NC Pediatric Society Fall Open Forum 2010

Those of us who had the privilege of sleeping at the Sheraton Imperial Hotel Durham awoke this morning at 5:30 to a shrill repeated whooping sound that could only mean one of two things. Either someone had pulled the fire alarm, or we were under attack from the Klingons. I rolled over, fumbled with my phone, brushed my teeth, and armed the photon torpedoes. Being on the ninth floor I figured I had time to pack up the MacBook before heading for the stairs, but thankfully the whooping stopped and an apologetic voice came over the loudspeakers to let us know we could go back to sleep. I did so until 6:30, when I put on sneakers and ventured downstairs to discover the only workout facility is the Gold's Gym next door. It would seem having a whole professional gymnasium is far better than having one rickety treadmill and an old Universal stack, but it's only better if it opens before 8:00 AM, which this one does not. So it was back up nine floors to brew the Starbucks sachet in the room and wonder aloud who thinks a cup of coffee that size needs only two tiny creamers. I should have taken advantage of the fire alarm to beg the other guests for their cream. Or maybe that's what they used to put out the fire.

Karen Breach, Laura Gerald, and John Rusher

Former AAP President David Tayloe of Goldsboro Pediatrics talks with Gordon Coleman of the Practice Formerly Known As The Children's Clinic. This is a little Wilmington inside joke, as Wilmington Health Associates recently re-named the venerable pediatric practice. Those in the community now know it as

Executive Director Steve Shore makes last minute preparations.

Introductions from NCPS President Karen Breach, MD and Executive Director Steve Shore

In a tradition that extends to the first NCPS Open Forum, held in a cave, we all pass around the microphone and introduce ourselves.

Brandon Rector, NC Immunization Program

Vaccine Update

• As of yesterday 92% of flu vaccine has been shipped to providers' offices
• By now everyone should have received at least half of their ordered flu vaccine
• Syringes are coming in a little slower than usual, also the Sanofi multiple-dose vials
• Multiple-dose vials should be in offices by Tuesday
• Provider agreements are coming out earlier than usual this year, please return those so site visits can start happening.
• Next week the holiday shipping schedule will be out. Order by November 12th for delivery by Thanksgiving, also varicella and MMRV won't be shipped if ordered after that date until 2011. These are the frozen ones.
• The immunization branch will be covering vaccines for college freshmen and TDaP for your office staff with the little leftover money from the old Universal Vaccine program.
• The branch will now allow providers to order whatever brand of vaccines they prefer when a choice is available.
• NC has had over 100 pertussis cases so far.
• There is a new screen from NCIR for mass vaccinations to make entry easier. Call the branch to have that feature activated if you need it for something Iike a flu clinic.
• Doctors in the room seem to perceive a fall off in patient demand for flu vaccine.
• People still seem to fear the H1N1 vaccine.
• Dr. Tayloe asks if Medicaid will cover TDaP for post-partum mothers and their partners. Yes for moms, no for dads.
• If your insurers are not reimbursing vaccines adequately then send a letter to Dr. Tayloe or Dr. Graham Barden. The AAP Department Of Insurance is fighting these issues as they come up.
• Immunization Branch ships flu vaccine to practices pretty much the same day it arrives in their offices.
• Per Dr. Barden there are two national distribution centers, all flu vaccine east of the Mississippi comes from Memphis, and our shipments seem to lag compared to the Western states' whose shipments come from Sacramento.
• CDC now recommends a booster of meningococcal vaccine at age 16

Gerri Mattson, Jane Foy

Gerri Mattson, MD, MPH

NC Division of Public Health

• We now have a $2.1 million grant for home visiting programs for mothers, infants and children.
• Hope to implement in 2011, but still awaiting guidance on implementation
• LAUNCH: Linking action to unmet needs in child health. Address social and emotional needs of children ages birth to 8 years. This program is also in the development stage, but it should offer support for screening services in pediatric offices.
• Innovative Approaches Projects are building care systems for youth with special healthcare needs, partnering with local health departments and service providers in four counties in the state.
• Child Service Coordination being redesigned to provide a children's care management system. Partnership with NCPS, NCAFP, department of medical assistance.
• Kindergarten Health Assessment (does NOT have to be blue!). We are now looking at using this form to collect and track health information about kindergarten aged children in North Carolina. 0.5% listed obesity as a problem on the form, 13% were actually obese by BMI.
• Early Hearing Detection and Inteverntion. There are notebooks for intervention that are supposed to be sent to providers who diagnose a child with hearing loss. If you have not gotten this when you should have, please call. Once a child is diagnosed the state steps in and mobilizes a number of services for the child. A tele-audiology pilot is now being tested.
• Alice Lenihan with WIC has passed out surveys to help make recommendations to the NC General Assembly about nutritional standards in child care facilities. Email her with your thoughts at alice.lenihan@dhhs.nc.gov.
• Cynthia from UNC metabolic and genetics clinic notes that reimbursement for special formulas for children with metabolic disorders is woefully inadequate.
• Alice Lenihan replies that if you have a child with a metabolic disorder on Medicaid contact the division of public health for assistance. They are aware and working on this problem.

Alice Lenihan

Jane Foy, MD

District Vice Chair, District IV

• Academy has a new informatics center. The director is hoping to acquire stories from pediatricians about problems we have had with our EMR's.
• Affordable Care Act need funding for pediatric specialty training.
• New AAP priorities are early brain and child development, foster care for the coming year.
• Mental Health Toolkit available from the Academy. Made with no PHRMA money at all. There is a practice readiness inventory. You can click on any item in the inventory and find resources to help your practice achieve that particular goal. There are also algorithms for incorporating mental health services at every phase of your practice. There is also coding guidance for every step in the algorithm. The toolkit takes seven commonly presenting symptom clusters and provides evidence based guidance on what you can do for these patients in a primary care environment.

Karen Breach, MD returns to the floor for a brief business meeting.

Introduction of Executive Committee

• NCPS has fallen behind on budget, has not raised dues in five years and has fallen well behind the consumer price index, will likely need a small increase this year.
• Bylaws are being updated, will be up for a vote at the Winter Open Forum, will be on website for review prior to that meeting.
• Our lobbyists are working to prevent pharmacists from delivering vaccines to children down to age seven, which would severely disrupt the Patient Centered Medical Home as many children would never come in for wellness exams.
• This coming election is likely to have a large impact on pediatricians and children, please vote.

Dr. David Tayloe

Healthcare Reform Update

• Your NCPS dues are your best investment. Our success in keeping Medicaid payments close to Medicare has made North Carolina one of the best states in the country to care for all children.
• There is a law on the books that requires Medicaid payments to be the same as Medicare, and we may have to bring that law to bear in the near future to protect access for children.
• AAP priorities for health care reform are Coverage, Benefits, and Access. Getting Bright Futures guidelines written into the law was an enormous victory for children and the Academy.
• CHIPRA reauthorization was a huge victory. It gives us the opportunity to ensure Children's access to care for a long time.
• Today's focus is on the Affordable Care Act. This is where we are still learning. Feel free to call the Academy for help (see website).
• Go to members only channel at aap.org for the State Heath-State Implementation of the Affordable Care Act.
• Joining the Section On Administration And Practice Management (SOAPM) can make a lot of advice and resources available.
• What is a heath insurance exchange? A large insurance pool composed of many small businesses with 100 or fewer employees. Families in these exchanges may be liable for up to $10,000 in out of pocket expenses. States may abandon CHIP once they do this it may be very difficult for families with children with special needs.
• There will be an adult version of CHIP. There will also be a public co-op eventually, still being designed.
• Most important for us is first dollar coverage for preventive heath services. This already went into effect in September, for non grandfathered plans. The danger here is that insurers will not let us collect co pays but will not increase their payment buy the value of the co pay.
• Medicaid will expand to include also adults under 133% of poverty level in 2014.
• Federal government will take over much of Medicaid burden from the states.
• Medicaid payments will go up to be the equal of Medicare in 2013-2014.
• We're going to have to fight to keep CHIP being funded.
• Hospitals are worried money they get now for uninsured patients (DISH) will go away once everyone is insured, not sure they'll come out on the positive.
• Recovery Audit Contractors will be strengthened, which may be bad for us if it continues as it has, every five years. New plan is to look for outliers and audit those offices.
• We are working on what it would look like in North Carolina to have a pediatric Accountable Care Organization. Our model needs to be different from the adult model, need to be measured on wellness provision, not management of chronic disease. Why this is not just the HMO model all over again has to do with quality of care measures, but there is some danger of repeating the same mistakes.
• Center for Medicaid and Medicaid Innovation is starting up to serve as a think tank on how we implement.
• Patients Bill Of Rights. Gives states the teeth they need to monitor the insurance plans.
• Medical malpractice has a pittance of money to investigate how to reform the tort system, but Obama is opposed to caps on malpractice, even though those are the only items that seem to really decrease the cost of malpractice insurance.
• Early Childhood Visiting Program. Evidence based programs to assist at risk children. Check with Gerri Matson on whether a program yet exists in your county.
• Prevention And Public Health Fund
• Office of Health Insurance Consumer Assistance. This puts a human in every state to help patients who have complaints about their insurance programs.
• School based health centers. Pays for bricks and mortar, not for staff.
• Community Transformation Grants. Supports evidence based community level programs to improve health.
• Graham Barden, MD reminds us that if the Sustainable Growth Rate does not get fixed it could lead to a 30% reduction in Medicare payments next year, which, if our rates are tied to Medicare, could be devastating. Dr. Tayloe replies that the AMA is hoping to do away with the SGR altogether. Nothing in the reform bill so far helps insure that health care costs will fall.
• Critical Access Behavioral Healthcare Agency (CABA) encourages mental health providers to cluster in larger organizations. This should be a good trend. medical homes could step in and serve this role if they choose.

Sarah Armstrong, MD and Sheree Vodicka, MA, RD, LDN

Childhood Obesity Overview, Clinical and Community Resources

Sarah Armstrong

• Obesity increased from 5% in the 1960s to 17% now. Children in poverty, African American girls and Hispanic boys at greatest risk, although in some groups poverty is not a risk factor.
• Rates are at least stable since around 2003, except among very obese boys and a couple of small subgroups. Are we as fat as we can get?
• We now call BMI over 85% overweight, over 95% obese. Should probably carve out over 99% as a special group, but have not yet done so.
• Huge barrier is the belief that education will not work even if you had time to do it in your clinic.
• Diabetes prevention program and Look AHEAD studies have shown that lifestyle modification really does work, in adults.
• TODAY trial showed adding lifestyle change to metformin does work.
• HEALTHY trial (not an acronym). Here school based intervention didn't move BMI but did improve comorbidities.
• Younger patients do better with lifestyle modification than older patients. Important to focus on the parent, especially with younger children.
• There are four stages of management. There is prevention focus, structured weight management, comprehensive multidisciplinary management, and tertiary care intervention.
• We should be checking BMI at every well child exam. This is getting much better.
• Prevention plus can involve any level provider delivering a consistent message to patients. Suggest 5-3-2-1-almost none program. Five servings of fruits and vegetables, three structured meals a day, less than two hours television, one hour of vigorous activity, almost no sugar sweetened beverages. Follow up every six months.
• Stage two includes monthly follow up, labs, special personnel trained in weight management strategy, could be a nurse, dietitian, counselor. Could use tracking devices, tailored meal plans.
• Stage three includes weekly visits, usually requires a dedicated space for the practice. Usually a collaboration between pediatricians, dietitians, and community based programs. Some private programs like weight watchers may qualify, but look at the specifics. Stage three is available at a few places including Wake Med (Energize Program), Goldsboro, Asheville. YMCA has been very involved in this, working with former NCPS president Bob Schwartz.
• Stage four is really thinking about bariatric surgery.
• Practice needs to agree upon a coordinated evidence based message on obesity.
• Have a written protocol for structured management of children with overweight/obesity.
• Involve the whole office staff in designing the protocol.
• Perform periodic chart reviews to see that the protocol is being followed.
• NICHQ has a toolkit for help your practice comply with and implement guidelines in three easy steps.
• Getting paid for all this is critical to success, this is part of the NICHQ information.
• USPSTF now recommends referring children age 6 and over to weight management program.

Sheree Vodicka

Works with Physical Activity And Nutrition Branch of NC Division of Public Health

• Eat Smart, Move More. Sixty plus organizations across the state, including ours.
• Healthy eating and activity should be the norm, not the exception!
• Screen BMI. create culturally relevant weight management services. Insure access to those resources.
• www.eatsmartmovemorenc.com is a great set of tools and resources we can all access. This includes pediatric obesity management tools, can be downloaded and printed for your staff.
• Site includes listing of pediatric tertiary care centers for obesity.
• Send consumers to www.myeatsmartmovemore.com
• Insurance does cover medical nutrition therapy in many cases. Medicaid, BCBS, state health plan all cover dietary counseling to some extent. In4kids study at Duke is looking at financial feasibility of having an RD in your practice.
• Role Modeling: if you're going to talk the talk...
• The website has free resources for worksite wellness. Start with your own practice!
• Cooking is becoming a lost art as children and even their mothers fail to learn how to cook food.
• Diet beverages do not seem to promote weight loss! Push water!
• Can promote diluting juice gradually down to nothing.
• Evidence based messages are: decrease soda, cut off the tv, have family meals, decrease eating out, breakfast, decrease portion size.

Sarah Armstrong, MD, David Collier, MD, PhD, Jenny Favret, MS, RD, LDN, Eliana Perrin, MD, MPH, Joey Skelton, MD, John Tomcho, MD

Panel And Participant Discussion - Obesity Treatment Pearls from NC Obesity Programs

Eliana Perrin, UNC

• Focus on prevention. Work on forming functional partnerships between parents and pediatricians.
• Use BMI charts to reassure parents who think their normal weight children are too thin.
• Surveys show most doctors in NC still are not using BMI charts in the office. Color coding the charts can make them easier to understand.
• Using BMI charts works much better than using height and weight charts alone to screen for obesity.
• Pediatricians' counseling really does make a difference when children get home.
• If you think of yourself as thin you have a hard time counseling parents on obesity, also the case if you feel you are overweight.
• In counseling we must be aware of what parents are dealing with. Don't use a boilerplate talk that doesn't take the individual's circumstances into account. Remember that parents with poor math skills may not understand what you're saying.

David Collier

ECU Comprehensive Pediatric Healthy Weight Center

• The comorbidities of obesity are largely mediated by inflammation. Their clinic keeps an on site periodontist to address issues from periodontal disease.
• Average child is age 12 with a BMI of 39, two or more comorbidities.
• Labs include insulin, glucose, liver function tests, thyroid function, CRP
• Stress motivational interviewing, family therapy, evaluate patient and family members for depression
• About half their patients have a significant drop in BMI
• Waiting list is now six months long, even this clinic cannot do recommended 12 week follow up schedule

Joseph Skelton, MD

Brenner FIT Program

• Tertiary care program including bariatric surgery
• Clinic is overwhelmed by demand, one response has been phone coaching. First hurdle is helping families understand what the program actually is.
• If family doesn't fill out the intake form for clinic it is a good predictor they will not comply with other demands of the clinic.
• Behavioral approach is critical. They use tracking forms customized to each family.
• Experimenting with a telemedicine program now, putting monitors in referring pediatricians' practices

John Tomcho, MD

Carolinas Weight Management and Wellness Center

• Seeing adolescents, age 12 and above
• Duke Healthy Lifestyles Program
• Have two locations in Durham and Raleigh
• All providers are trained in motivational interviewing. There is a network of trainers called MINT you can find to train you and your providers. http://www.motivationalinterview.org/index.shtml
• On site physical therapy and mental health professionals. Physical therapy is often key to making it possible for these kids to exercise.

Questions and answers

• Jennifer Lail of Chapel Hill Peds asks about new recommendations that we use World Health Organization growth charts up to age 24 months. The old CDC charts we have been using are historical, but the WHO charts look at how children should grow if they were fed ideally, so these are ideals. An example is children up to age four months kids included in the sample data are exclusively breast fed.
• WHO charts will lead fewer parents to worry about failure to thrive in breastfed children.
• WHO charts are also akin to BMI, using length squared as opposed to CDC weight to length ratio.
• Question about BMI and trained athletes. BMI is a screening tool, works best in prepubertal children. You can make a judgement when looking at a muscular athlete as to whether there's a real obesity problem.
• Color coded growth charts are available at the Eat Smart Move More website
• Question about who gets bariatric surgery. The restrictions on surgery are quite strict. You really need a child who has participated in and failed an intensive program. So far the outcomes at at least one center have been quite poor. Patient and family psychological evaluation is key.
• The older an overweight child is when intervention begins the worse the likely outcome. Much study is now dedicated to evaluating what factors even in utero and certainly in the first two years of life contribute to obesity later on. Think for example about how much very young children are watching TV, being constrained in things like swings, slings, and saucers and prevented from moving. Rapid weight gain in infancy may be a real red flag to look at.
• In patients on atypical antipsychotics metformin may be helpful when insulin resistance is present. Interestingly if you give atypical antipsychotics to children with anorexia nervosa they still don't gain weight.
• A dramatic weight gain during infancy in a formula fed infant is more alarming. Parents looking at bottles stress about making sure the baby is getting enough and tend to blunt the learning of satiety clues. Nursing infants are more likely to learn to follow hunger and satiety cues. Even bottle feeding breast milk may have the same impact as formula here. That said the protective effect of breast feeding on obesity is tenuous, the evidence could be much better.
• Kids with ADHD have more obesity because their lack of impulse control outweighs their increased activity (so to speak).
• Activity is a goal in and of itself, regardless of whether you'd call it "moderate" or "vigorous". Try to ask the patient to trade thirty minutes of TV time for any activity whatsoever. Being outdoors will also improve their vitamin D levels.
• ICD9 still does not consider obesity a medical diagnosis, so we still have to code for the comorbidities. Worst case is families get billed for your services after being denied by insurer.
• Obese children do not have higher rates of actual depression although they do have lower self esteem and some depressive symptoms.
• We are working with WIC to improve their practices, but it is possible past practices have contributed to the obesity problem. Alice Lenihan answers this concern. Notes WIC has stopped providing juice for infants, working on eliminating it for children. She notes mothers tend to gain weight from one pregnancy to the next. WIC is kicking off a five star breastfeeding program for hospitals in North Carolina. There is now less milk on the WIC program and that milk is now low fat for children over age two years. There is also a push for whole grains. Working hard now on improving nutrition in child care centers. WIC has eliminated BPA in their breast pump components.
• North Carolina Medicaid covers obesity, as does Blue Cross Blue Shield NC, the state health plan. Another problem is that no show rates for these appointments are often quite high. Technically the abnormal weight gain code is not applicable in the case of obesity, but people around the room report they are being paid and have not yet gone to jail. V85.54 and 53 codes count, but they don't cover labs and the reimbursement is miserable, on a par with the price of a Fun Size Snickers bar.

Sadly I had to stop at this point and drive back to Wilmington for a neighborhood Halloween party. This meant missing perhaps the most critical lecture, an introduction to motivational interviewing. I did learn we have a MINT certified instructor here in Wilmington at UNCW, and Gordon Coleman and I may try to arrange a training session for anyone who wants to come. I'll send around an email if we can make it happen.

One last note. At Executive Committee I always walk away terrified at the forces arrayed against access to healthcare for children. A very few very dedicated people at the NCPS and the Academy are fighting terribly hard against interests with much more money and power to ensure the patients we serve get anything at all. If we do not all chip in, involve ourselves, and help in the effort, the children will get trampled by political and economic forces that have no interest in their wellbeing. Please, please involve yourself in the Pediatric Society and the AAP. Become an AAP Key Contact on the Member Center and take five minutes to call a legislator when a children's issue comes up. Donate to the NC Peds PAC. Go out and vote for candidates likely to support Medicaid, CHIP, WIC, and the other programs that attempt to provide a modicum of stability to the most vulnerable and yet most important members of our society. And if you hear a whooping sound at 5:30 AM, get your boots on and set your phasers for extra half and half.