoonotic Diseases

Vaccine Preventable Diseases

4

Extrapulmonary TB

Mycobacteria Other Than TB

Hepatitis A (acute) Enteric Diseases

III

Pulmonary Tuberculosis (TB)

7

Pertussis

Zoonotic Diseases

II

Mycobacteria Other Than TB

HIV Disease

Extrapulmonary TB

5

Chlamydia HIV Disease

Early Latent Syphilis Mycobacterial Diseases

Sexually Transmitted Diseases

Primary & Secondary Syphilis

Gonorrhea I

III

Public 0 Health 3 District 0 2

1

Early Latent Syphilis

II

14

0 0

164

3 0

44 679

1 0

7

10

0

695

Shigellosis

0

0

0

0

2

0

0

0

1

3

29

114

163

Campylobacteriosis

8

7

7

0

6

3

1

3

8

43

48

424

415

E. coli O157:H7/STEC/HUS

1

1

0

0

0

0

1

1

0

4

15

57

88

Animal Rabies (bats)

0

0

0

0

0

0

0

0

0

0

0

1

4

Lyme disease

0

0

0

0

1

0

0

0

0

1

1

2

4

Rocky Mountain spotted fever

0

1

0

2

1

2

2

1

0

9

24

94

128

6

15

11

37

0 0 0 0 1 1 1 3 0 West Nile virus *Totals include reports from Department of Corrections and those not reported from a specific District.

SEPTEMBER â&#x20AC;˘ JOURNAL MSMA

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SOUTHERN SURGICAL ASSOCIATION MEETING, DECEMBER 1936, HELD AT EDGEWATER PARK AT THE EDGEWATER GULF HOTEL — This panoramic photograph features the 49th Annual Session (or meeting) of the Southern Surgical Association held at the famous Edgewater Gulf Hotel at the community of Edgewater Park, Mississippi, which met from December 15-17, 1936.

Among the icons of surgery of the South in attendance are such men as the legendary Rudolph Matas, MD (1860-1957) of New Orleans (white beard, front row, twelve from the left), whom many consider the “Father of Vascular Surgery” (including Sir William Osler); the highly regarded surgeon of Greenville Hugh A. Gamble, MD (second row, fourth from left); and Harley Roseborough Shands, MD (back row, 16th from left) of Jackson, one of the founders of Jackson’s Mississippi Baptist Hospital as well as one of the most respected surgeons in the state. [For more on Shands and the founding of Baptist, see Lampton, L. “Mississippi Baptist Hospital, Jackson, 1914,” JMSMA. January 2019 (60:1), page 34].

The Southern Surgical Association was founded in 1887 by brothers W. E. B. Davis and J. D. S. Davis in Birmingham, Alabama. Originally, the association was called the Alabama Surgical and Gynecological Association, but it was soon renamed the Southern Surgical and Gynecological Association. By 1916, the gynecological distinction was dropped due to the association's expanded focus on the entire field of surgery. Featuring an etching on its official seal of the famous “father of ovariotomy” and abdominal surgery Dr. Ephraim McDowell of Kentucky, the association still meets annually in December, with the 131st Annual Meeting to occur December 8-11, 2019 at the Homestead in Hot Springs, VA. This photograph originally belonged to Dr. Harley R. Shands. It was gifted to Dr. Ralph Didlake by Shands’s granddaughter Susan Shands Jones of Jackson. “My Dad (Wilbourn Coupery “Coup” Shands), who kept this picture in his home office and also was an active member of the Southern Surgical Association, told me it was the only time the group met in Mississippi. They changed and began going to the Homestead in the fall and Florida in the spring,” she relates. The Edgewater Gulf Hotel stated on its stationery that it was located “Midway between Gulfport and Biloxi” at the community of Edgewater Park. This community was actually a western subdivision of Biloxi established during the 1930s and named after the hotel. The community had its own train station and post office and used the address of “Edgewater Park.” The elegant resort, which had a modernist exterior with a central tower of Moorish design, was opened in 1926 and operated as one of the queen hotel establishments on the Mississippi Coast until it closed in 1970, soon to be imploded and replaced by an addition to the present-day Edgewater Mall Shopping Center. The hotel was the largest on the coast during its era and was built by the owners of Chicago’s Edgewater Beach Hotel, who chose as their architects the famous Marshall and Fox. The fireproof structure was designed to allow 95 percent of its 400 rooms to have a view of the Mississippi Sound. Its 600 acres included expansive gardens, gourmet dining, tennis courts, a golf course, and a glass-enclosed swimming pool. The famous lounge featured a conical fireplace open on all sides. Due to its size, the hotel was a popular meeting place for many national and state organizations.

318 VOL. 60 • NO. 9 • 2019

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I would like to thank Susan Shands Jones, Dr. Didlake, and Pamela C. Steadman, Executive Assistant to Dr. Didlake, for their assistance in sharing and researching this important photograph. If you recognize any other of the surgeons in this image, let me know. If you have an old or even somewhat recent photograph or image which would be of interest to Mississippi physicians, please send it to me at lukelampton@cableone. net or by snail mail to the Journal. n msbrp Baron 58 ad V3.pdf 1 6/18/2019 7:41:30 AM 41133 — Lucius M. “Luke” Lampton, MD; JMSMA Editor

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Edited by Lucius Lampton, MD; JMSMA Editor [This month, I continue a multi-issue focus on the poetry of the late physician-poet Merrill Moore, MD (1903-1957), a noted American psychiatrist and neurologist who also achieved fame as a poet and sonneteer. This poem’s subject is poetry itself rather than medicine, but it seems to embody clearly a physician’s view of the “meeting ground” of poetry. As a physician, Moore sees the almost medicinal effects of the tonic of poetry for the minds of men and women. “Poems stimulate the minds of men/ To think and rise and rise and think again” upon the “daily dear or commonplace,” he writes. And he asserts further than what one sees in them often depends on the reader and his personal perspectives and experience. This poem is from “M: One Thousand Autobiographical Sonnets” published in 1938 (see page 171). The tome includes a memorable frontispiece engraving by Rockwell Kent. I encourage you to find a copy for your bookshelf in an antiquarian bookstore, at Lemuria or Square Books, or via the internet. Any physician is invited to submit poems for publication in the Journal either by email at lukelampton@cableone.net or regular mail to the Journal, attention: Dr. Lampton.] — Ed.

Poems are Stimulants Poems are stimulants like alcohol Or tonics that are administered in the fall.

Poems stimulate the minds of men To think and rise and rise and think again Upon the daily dear or commonplace, The window passed at evening, the face….

What you see and what I see in them Wander from the sharp into the dim Confines of what I think and what you think, What I eat and what you have to drink….

Poems can afford a meeting ground Of common thought as safe as it is sound At times; at other times, a poem is An index to a book of histories.

— Merrill Moore, MD (1903-1957)

320 VOL. 60 • NO. 9 • 2019

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