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The Florida The Newsletter of the Florida Pediatric Society/ Florida Chapter American Academy of Pediatrics Pediatrician May 2003 Volume XXVI Number In this issue............ THE SCIENTIFIC PAGE WHO’S WHO Page 9 Page 2 THE PRESIDENT’S PAGE FROM THE FCAAP SPECIAL ARTICLE SARS Page 11 Page 3 THE EDITORIAL PAGE Page 20 THE HISTORY CORNER COMMITTEE REPORT WOMEN’S SECTION Page 13 Page 5 Page 21 C.A.T.C.H. FROM THE RESIDENTS’ SECTION THE GRASS ROOTS Page 18 Page 23 Page 14 Page 6 Add-a-‘Pearl’ MANAGED CARE FROM THE DEPARTMENT CHAIRMEN Page 25 Page 15 Page 7 ANNUAL MEETING SPECIAL REPORT NEW RESIDENCY Page 16 Page 30 PROS REPORT UPCOMING CME Page 8 RISK MANAGEMENT REACH OUT AND READ Page 8 Page 17 FROM THE AAP Page 32 2 WHO’S WHO in the Florida Pediatric Society/Florida Chapter American Academy of Pediatrics EXECUTIVE COMMITTEE Office rs Chapter President D e b or ah M ul li ga n -S m i th , M .D . Coral Springs, FL ( e- m ai l: de b m sm i @ a o l. co m ) Chapter President Elect D a v id M ar cu s , M .D . Ft. Lauderdale, FL ( e- m ai l: st ar do c 5 5@ a o l .c o m ) First Vice President P a tr ic ia B la n c o, M D Sarasota, FL ( e- m ai l: pb la n c od @ h o tm a il .c o m ) Second Vice President J o se D e lT o ro -S i lv e st ry , M D Ft. Lauderdale, FL ( e- m ai l: Jo rg e _ de lt or o@ p e d ia tr ix .c o m ) Immediate Past President R ic h ar d L . B u cc ia re ll i, M .D . Gainesville, FL (e-mail: [email protected]) Regional Representatives Region I T h o m a s T ru m a n , M D Tallahassee, FL Re gion II J a m e s W a l er , M D Jacksonville, FL Re gion III J yo ti B ud a n ia , M D Gainesville, FL Re gion IV L lo yd W e r k , M D Orlando, FL Region V C a r ol Li ll y, M D Tampa, FL R e g io n VI J o h n D o n a ld s o n, M D Ft. Myers, FL Re gion VII M a rs h a ll O hr in g , M D Hollywood, FL Re gion VIII K i m b er ly S ch w a rt z, M D Miami, FL Ex-Officio Members U. Florida Pediatric Chairman T e rr y F lo tt e, M D . Gaineville, FL U. Miami Pediatric Chairman R . R o d ne y H o w el l, M .D . Miami, FL U . South Florida Pediatric Chairman R o b e rt D . C h ri st en s e n, M D Tampa, FL Nova Southeastern U. Pediatric Chairman E d wa rd P ac k er , D .O . Ft. Lauderdale, FL EXECUTIVE OFFICE Executive Vice President Louis B. St. Petery, Jr., M.D. 1132 Lee Avenue Tallahassee, FL 32303 (Ph)850/224-3939 (Fax)850/224-8802 ( e-mail:[email protected]) Membership Director Edith J. Gibson-Lovingood (Ph)850-562-0011 (e-mail: [email protected]) Legislative Liaison Mrs. Nancy Moreau (Ph)850/942-7031 (e-mail: [email protected]) Page 2 COMMITTEE STRUCTURE Key Strategic Plan Chairmen Advocacy Committee Richard L. Bucciarelli, MD/Tom Benton, MD Gainesvil le, FL Communications Committee Deborah Mulligan-Smith, MD Coral Springs, FL Practice Support Committee Jerome Isaac, MD/Edward Zissman, MD Sarasota, FL/Altamonte Springs, FL Member and Leader Development Committee Patricia Blanco, MD Tampa, FL Liaison Representatives and Sub-Committees Breast Feeding Coordinators Arnold L. Tanis, MD Hollywood, FL Joan Meek, MD Orlando, FL Child Abuse and Neglect Committee Jay Whitworth, MD Jacksonville, FL CATCH Karen Toker, MD Jacksonville, FL Deise Granado-Villar, MD Coral Gables, FL Child Health Financing and Pediatric Practice Edward N. Zissman, MD Altamonte Springs, FL CHEC Ramon Rodriguez-Torres, MD Miami, FL Collaborative Research/PROS Network Subc ommittee Lloyd Werk, MD Orlando, FL CPT-4 Edward N. Zissman, MD Altamonte Springs, FL Envinmental Health, Drugs, and Toxicology Charles F. Weiss, M.D. Siesta Key, FL Home Health Care F. Lane France, M.D. Tampa, FL FMA Board of Governors Randall Bertolette, MD Vero Beach, FL Federal Access Legislation Susan Griffis, MD DeLand, FL Healthy Kids Corporation Louis B. St. Petery, Jr., M.D. Tallahassee, FL Pediatric Critical Care and Emergency Services Phyllis Stenklyft MD Jacksonville, FL Jeffrey Sussmane, MD Miami, FL Residents Section Sharon Dabrow, MD Tampa FL Lloyd Werk, MD Orlando, FL School Health/Sports Medicine Rani Gereige, M.D. St. Petersburg, FL Wom en’s Section Shakra Junejo, MD Apalachicola, FL Cou ncil of Pa st Pre sidents Edward N. Zissman, M.D. Edward T. Williams, III, M.D. John S. Curran, M.D. David A. Cimino, M.D. Robert F. Colyer, M.D. George a. Dell, M.D. Kenneth H. Morse, M.D. Robert H. Threlkel, M.D. Arnold L. Tanis, M.D. Gary M. Bong, M.D. Council of Pediatric Specialty Societies Lawrence Friedman, MD (Florida Regional Soci etyof Adolescent Medici ne) Michael Paul Pruitt, MD (Florida Societyof Adolescent Psychiatry) Andrew Kairalla, MD (Florida Soci ety of Neonatol ogists) Jorge M. Giroud, MD (Florida Associ ation of Pediatric Cardiologists) Jorge I. Ramirez, MD (Florida Soci ety of Pediatric Nephrologists) David E. Drucker, MD (Florida Association of Adolescent Psychiatry) E-Mail Barrett, Douglas, M.D. [email protected] Bauer, Charles, MD [email protected] Benton, Thomas, MD [email protected] Berget, Bruce, MD [email protected] Blavo, Cyril, DO [email protected] Budania, Jyoti, MD [email protected] Christensen, Robert, MD [email protected] Cimino, David A., MD [email protected] Curran, John, MD [email protected] Dabrow, Sharon, MD [email protected] Del Toro-Silvestry, Jorge, MD [email protected] Drucker, David, MD [email protected] Flotte, Terence R, MD [email protected] Friedman, Lawrence, MD [email protected] France, F. Lane, MD [email protected] George, Donald E., MD [email protected] Gereige, Rani S., M.D. [email protected] Giroud, Jorge, MD [email protected] Griffis, Susan, MD [email protected] Granado-Villa, Deise, MD [email protected] Howell, Rodney, M.D. [email protected] Isaac, Jerome, MD [email protected] Junejo, Shakra, MD [email protected] Kairalla, Andrew, MD [email protected] Katz, Lorne, MD [email protected] Lilly, Carol, MD [email protected] Meek, Joan, MD [email protected] Miilov, David, MD [email protected] Ohring, Marshall, MD [email protected] Pomerance, Herbert, MD [email protected] Reese, Randall, MD [email protected] Rodriguez-Torres, Ramon, MD [email protected] Schwartz, Kimberly, MD [email protected] Stenklyft, Phyll is, MD [email protected] Sussmane, Jeffrey, MD [email protected] Truman, Thomas, MD [email protected] Waler, James, MD jawaler@hotmail,com Weiss, Charles, MD [email protected] Werk, Lloyd, MD [email protected] Whitworth, Jay, MD [email protected] Yee, Patrick, MD [email protected] Wood, David, M.D. [email protected] The President’s Page D ear Colleagues: It is hard to believe that this will be the last time that I write to you as your President. The past two years have certainly flown by rapidly. The opportunity that you gave me to serve as President is one I will not forget. As President, I was able to appreciate more completely the challenges facing Pediatricians throughout our state. As you know I have been in academic medicine for my entire career, and although I often practice neonatology in community settings, I have been somewhat insulated from many of the pressures and complexities of practice. This opportunity has taught me more about the practice of pediatrics in the State of Florida than I ever could have imagined. Learning and understanding the issues you are facing in your in daily practice has helped me represent you better in Florida and also at the national level as Chair of the AAP Committee on Federal Governmental Affairs and now the Subcommittee on Access to Care. Without a doubt, I will continue to seek your help and input as I continue to work on the issues of access to quality pediatric care for the AAP. ***** “..I was able to appreciate more completely the challenges facing Pediatricians throughout our state.” ***** I know that I was very fortunate to follow two individuals who I think were outstanding chapter presidents, Dr. Edward “Bill” Williams and Dr. Ed Zissman. In addition, I have had the pleasure to work very closely with my former Chief Resident, Dr. Louis St. Petery, Executive Vice President of the Chapter. Unless you become an officer in this organization, you can never fully appreciate what Louis does for us. Louis provides the valuable institutional memory and stability to the Chapter without which we would be lost and terribly ineffective. His dedication and the hours he commits to our mission far exceeds his compensation. He does it because he is truly an advocate for pediatricians and the families we serve and because he wants to do what is right! All of us benefit from his commitment to the Chapter. This legacy of past leadership and our sound foundation will continue to serve us well as we look to the future. And the future Chapter leadership will be even better! President-Elect, Deborah Mulligan-Smith, is a very capable individual with a keen sense of policy and politics. Without a doubt, David Marcus and Pat Blanco will, in their turn, also provide visionary leadership for our Chapter. Don’t forget, David Marcus was responsible for successfully engineering FMA support for our 0-21 Medicaid fee increase after all other efforts failed. Now, I would be less than honest if I did not admit that I am a little disappointed on what we were able to achieve these last two years. I had higher expectations for us; however, I do recognize that we were in the most difficult fiscal times the state has faced in over fifty years! For the last two regular sessions and three special sessions, we were relegated to playing defense and I think we did it pretty well. There are so many more things that we could have done for Pediatricians and families, if the budget and the political will of many of our legislators were better. But we had to play the hand we were dealt. (See President, page 26 <) Page 3 FPIC ad The Editorial Page It’s a Difficult Time Y es, it is a difficult time. I sit here writing this piece in mid-April. There are two trouble zones: a big international one, and a smaller one here in Florida. The international problem is of course the larger one, with hundreds of thousands of our young men and women still “in harm’s way”. Two big questions arise: should we be doing this “...in harm’s way...” and can we afford it.? Should we do it? You the readers are divided mainly into two groups: those who oppose war, and correctly so. And those who feel that Saddam is indeed a threat to the security of the American people and should be removed, also correctly so! Yes, both groups are right, each in its own argument. Yet, there is a third group, one with whiter hair and longer memories, which remembers back before we fought World War II. We remember the “great appeaser”. We remember Neville Chamberlain and his umbrella, mouthing over and over “peace in our time”, to be obtained by giving Hitler that first expansion he wanted, since “that will satisfy him” and peace will prevail.. I don’t think one has to be a veteran of WWII to understand this, although many of our younger people do not even recognize the name. The older group lives in fear of a reprise of pre-WWII thinking, while hating the idea of war, thus really occupying a middle ground. Sad also is the fact that we apparently were unable to prevent the loss of much of the history of human-kind to looters and thieves. And we still need to prove we can win the peace! Can we afford it? We are faced with a battle the timing or the result of which we cannot begin to fathom, although we know that the costs will be high. And these are costs coming at a time when our economy is soft. Many folks do not buy the idea that reducing taxes increases the money coming into the federal coffers. Some cry that the benefit goes mostly to the upper earners of the country. Does this sound a little like the almost completely discredited concept of “trickle down economy”? In any event, the next few years will find the federal budget cutting back more and more on programs which would improve the health of Americans, and for us, of children. To put it succinctly, the federal government (that’s us) will turn around and say that some programs belong really to the states (that’s also us). We may pay end up paying less tax to the federal government, but be forced to pay more at state level. Does that hurt any less? And so to problem number two. As I write, the Florida Legislature is in session. Florida shares, with the other states, the problems thrust upon us by the feds. Florida has its own financial problems, with a sizeable deficit from last year. The only way to try to create some balance is to cut back on programs, and the ones must susceptible are child health and education. I would be preaching “Florida has ...sizeable to the choir if I pointed out that basically, deficit...” these are the most important facets of EDITORIAL OFFICE civilization! Bear in mind that we have Herbert H. Pomerance, M.D., Editor no state income tax, and no real chance Carol Lilly, M.D., Associate Editor of having one. Department of Pediatrics Is it any wonder, then, that this editorial has a kind of University of South Florida College of Medicine MDC somber tone? Of course, we can add that our country will 15 Tampa, FL 33612 prevail, and our children will prevail, and things aren’t half (Ph)813/259-8802 as bad as theylook! It’s just hard to say it and smile at the (Fax)813/259-8748 same time. -The EditorG e-mail: [email protected] (Please address all correspondence, including Page 5 The Grass Roots THE REGIONAL REPRESENTATIVES REPORT (Each month, we provide reports from two of our eight regions) Region III repo rts: The Broward C ounty Ped iatric Society was honored to Along with Drs. Cartwright, de Miranda, Montgomery, have the President Elect of the Academy of Pediatrics, Dr. Carden Payne and Zanga, I traveled to Chicago for the AAP Chapter Forum Johnston, speak at our last meeting on February 27th in Fort to put forth the proposition that the Same Sex Co-Parenting Adoption Lauderdale. He gave an overview of the Academy’s positions and Policy is flawed and should be rescinded. This was in response to my strategies for action in the coming year. A network is being personal conviction as well as to represent others who share this view. developed to find D octors who have c onne ctions and ac cess to Request denied. Instead, the following resolution was impo rtant po litical figures. T wo were identified at our meeting! passed: “The Chapter Forum of the Academy (representing the The Joe DiMaggio Children’s Hospital 14th annual grassroots leadership), add(s) its support to the AAP policy, ‘CoPed iatric Symp osium was held in November in Ft. Lauderdale and parent or Second-Parent Adoption by Same-Sex Parents’. The attracted a record 240 registrants who heard interesting talks by Chapter Forum commends the National AAP for remaining true to its nationally renowne d speakers on a variety of P ediatric topics. mission of acting in the best interest of children wherever they are.” The Joe DiMaggio Children’s Hospital celebrated it’s 10 th There are still a few of us blades of grass who don’t agree with this. anniversary recently. It is presently searching for a Pediatric Ok, we lost that one. How about: “The Academy suspend Cardiac Surgeon to complement its cadre of Pediatric subany support for homosexual or same-sex “co-parent” adoption until specialists. longitudinal, well designed, case-controlled studies of statistically Rallies were held recently both in Palm Beach and adequate sample size exist which can confirm that such arrangements Broward in support of implementation of Gov ernor B ush’s task are truly in the best interest of the children involved.” force recommendations o n med ical malpractice reform. Request denied. The prevailing opinion is that there is not Ped iatricians and their staff participated in both rallies. good scientific data to support this policy (I sat next to Lou Cooper Marshall Ohring, M.D. who says this. It was repeated throughout the meeting). It just doesn’t Region VII RepresentativeG matter, I guess. Ironically, the statement was printed in Pediatrics, the peer-reviewed scientific journal of the American Academy of Pediatrics (AAP). Ouch! In fact, at the Chapter Forum, they rejected this resolution: “That the Academy rescind family policies that fail to meet reasonable scientific research and epidemiological standards.” They also rejected this: “That the Academy acknowledge and promote the value of the marriage of supportive mothers and fathers to the wellbeing of children.” In an effort to appease the supporters of the 17 resolutions opposing the policy and perhaps hoping that over time the policy REGISTRATION would garner wider support, the Chapter Forum voted to: “Pursue a course of providing a full range of available scientific literature on Have you registered yet for the parenting, including same-sex parenting, plus providing educational opportunities where the issues can be discussed in the AAP tradition Annual Meeting of unbiased scientific inquiry, respect for colleagues, and concern for in Orlando, June 20-22, 2003? children.” This causes me to ask: where is that report from the Task Important Business CME Credit Force on the Family – its release delayed because the report defends the scientific benefits of the traditional family unit? (I’m not ready to accept the policy at this time) If you, like me, are having difficulty accepting this policy, I want to hear from you – how many of us feel as I do about this action on the part of the AAP? Please contact me at [email protected] or 5612 NW 43RD ST, GAINESVILLE, FL 32653-3332 if you do not support this AAP policy. Thomas Benton, M.D., FAAP Region III Representative [Disclaimer: Dr. Benton writes this report in a very personal vein. His opinion is not the opinion of all of the members in his region nor of the chapter. With the consent of the writer, and at the behest of the Editorial Board of the newsletter, it is stated that the above is recognized as a personal statement by Dr. Benton.-Ed] G Page 6 Region VII reports: From the Department Chairmen The Department of Pediatrics at the University of Miami R. Rodney Howell, M. D. Professor and Chairman Department of Pediatrics University of Miami School of Medicine Miami, Florida As with other training programs throughout the nation, we have recently received the results of the “Match” for next year’s interns at Jackson Memorial Hospital at the University of Miami/Jackson Memorial Medical Center. Florida continues to be a highly desirable destination for young physicians training in Pediatrics, and again, we are very pleased with the talented and diverse group of incoming interns who will be joining us here in Miami. Nationally, this year saw a significant increase in the percentage of graduating medical students choosing pediatrics, while Internal Medicine had a very small increase, and Family Practice saw a significant decrease in the students choosing this profession. The reasons behind these changes are the subject of considerable discussion and conjecture. In recognition of the multi-million dollar gift from the Holtz family, the Public Health Trust and the MiamiDade County Commission(the governing body of our hospital) have approved the official naming of our Children’s Hospital as the Holtz Children’s Hospital a the University of Miami/Jackson Memorial Medical Center. The Holtz family gift will not only result in a name-change but lead to some major construction projects; the first of these, a new state of the art 30 bed pediatric intensive care unit is about to begin. The Holtz family is well known in Miami for their philanthropy. Needless to say, we are very pleased with this new name, which clarifies our situation as a large children’s hospital, contained within the vast Jackson Memorial Hospital. Our institution suffered a great loss during the year with the death of Dr. Charles (Chuck) Pegelow. Chuck served as a leading Professor in our Hematology/Oncology Division and was responsible for our very large Sickle-Cell Program. Importantly, he had led our Housestaff Program with skill and distinction. Although he had a rapid downhill course after a malignancy was diagnosed, he continued to work essentially full-time until his death. We have been fortunate to have had a very active Housestaff Education Committee for many years, which enabled our program to continue without interruption. A leader of this group, and an outstanding clinician and educator, Dr. Barry Gelman, of our Critical Care faculty was appointed Housestaff Director, and has taken charge of the program with great vigor and skill. His appointment has been enthusiastically received by the faculty, Housestaff, and all the staff of the hospital. The new Housestaff regulations from the ACGME dealing with hours and other areas begin this summer, and will require a number of changes for us to comply with the new rules and regulations. Our Housestaff has been unionized for some years, so we will have many fewer changes to make than some other institutions. Our Batchelor Children’s Research Institute has now been open for over a year, and much of the building is fully occupied and productive at this time. The new NIHfunded ambulatory Clinical Research Center, which was designed for this purpose and is based on the second floor, is now in operation and seeing children at this site. The completion of the animal facilities on the 8th floor of this 147,500 square foot building will have the new analytic MRS system in place by the summer. All of the remaining areas of the building are either occupied, under construction, or in final design for construction. And perhaps most important , the Search for the new Chair of Pediatrics at the University of Miami is coming into the home stretch, and we hope a new person will be in place this summer. Dean Clarkson is working closely with finalists at the current time. I am in the process of arranging my new responsibilities, which will begin in the summer. After leaving the Chair, I will remain a Professor of Pediatrics at the University of Miami but will be assigned to the NIH and will spend the vast majority of my time in Bethesda, Maryland as Special Assistant to the Director of the National Institute of Child Health and Human Development, of the National Institutes of Health. I view this with great excitement and I will work closely with Dr. Alexander, the Director, on issues of genetic testing which focus on the scientific aspects of newborn screening. I will continue to maintain contacts in Miami for a long time.G Page 7 Collaborative Research and PROS PROS practices have ignored recruitment materials and (See PROS, page 28 <) Page 8 Reach out and Read Report Representatives from throughout the nation met in chilly Chicago in early April to discuss the status of old and current projects, review proposed studies, and determine the future of our AAP practice network. Established in 1986, the practice based research network consists of about 1700 pediatric practitioners from almost 600 practices located in all 50 states, Puerto Rico and Canada. Our mission has remained firm: to improve the health of children by conducting collaborative practice-based research to enhance primary care practice. PROS practitioners and researchers work together to generate research questions, design study materials and protocols, obtain research funding, collect study data, analyze collected data, and publish results. This collaboration is accomplished through AAP chapter-based groups of practitioners recruited and maintained by pediatrician chapter coordinators, who in turn meet twice a year with PROS research staff and consultants. Analysis of the data collected by the LAND study (4351 mother/baby pairs enrolled by 113 PROS practices – 4 in Florida) reveal insights on maternal readiness for discharge, maternal depression, and practitioners practicing beliefs. Three LAND abstracts were accepted for presentation at the 2003 Pedatric Academic Societies meeting in Seattle, WA in May. If your practice participated in the study and you are interested in contributing further (for example, writing and / or editing a manuscript), contact us ASAP. How is the Safety Check project coming along? Recruitment of practices has started and already 698 eligible patients have been enrolled. Regretfully, many New Collaboration Between FPS Foundation and ROR Recently, the Florida Pediatric Society (FPS) Foundation agreed to serve as the fiscal agent for the newly formed Reach Out and Read (ROR) Florida Coalition. This collaboration fits naturally with the FPS Foundation’s goals to nurture programs to benefit the children in Florida so that they may attain optimal physical, mental, and social health and well-being. The ROR Florida Coalition seeks to make early childhood literacy an integral part of pediatric primary care throughout Florida. More than 70 pediatric practices, family practices, and community medical centers throughout Florida are ROR sites – serving more than 60,000 children per year. Several randomized, controlled studies demonstrate the ROR program significantly improves parent attitudes about books, parent-child reading activities, and child vocabulary. The program was created to most benefit low-income families presenting at well-child visits for their children 6 months through 5 years of age. The Reach Out and Read model has three parts: 1. At each well-child visit, the pediatrician or primary care provider speaks with a child’s 2. 3. parents and/or caregiver regarding the importance of reading aloud daily to their children; During the well-child visit, the pediatrician or primary care provider gives the child a free, developmentally appropriate and culturally sensitive book to take home; and In the waiting room, volunteers read aloud to the young children – modeling this behavior to (See Reach out and Read, page 28 <) The Scientific Page Pediatrician Involvement, Florida Youth Suicide Prevention Prototype Project, and Broward One Community Partnership. Deborah M ulligan-Smith, MD FAAP FACEP President-elect FCAAP Maria Elena Villar, MPH Greta Costa, MPH Institute for Child Health Policy at NSU Improvements in child mental health services and outcomes can only be accomplished through the systematic, coordinated efforts of agencies, funding organizations, service providers, families and professional groups. Pediatricians and family medicine practitioners play a key role in early intervention for mental health conditions, including suicide ideation and severe emotional disturbance. The Institute for Child Health Policy at Nova Southeastern University (ICHP-NSU) is focusing on improvement of child mental health screening and referral within the continuum of service from emergency response to therapeutic and rehabilitative care. Through its involvement in the One Community Child Mental Health Initiative and the Florida Youth Suicide Prevention Prototype Project (YSPPP), the Institute is developing collaborative research initiatives that address child mental health. The Florida Youth Suicide Prevention Prototype Project (YSPPP) builds on the Florida State Suicide Prevention Task Force, Preventing Suicide in Florida: a White Paper. The YSPPP considers the continuum of community-based youth suicide prevention, intervention, and postvention by cutting across the public/private sectors. Among the objectives of the YSPPP is to “increase the use of schools, primary care providers, clergy and work places as access and referral points for mental health, health, and substance abuse treatment centers.” The Broward County One Community Child Mental Health Initiative seeks to develop a system of care that will sustain and support children with serious emotional disturbance within this community in a least restrictive and clinically appropriate environment. A singularly important objective of the One Community Partnership is to coordinate efforts of primary care and behavioral health services to establish “a single point of entry” for children with severe emotional disabilities and their families; the intent is to facilitate and streamline access to services and promote the use of assessments that focus on discovering individual strengths and preferences. Exploring the Link Between Child Mental Health and Suicide In Florida, Mental Health conditions rank third among all reasons for hospital discharges. White children are more than twice as likely as Black children to have a mental health-related primary diagnosis. After psychoses, the leading mental health diagnoses among children are associated with suicide risk: depressive disorders in younger children and substance abuse or dependence among older youth. (Figure 1) Suicide forces us to consider the interrelation between injuries and mental health disorders. In Broward, the majority of injuries among children with primary diagnoses that were mental health related were self-inflicted. (Figure 2) However, data collection and reporting has to improve to accurately capture the full picture. Of the 2,644 primary diagnoses for Broward 15-24 year olds, only 3% contained a valid e-code (external cause of injury). Therefore, this graph likely under-represents the number of patients with both an injury and a mental health diagnosis. The pediatrician’s role, especially acute care specialists and those that are hospital based, cannot be underestimated in the effort to improve reporting. While primary care pediatricians struggle with prevention and early identification, tertiary care doctors must do their part to inform prevention planning through accurate reporting. Pediatricians and Mental Health The role of pediatricians and family medicine practitioners has been identified as key for early intervention of mental health conditions, including (See Scientific, next page <) Page 9 Scientific (= continued from page 9) suicide ideation and severe emotional disturbance. In an effort to better understand perceptions and practices of primary care physicians in mental health and mental health services in their communities a survey tool was designed and implemented. This survey gathers data on suicide risk and other mental health screening and referral practices, as well as primary physician’s perceptions of and experiences with the mental health care system in Broward and Alachua counties. We are complementing the quantitative survey, with key informant interviews with pediatricians and family medicine practitioners, to obtain qualitative information to support and to explain survey findings. The interviewer elicits open ended responses about the use of youth mental health referral practices, and barriers to effective mental health referral practices, as identified by primary care physicians. This undertaking is of great significance because we understand that without insight from primary care providers it is doubtful that we will be able to identify the true magnitude of the mental health community needs for the pediatrician and their patients. Results from these studies will provide a basis for future studies in the interaction between medical care providers and mental health providers, an area that has been understudied. We extend our thanks to the Alachua and Broward pediatric community for their cooperation and commitment to families as demonstrated by their responsiveness.G Page 10 Figure 1. Primary M ental Health Diagnoses in Broward Pediatric Discharges Figure 2: Pediatric Injury and Mental Health Diagnoses Special Article SARS Information Robert S. Baltimore, M.D., FAAP Memb er, AAP Committee on Infectious Diseases The recent outbreak of severe acute respiratory syndrome (SARS) has prompted the Academy to evaluate what is known about the disease, particularly with regard to children. Information about SARS is evolving rapidly, and pediatricians are encouraged to access the Web sites listed below for up-to-date information. Evolution of SARS On Feb. 11, the Chinese Ministry of Health notified the World Health Organization (WHO) that 305 cases of acute respiratory syndrome of unknown etiology had occurred in six municipalities in Guangdong province in southern China from Nov. 16, 2002, to Feb. 9, 2003. During late February 2003, an outbreak of a similar respiratory illness was reported in Hong Kong among workers at a hospital. On March 12, WHO issued a global alert about the outbreak and instituted worldwide surveillance for SARS. Subsequently, there has been spread to other countries, but at this time all cases can be traced to contact with individuals from Asian countries. However, a few of these cases appear to be the result of community spread from an individual whose illness could be traced to Asia. The agent of the disease appears from early reports to be a member of the coronavirus family, but this is still being investigated. There is no proven effective treatment for this virus. Although various therapies including using intravenous ribavirin and steroids have been administered to SARS patients, the efficacy of these therapies has not been determined. For treatment of suspected cases, consultation with an infectious diseases expert should be sought. Current case definition On the basis of these early reports, the following case definition was developed: < Measured temperature 100.4° F (>38°C) and < one or more clinical findings of respiratory illness (e.g., cough, shortness of breath, difficulty breathing, hypoxia, or radiographic findings of either pneumonia or acute respiratory distress syndrome) and < travel within 10 days of onset of symptoms to an area with documented or suspected community transmission of SARS. or < Close contact within 10 days of onset of symptoms with either a person with a respiratory illness who traveled to a SARS area or a person known to be a suspect SARS case. This case definition will be updated as new information becomes available. (See Centers for Disease Control and Prevention (CDC) Web site below.) In the first approximately 2,300 cases of individuals who met the case definition, the fatality rate was about 4% and infections in children were uncommon (approximately 2% of SARS cases in the Canadian data, 14% in early U.S. data). It is unclear, so far, if the small number of children represents host resistance to infection, illness too mild to come to medical attention or lack of contact with infected individuals. WHO, CDC and other public health agencies worldwide are continuing to investigate this multicountry outbreak. The number of SARS cases and countries reporting such cases continue to increase worldwide. In the absence of a complete understanding of SARS' etiology and how SARS is transmitted, efforts to limit transmission in the United States have focused on early identification of potential cases through surveillance and implementation of infection-control measures in health care settings and the community. Infection-control precautions, which include standard, contact and airborne precautions, should be instituted immediately for people who meet the case definition. Materials sent to diagnostic laboratories require high-level precautions against dissemination. Specimens require special handling, and laboratories must be contacted in advance of sending any specimens from suspect cases in order to apply the appropriate precautions. CDC has developed interim infection-control guidelines for use in U.S. health care and household settings. These recommendations are based on experience in the United States to date and will be revised as more information becomes available. Infection-control practitioners and clinicians providing medical care for patients with suspected SARS should (Continued next page <) Page 11 exposure or children who have traveled to an area where SARS is occurring (e.g., Toronto, Hong Kong, mainland China, Singapore) should be evaluated based on the following: • If well, parents should self - monitor the Sars ( = continued from previous page) consult these guidelines frequently to keep current with recommendations. Health care providers of patients whose illness is consistent with the case definition for SARS should continue diagnostic evaluation for other causes of respiratory tract illness and, when appropriate, empiric therapy including agents active against organisms associated with community-acquired pneumonia of uncertain etiology, including both typical and atypical respiratory tract pathogens. WHO and CDC have issued travel advisories recommending that persons consider postponing non-essential or elective travel to affected areas until further notice. Persons who recently have traveled to affected areas are urged to: monitor their health for 10 days after return; seek medical care if they develop fever and cough or difficulty breathing within 10 days of travel; and inform their health care providers about recent travel to regions where SARS cases have been reported. Ten days appears to be the outside limit for the incubation period of SARS (two to 10 days). To detect possible SARS cases among travelers returning to the United States from these areas, CDC and state and local health authorities have implemented enhanced surveillance. Clinicians and public health officials are requested to report suspected cases of SARS to their state health departments. Current information on SARS, including case definition, infection-control practices, diagnostic valuation, treatment, reporting and travel advisories can be found on the CDC Web site at www.cdc.gov/ ncidod/sars/exposuremanagement.htm. Updated case counts and additional information also are available on the WHO Web site at www.who.int. The following points will be helpful in speaking with parents and schools posing SARS-related questions: < Children do not need to restrict their activities except as related to official travel alerts. For travel advisories, access www.travel.state.gov. < Children who have been exposed to individuals who are not ill but have traveled to areas where SARS is occurring do not require isolation. < Children who have been exposed to an ill individual who is suspected of having SARS at the time of the Page 12 • • child's condition for fever or respiratory tract illness. At present, attendance at child care or school is not restricted, although this may change as new information becomes available. If the child is not well, parents should contact their pediatrician and the child be isolated at home, according to procedures established by public health authorities. If a child is not well and experiencing hypoxia, shortness of breath or breathing difficulty, he/she should be hospitalized and health care workers informed before the admission so SARS precautions can be initiated. (See CDC Web site.)G MEMBERSHIP ALERT! Do you know any pediatricians, Fellows of the Academy or not, who appear to have been overlooked by the Society, and are therefore not members? Contact the Executive Vice President or Membership Director. There are several kinds of membership in the Society: Fellow: A Fellow in good standing in the American Academy of Pediatrics - automatic membership on request. Member: A resident of Florida who restricts his/her practice to pediatrics. Associate Member: A physician with special interest in the care of children. Military Associate Member: An active duty member of the Armed Forces stationed in Florida and limiting practice to pediatrics. Inactive Fellow or Member: Absenting self from Florida for one year or longer. Emeritus Fellow or Member: Having reached age 70 and having applied for such status. Affiliate Member: A physician limiting practice to pediatrics and in the Caribbean Basin. Allied Member: A non-physician professional involved with child health care may apply for allied membership. Honorary Member: A physician of eminence in pediatrics, or any person who has mede distinguished contributions or rendered distinguished service to medicine. Resident Member: A resident in an approved program of residency. Medical Student: A student with an interest in child health advocacy.G Committee Reports Report from the Women’s Section, Florida Chapter AAP Shakra Junejo, M.D. Section Chairman Franklin’s Promise Franklin’s Promise, Inc. (FPI) is a non-profit entity formed over two years go to address growing community concerns surrounding quality of life issues and to take the lead in improving efforts to identify and obtain resources that could serve the needs of Franklin County. Awareness of the community's needs, conceptualization and final incorporation as a non-profit organization eligible for public funding took more than two years, yet once formed, the organization grew rapidly and is considered by many in the community to be more effective than any other of its type in Franklin County. FPI's purpose is to promote a better life for children and families in Franklin County. Through the usefulness of several action committees, a highly motivated and committed volunteer group continues to serve the organization and works hard to distribute food and medicine, mentor children, extend job-training opportunities and proactively participate in addressing health and social service issues within the community. Action committees dedicated to the Franklins Promise effort include: < Health and Nutrition < Recreation < Social Services < Education, and < Elders The Health and Nutrition committee has taken the responsibility for coordinating community needs by working with professionals from county health department management and staff personnel. In order to focus a course of action, FPI facilitated countywide needs assessment of health, nutrition and social services that was the first ever initiated in Franklin County. Work on the yearlong assessment consisted primarily of data collection surveys, focus group discussions and statistical analysis of health status indicators. Documentation that was developed, which defined the needs and available resources to promote good standards of health and nutrition, now forms the baseline for strategic health planning in the County and for further exploration of funding options that agencies may find most helpful in advocating for additional resources. So far, five grant applications from FPI have been supported to help the Franklin Health Department and the Franklin County Medical Society improve health and social services in the community. An indigent drug assistance program allows FPI volunteers to keep high-risk individuals on maintenance drugs. The volunteers assist medical providers in conducting a weekly primary care clinic; and they assisted health department staff in developing a bioterorrism preparedness program that includes small pox vaccinations. The Recreation committee, working through the Chronic Disease Intervention Program at the County Health Department, identified funding sources enabling walkway exercise paths to be developed within the community. The leader of the Recreation committee is taking responsibility for organizing and coaching the only high school tennis team in the county; and several computers have also been brought into schools through donations to this organization. When the local food bank suddenly closed its doors, a volunteer pastor immediately took over food distribution services; while the nutritionist on the Health and Nutrition Committee reviewed food packages provided nutritional expertise. The social services are streamlined by way of regular dialogue offered through this organization involving Healthy Start, Healthy Families, School Readiness, Head Start, Even Start occupational services and other social services organizations; the county victim (See Women’s, page 26 <) Page 13 From the Resident Section Laura P. Stadler, M.D. Resident Chairperson for FL USF P rogram Representative [In each issue, we will focus on the State’s Residency Programs and/or on issues affecting all programs. ] Spotlight on Tampa The Pediatric Residency Program at the University of South Florida combines the strengths of a number of clinical settings to pro vide an exce llent variety of patient care exposure. The program consists of 16 catego rical pe diatric residents each year, along with 4-5 combined medicine-pediatric residents. In addition, fellowships in neonatology and allergy/immunology are offered. In future years, additional fellowships may become available. The major training sites are All Children’s H ospital in St. Petersburg and Tampa General Hospital in Tampa. A national parenting publication has for the second year in a row named All Children's Hospital as one of the top twenty child ren's hosp itals in the U nited S tates. Fo r the co ver story of its February 200 3 edition, Child magazine released results of a survey it conducted of children's facilities across the natio n. All Children's was tied for 16 th with W olfso n C hildren's Hospital in Jacksonville, FL. That's the highest ranking of all children's facilities in the state of Florida. T he first Child magazine survey of children's hospitals, published in February of 2001, also ranked All Children's Hospital in the 16 th spot nationw ide. T his honor places All Children's among some very d istinguished compa ny. All Children's Hospital is a leading center for pediatric treatment, education and research. All Children's provides specialized care for children of all ages, from newborns through teens. Located in Downtown St Petersburg, All Children's Hospital is one o f only 47 free-standing children's hospitals in the US, one of two freestanding children 's hospitals in the state of Florida, and the only one on Florida's west coast. It has one of the highest levels of patient acuity in the country and provides care for children from Florida, throughout the United States and the rest of the world. A wide range of specialized services make s All Children's H ospital a 216-bed center of excellence for treatment of congenital and chronic diseases. Th e Neo natal Intensive Care N urseries accommodates 60 premature and at-risk infants. Two additional intensive care units provide critical care staffing to acutely ill children and patients who are recovering from complicated surgery. Tampa General p rovid es approximately 120 pediatric beds including dialysis, NIC U (including EC MO), and P ICU . Research occurs in outpatient clinics and includes bo th general pediatric and HIV patients. The different hospitals provide residents with a diverse exp erience and allows them to train in 2 unique settings. The Department of Pediatrics, under the leadership of Dr. Robert Christensen, has been selected for the second year in a row by the USF medical students to receive the clinical department teaching award. Dr. Christensen has recruited and filled eight endowed chair p ositions with top national researchers in their fields who will be making the Children Research Institute their Page 14 home. This is in accordance with the chairman's five-year vision to bring the department to a national level at the forefront of pediatric research. Resid ents gain outpatient clinical p ediatric experiences in a wide variety of settings. They rotate through many teaching centers, including the USF pediatric clinic, Genesis Clinic and the ACH Clinic. R esidents gain further experience in a number of local private practice offices during their second continuity clinics during second and third years. They spend time in a variety of advocacy sites and schools as part of an advocacy rotation. Seve ral residents participate in the Rural Track at Lawton Chiles Co mmunity Health Center in Bradenton. These residents elect to work in the rural setting instead of the ambulatory settings in Tampa and St. Pete to gain a unique expe rience. Our Med icine-Pediatrics program is designed to prepare physicians to function as both pediatricians and internists. This rigorous four-year program gives enhanced flexibility in career options, including ge neral and sub specialty choices. Dr Lynn Ringenberg, the program director, has been missed since ea rly 2003. She is serving our country as part of the reserves. In her absence, Drs Dabrow and Gereige have assumed the responsibilities of program directors in addition to their active mem bersh ip in the AAP. D r. Dabrow serve s as faculty adviso r to the resident section of the A AP . In ad dition she has been instrumental in the Reach Out and R ead initiative. Dr Gereige is Chair of the Committee for School Health and is looking for volunteers to participate on this committee. If interested in joining this com mittee, please email him at GE RE IGE R@ allkids.o rg. Dr Gereige and Dr BethAnn Gemunder received AAP recognition for the “Reaching Children: Building Systems of Care (REACH OUT)” grant for $10,000 presented from Healthy To morro ws, an AAP partnership with the Health Resources and Services/Maternal and C hild H ealth Bureau to obtain medical care for children through the Lawton Chiles Community Health Center in Bradenton. They will be presenting data from their pro ject this May at the Pediatric Academic Societies Meeting in Seattle, WA. In addition, they will present at this June’s Annual Chapter meeting. Marisa Lejkowski, DO and Laura Stadler, MD received a CATCH (Community Access To Child Health) grant entitled “CATCH Us At Asthma Clinic” The focus of the project is to increase Influenza vaccination among asthmatics in the general ped iatric clinic at All Children’s. L au ra Stadle r, M D University of South Florida Pediatrics FL Chairperson, District X Chairperson for Resident Section G (See Resident, page 27 < ) Managed Care Some Thoughts on M anaged Care Edward N. Zissman, M.D. Altamonte Springs, FL 2. CHALLENGE NON-STANDARD CODING PRACTICES The AAP has been working with other national medical specialty societies to challenge non-standard coding practices by insurance carriers. Since July 20 02, the Academ y has signe d-on to letters to Anthem, Aetna, Cigna, United Healthcare, Blue Cross Blue Shield of Florida, B lue Cross B lue Shield of South Carolina, CareFirst, Coventry Healthcare, Health Net, Humana, MA MS I, Medical Mutual, One Health P lan, Pa cificare, P HC S, and W ellpoint. W hi The Florida Pediatrician has had and continues to le have a policy to print an article on Managed Care in each th issue. This policy will be adhered to so long as suitab le e articles are submitted. Both sides of the issue will be m represented. a Publication of an article does not indicate any n endorsement of the opinion by The Florida Pediatrician or a by the FCAAP/FPS.G g Some issues of interest to pediatricians include: e "The undersigned medical asso ciations opp ose arbitrary and d care area has been relatively quiet, there are several areas of note. unilateral code-collapsing and recoding p ractices that result in unfair paym ent. W e encourage third parties to accept physician claims that have been accurately rep orted using ap plicab le CP T code s and to A. Renegotiating fees with third party payers. report back to p hysicians and patients using the same cod es or W hen meeting with third party payers to renegotiate the necessity for terminology, regardless of reimbursement methodology and levels. Procedural descriptions should not be modified without appropriate increased reimbursement, please consider the following: 1. The cost of employee benefits including, but not limited to, professional medical consultation. Use of inappropriately modified data does not provide a proper basis for reimbursement, measuring health insurance has inc reased about thirty percen t. 2. Employee salaries have increased greater than the cost of living. practice patterns, peer reviews or utilization reviews, or other related 3. The cost of professional liability insurance, where available, has uses. The AM A has as one of its priorities to encourage consistency in the use of CPT cod es, guidelines and conventions, as well as to increased twenty-five to thirty percent. advocate the ad optio n of these stand ards. 4. HIP AA ha s added a new business expense The undersigned medical associations object when health plans 5. Third party auditing has increased overhead. seek to arbitrarily and unilaterally recode or inapp ropriately bundle 6. CLIA and OSHA expenses have increased. codes and services. We feel compelled to identify specific CPT code 7. Vaccine costs have increased. 8. Vaccine administration costs have increased including additional bundling problems and seek to educate health plans and other payers record keeping requirements and the mand ated use of "safety" in dealing with these pro blems." needles and syringes. Downco ding, bundling and lack of recognition of CPT modifiers by B. Both the AAP and the AMA, in concert with other physician IBC: Modifier –25 has be en de nied fo r the purpose of bundling. organizations have been advocating on our behalf. Mod ifier –25 is appended to indicate that on the day a procedure or service identified by a CPT code was 1. HEALTH PLAN COM PLAINT FORM In the summer of 2001, the AMA H ouse of Delegates directed performed, the patient’s condition required a significant, separately the AM A to establish an electronic information clearinghouse so identifiable evaluation and management (E& M) service above and physicians could report information about administrative disputes that beyond the other service provided or beyond the usual preoperative they encounter with third-party payers. Consistent with this and postoperative care associated with the procedure that was resolution, Private Sector Advocacy (PSA) developed the "H ealth perfo rmed . (See Managed, Page 29 <) Plan Complaint Form." This form serves as a tool for the collection Page 15 of information related to the administratio n of health plan s by hea lth insurers and third-party payers. It gathers very sophisticated data on the types and the severity of the administrative "hassles" that physician office experience on a day-to-day basis in the managed care environment. Using these data, PSA provides updates and presents findings associated with the information collected through this form, including the types and numb er of co mpla ints and the aggregate number of complaints or co ncerns by geo graphic and dem ographic chara cteristics o f physician practices. To submit a complaint to the AMA, go to <http://www.am a-assn.o rg/ama/pub /catego ry/2387.html> and click on Health Plan Complaint Form. Note: As a result of this initiative, the organizations have done as follows: Special Report A New Residency Program Edward E. Packe r, D.O Chairman, Department of Pediatrics Nova So utheastern College of Osteopathic Med icine Palms West Hospital of Palm Beach County, Florida is proud to announce the opening of a new pediatric residency developed in conjunction with Nova Southeastern University’s College of Osteopathic Medicine in July 2003. Many graduates of Nova Southeastern University and other institutions dedicated to producing primary care physicians have expressed an interest in finding a graduate program in pediatrics devoted to the training of general pediatricians with an interest in primary care. The new program at Palms West Hospital was established to help provide training for new primary care pediatricians prepared to meet the challenges presented in both a general ambulatory pediatric practice and the care of hospitalized pediatric patients. The American Osteopathic Association has accredited the new pediatric residency established at Palms West Hospital. The program was developed to meet the special criteria of a “Fast-Track” training program. A “Fast-Track” program meets the unique licensure requirements needed for osteopathic physicians in many states that require a physician to have completed a traditional internship prior to applying for a license to practice. Incorporated into the pediatric residency are the core rotations of emergency medicine, internal medicine, surgery, and obstetrics and gynecology. After completion of the three-year pediatric residency, the resident will be considered to have completed both an internship and a pediatric residency in the three-year time span. Palms West Hospital boasts a newly expanded pediatric unit with an active pediatric emergency room staffed by specially trained pediatric emergency physicians. The pediatric unit now has 24 private pediatric beds and an eight bed pediatric intensive care unit staffed by a team of pediatric critical care specialists. The newly designed units house the latest in pediatric equipment and are designed with rooms and centers for research and education of the house staff. The patient environment has been enhanced by the addition of playrooms and child life services. Specialized services at the Palms West pediatric Page 16 residency are diverse with virtually every pediatric medical and surgical specialist working as part of the staff. This large array of specialists will allow the residents to become experienced in all of the various health care needs that are unique to the pediatric population. Residents will work directly with the various specialists in daily patient care, and be provided opportunities to take elective rotations on most of the pediatric specialized services. All of the pediatric residents at Palms West Hospital will maintain a small continuity of care practice in a private office setting on the hospital campus. The residents will learn to develop a pediatric practice, and they will provide all aspects of care including phone advice and prenatal counseling visits. The pediatric residency will work in conjunction with the Palm Beach County Health Department to care for children with special needs including health issues related to poverty, developmental disabilities, chronic illness, and HIV infections. A rural program in Belle Glade, Florida will serve as a permanent site where residents will care for children in the rural environment. Applications for residents are currently being accepted. Pediatricians in the area of Palms West Hospital who are interested in participating in the training program are also being recruited. All interested individuals should contact Edward E. Packer, D.O., FAAP, FACOP at 954-262-1702 or by E-mail at [email protected]. G Note: Visit our society’s permanent website at: http://www.fcaap.org for all you want to know about our society, including a summary of The Florida Pediatrician.G Risk Management [The Florida Physicians Insurance Company (FPIC) is endorsed and sponsored by the Florida Chapter of the American Academy of Pediatrics as its exclusive carrier of m alpractice insurance for its mem bers. In each issue, FPIC will present an article for our readers on ma tters pertaining to risk m anagem ent] The Keys to Documenting Phone Calls The most important phone call a physician ever receives may be the one you or your staff forgets to document. In today’s legal climate it has become even more important to document all medically relevant phone calls. All phone conversations need to be documented in the patient’s chart regardless of whether the call is received by you or your staff. Your office should have an established procedure for dealing with all calls. Failing to document a call is tantamount to forfeiting evidence in the event a defense become necessary. When a patient calls your office with a problem, have your staff document the phone call in the patient’s chart. Be sure they include important details of the conversations, including the time and date that the call was received, who called, the person who received the call, when the call was returned to the patient, and what was discussed. In addition, vital patient information and the condition or clinical status of the patient should be noted at that time. It does not matter what your office procedure happens to be, what matters is that the phone call gets documented in the patient’s chart. Without documentation, in the event of a claim, it is extremely hard to defend details of discussions and specific instructions. In most cases, if a phone call is not documented and a claim is made and goes to court, it becomes your word against the patient’s word. Without documentation, the patient’s memory may carry more credibility than that of you or your staff who may have seen 20, 30, or more patients that day. Remember to treat after-hour calls the same as any telephone conversation. If you are on-call you may want to consider establishing a procedure for these phone calls to be documented in the patient’s chart as part of the communication process. You may want to consider designating one staff person to follow-up with these patients and the on-call physician. Be sure your staff documents the salient portions of each conversation and what treatment was rendered to each Cliff Rapp, LHRM Vice President of Risk Management, FPIC patient. Protocols should also ensure that the communication loop is completed such that each patient receives a follow-up call. The following are suggested elements to include when documenting phone calls: · Date and time of the call · Patient’s name · Chief complaint or concern · Brief history · Assessment · Disposition/advice · Necessary follow-up by advice-giver · Symptoms that develop which require the patient to call back · Signature or other information to determine advicegiver · Date and time of call to the patient, if applicable [Information in this article does not establish a standard of care, nor is it a substitute for legal advice. The information and suggestions contained here are generalized and may not apply to all practice situations. FPIC recommends you obtain legal advice from a qualified attorney for a more specific application to your practice. This information should be used as a reference guide only.] Note: Another summary of The Florida Pediatrician is on the website for the AAP. The URL is: http://www.aap.org/member/chapters/florida.htm G Page17 From the AAP CHILDREN SHOULD NOT BE GIVEN SMALLPOX VACCINE Washington, DC---As the Bush Administration implemented the first stage of its smallpox vaccination plan, the American Academy of Pediatrics (AAP) testified before Congress that given the information currently available, the general public, particularly children, should not receive the vaccine prior to an outbreak. “Unfortunately, the concept of a pre-event voluntary vaccination program for the public makes the least sense from a scientific and public health standpoint,” said Jon S. Abramson, M.D., chair of the AAP Committee on Infectious Diseases, in testimony before the U.S. Senate Health, Education, Labor and Pensions Committee. “The concept of voluntary vaccination is a misnomer. If the vaccine is made available to the general public, infants and children who don't get the vaccine could be unintentionally inoculated from a vaccinated adult. This could have serious consequences since we know children are particularly vulnerable to suffering complications from the vaccine.” Last year, the Academy announced support for the "ring vaccination" strategy that is an effective method for containing the disease, if it occurs, while minimizing risks. The Academy does recognize the need for select medical and emergency personnel to be vaccinated now in order to carry out their responsibilities to the public if any smallpox cases occur, but liability and compensation for adverse events from the vaccine still needs to be addressed. “If I as part of the healthcare team suffer a serious adverse event from getting the vaccine, I am covered by my state workers' compensation program,” said Dr. Abramson. “However, if I indirectly inoculate one of my children at home or a patient I am caring for in the hospital, and they develop a serious side effect, they are not covered.” The Academy urged Congress to enact a “no-fault” system to compensate those injured directly or indirectly by the smallpox vaccine. It could function in a way similar to the National Vaccine Injury Compensation Program established in the mid-80s. The AAP testimony also called for Congress to ensure that the smallpox vaccine is tested for use in children, similar to the testing required for other childhood vaccines. Page 18 “We don't even know if the vaccine is safe for use in children,” Dr. Abramson said. “If a smallpox attack did occur are we really willing to let millions of children be part of an emergency experiment? We need to be prepared to help children at the time of an outbreak with an effective vaccine at the right dose. Congress can see to it that the necessary studies are done now.”G AAP Partners with March of Dimes, ACOG, and AWHONN The American Academy of Pediatrics (AAP) is excited to be a partner with the American College of Obstetricians and Gynecologists (ACOG), Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) and the March of Dimes to accomplish the goals and aims of the March of Dimes Prematurity Campaign. The five-year Campaign has two goals: to increase public awareness of the problems of prematurity to 60% and to lower the rate of preterm births by 15%. On the National level, the Academy will: # Meet with March of Dimes chapter/division representatives to determine the best strategies to accomplish the Campaign goals. # Designate speakers for the Campaign to address prematurity issues at conferences, Grand Rounds and train-the-trainer events (with funding available through March of Dimes chapters), and at other meetings. We also encourage you to talk with your pregnant patients (or pregnant parents of patients) about the signs of preterm labor, especially those who are already parents of children born prematurely and are at increased risk of subsequent preterm delivery. The Campaign is a concerted effort to address this major pediatric challenge in the US and we want to be recognized as active partners in that effort. G FYI The AAP will no longer print the tax deductibility disclosure statement on the membership dues invoice. Since we are incorporated as a 501 (c) (6) organization, we are required by the IRS to notify our members of the amount of dues that can be deducted as a business expense: Dues remitted to the Florida Chapter are not deductible as a charitable contribution but may be deducted as an ordinary necessary business expense. However, 30% of the dues are not deductible as a business expense for 2002 because of the chapter’s lobbying activity. Please consult your tax advisor for specific information.G More from the AAP It’s Not Too Early To Get Started on HIPAA [HIPAA went into effect on April 14, before press time for this issue. However, it is not too late to be sure of the details, even in review] Implementation of the Administrative Simplification requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) may seem like it is a long way off, but it is not too early to get started. Some of the steps require you to contact your software vendors, your billing clearinghouse (if you use one), and the major health plans that you contract with. This could take time. The American Academy of Pediatrics (AAP) has developed manuals to help you through the process. Beginning in June, AAP News will carry a monthly article highlighting some aspect of HIPAA implementation. It will include timelines and suggested tasks for that month to keep you on track. Here are a few steps to get you started. Download Copies of the Manuals. The first thing to do is to download a copy of each of the two manuals – Electronic Transactions and Code Sets and Privacy. Go to www.aap.org and select the Members Only Channel (MOC) button in the upper right corner of your screen. You’ll be asked for your member ID. Once on the MOC, select the HIPAA link on the left side of the screen. Select the link “AAP HIPAA Compliance Manuals and Tool Sets.” Be sure to download the Word files that contain the template forms you’ll be able to customize for your practice. Read the Overviews. Read the overview of each of the two rules. They will give you a sense of the tasks ahead and the purpose and goals of the rules. Identify a Lead Person for Transactions and Tool Sets. This person should be someone who is familiar with your practice software. It might be you, your office manager, or a billing staff person. Once you have taken the necessary steps to get started plan on actively preparing for HIPAA in the upcoming months! It is important that you give yourself enough time for completing necessary activities to become compliant. The effective date for the Privacy Rule is April 14, 2003. The effective date for the Transactions and Code Set standards is October 16, 2002, but you can file an extension. For more information about HIPAA, contact Aiysha Johnson at [email protected] or 800/433-9016 ext 4089G. Bright Futures at the AAP The American Academy of Pediatrics (AAP) is pleased to announce that it was awarded two cooperative agreements from the Maternal and Child Health Bureau (MCHB), Health Resources and Services Administration (HRSA), to promote the use of Bright Futures among pediatric health care providers and the public. Bright Futures, initiated by the MCHB over a decade ago, is a philosophy and approach that is dedicated to the principle that every child deserves to be healthy, and that optimal health involves a trusting relationship between the health professional, the child, the family, and the community. As part of this initiative, Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents was developed to provide comprehensive health supervision guidelines, including recommendations on immunizations, routine health screening, and anticipatory guidance. Topic specific Bright Futures materials are also available. The first cooperative agreement, the Bright Futures Education Center (EC) focuses on revising the Bright Futures guidelines; improving awareness of the importance of preventive services among health care professionals, public/private partners, communities, and families; and developing materials to assist in implementation of the guidelines. The second cooperative agreement is the Bright Futures: Pediatric Implementation Project (PIP). The purpose of the project is to examine barriers to pediatric provider implementation of Bright Futures guidelines and to develop new strategies to improve implementation of the guidelines. The two AAP programs will work closely together on joint project activities including the development of a new website (http://brightfutures.aap.org) and newsletter. Be on the lookout for the new website (January 2003) and the newsletter (March 2003). If your practice or agency is currently using Bright Futures we would like to hear from you. Our newsletters will feature highlights from groups around the country who are putting Bright Futures into practice. For more information or to share how you are using Bright Futures,please contact Darcy Steinberg, MPH, Director, Bright Futures EC, at 800/433-9016, ext 7935 ([email protected]) or Laura Thomas, MPH, CHES, Manager, Bright Futures EC, at ext 4980 ([email protected]). For questions regarding the Bright Futures: PIP, please contact Linda B. Paul, MPH, Manager, Bright Futures: PIP at ext 7787 ([email protected]). To order Bright Futures materials please call 888/2271770 or log onto the Bright Futures website (http://brightfutures.aap.org).G Page 19 From the FCAAP Gov. Jeb Bush declared Wednesday, March 26, 2003, Suicide Prevention Day and announced a goal of reducing suicide rates by one-third by 2005. "It is something that is clearly preventible and if we believe in the sanctity of life, we believe all life is precious, this should be something we're actively involved in," Bush said. "Suicide is a serious problem in our country and our state. It is the ninth leading cause of death in Florida. Florida is ranked 11th in the nation for suicide among all age groups. In 2001 there were 2,200 suicide deaths in Florida - that's more than double the number of homicides." As part of the effort, schools will be given kits that provide information on how to assist students who pose a suicide risk. G STATEMENT BY TOMMY G. THOMPSON Secretary of Health and Human Services Regarding New F ederal Privacy Regulations From the time of Hippocrates, privacy in medical care has been of prime importance to patients and to the medical profession. Today, as electronic data transmission is becoming ingrained in our health care system, we have new challenges to insure that medical privacy is secured. While many states have enacted laws giving differing degrees of protection, there has never before been a federal standard defining and ensuring medical privacy. Now new federal standards are coming into force to protect the personal health information of every American patient. Page 20 As of Monday, April 14, millions of health plans, hospitals, doctors and other health care providers around the country must comply with new federal privacy regulations. To develop these regulations, the Department of Health and Human Services went through an extensive process of consultation and consensus that included reviewing and considering more than 100,000 public comments. These new federal health privacy regulations set a national floor of privacy protections that will reassure patients that their medical records are kept confidential. The rules will help to ensure appropriate privacy safeguards are in place as we harness information technologies to improve the quality of care provided to patients. Consumers will benefit from these new limits on the way their personal medical records may be used or disclosed by those entrusted with this sensitive information. The new rules also reflect a common-sense balance between protecting patients' privacy and ensuring the best quality care for patients. They do not interfere with the ability of doctors to treat their patients, and they allow important public health activities, such as tracking infectious disease outbreaks and reporting adverse drug events, to continue. Over the past two years, we've worked aggressively to provide doctors, hospitals and other covered entities with the information that they need to comply with the rule. We've held a series of regional conferences on the privacy regulations and participated in hundreds of other conferences and meetings with those affected by the regulations. We've provided extensive guidance and other technical assistance materials that clarify key provisions of the rule, so those affected take the right steps but don't go overboard at the expense of the quality of their patients' care. Many of these materials, including an extensive collection of frequently asked questions, are on our Web site at http://www.hhs.gov/ocr/hipaa/assist.html. We will continue our efforts to encourage covered entities to comply with the regulations' requirements. After all, this is the best way to ensure that patients get the rights and protections that they expect. Of course, we have all the enforcement options available to us under the rule, including civil monetary penalties, and we will use them as and when necessary to obtain our goal of protecting the confidentiality of personal medical information.G The History Corner PEDIATRICS IN FLORIDA A TRADITION OF COMPASSIONATE CARING Deborah Mulligan-Smith, M.D. President Elect [A continuation of the history of FPS/FCAAP, from the previous issue) The past causes the present, and so the future. 1970 - 1980 An important contribution to the affairs of the Chapter and Pediatric Society were periodic newsletters by the Chapter Chairman and the President of the FPS. The first of which was that by Dr. Bob Grayson, dated February 1965. < From a one or two page copy machine production, an improved Newsletter of the FPS was formally initiated (volume 1, July 1979) under the editorship of Dr. Louis St. Petery. A Tallahassee pediatrician, Dr. Louis St. Petery, became Executive Secretary of the FPS and has filled this position continually since then, with the current title of Executive Vice President. The terms of office of the officers of the two organizations were not synchronized, and because the FPS was continually active and successful in its legislative advocacy, it became the dominant organization in our state. During this time, however, most other states combined their Pediatric Societies and Chapters not only in name, but in operating reality. Among legislative victories were: < Change of the Florida Crippled Children's program to the Children's Medical Service which would cover all chronic medical and surgical conditions rather than only orthopedic problems. The constitution was amended so that eight regional districts were established in the State, and an elected representative from each district served on the Executive Committee. This was initiated to improve grass roots member participation, and to inform the membership of the activities of the Executive Committee and of the National Academy. < The AAP Chapter Forum was initiated in 1977 and has continued to gain in importance as the method of communication for the general membership and the AAP Executive Board. Our current Editor of the Florida Pediatrician was one of the members of the five-person Task Force which created the Forum. The Chapter Chair (later called the Chapter President) and the Alternate Chair, (Vice President) attended the Annual Chapter Officers Forum to learn about and discuss issues concerning child health and child well being. 1980 – 2000 The 1980's dawned with a rapidly growing membership, augmented by many Cuban and Central American pediatricians who emigrated to the United States and Miami area to escape the political changes in their native countries. The University of Miami had been particularly helpful in the late 60's and 70's in preparing these pediatricians for taking the Florida licensing < examinations through review sessions in Spanish and English. < During a ten-year period, the Chapter membership nearly tripled from 555 in 1980 to 1463 members in 1990. < A major accomplishment of the nineties, anticipated in the constitution approved in the seventies, was the amalgamation of the FPS and the Florida Chapter in 1994. By-laws, the long sought goal were achieved. < In addition to the Regional Representatives, a strong Legislative Committee was formed under the leadership of Dr. Bob Stempfel of Miami. < A Child Advocate, Dr. Gerold Schiebler, was made an ex-officio voting member of the Executive Committee. < Following the “Annual Post-Graduate Course”, Dr. Altman and faculty members provide a "mini course" in three Central or South American cities. < In 1985, the entire annual course was simulcast in English and Spanish via satellite to the nations of Central America, South America, and the Caribbean. < The annual attendance of pediatricians at Miami Beach numbered as many as 1,700, and estimates of 15,008 physicians attended via satellite. < Drs. Reed Bell and Donald Ian MacDonald were appointed to positions in the Federal Alcohol, Drug Abuse and Mental Health Administration. Dr. MacDonald was Administrator of this Agency for several years during the Bush administration (Continued next page) Page 21 < < < < < < < History ( = continued from previous page) < < < Drs. Reed Bell and Donald Ian MacDonald were appointed to positions in the Federal Alcohol, Drug Abuse and Mental Health Administration. Dr. MacDonald was Administrator of this Agency for several years during the Bush administration. Pediatrician, clinician, cardiologist, educator, administrator, advocate, lobbyist, politician, and friend of children, Dr. Gerry Schiebler, took a sabbatical as University of Florida Chair to become the first head of the CMS to secure a firm beginning. Dr. Gerry Schiebler was recognized in 1993 by the AMA and AAP, jointly, with the Jacobi Award, given for contributions to the practice of pediatrics, for < excellence in teaching and for advocacy in behalf of children. In 1994, the Newsletter was taken over by Herbert Pomerance of USF, Tampa, who assumed the role of editor. The Newsletter, now entitled "The Florida Pediatrician" runs some 25 or more pages, professionally printed on glossy hard paper, and supported by advertising of pediatric products. 1990s, FPS President Dr. Ken Morse and Chapter President Dr. David Cimino arranged for a single slate of officers for the combined organizations. In the early 90's another creative insurance innovation was introduced by Steven Freedman, PhD, an honorary member of the FPS and AAP. Through Freedman and the Society's efforts, the Healthy Kids Corporation Act was passed. This provided for health insurance through the school system, starting in Volusia County (Daytona), and now being offered in county school systems throughout the state. 1993 – 1994, AAP Chapter Award for outstanding Chapter activities is received. In l995 Dr. John Curran assumed the office of the combined presidency of the joined organizations for the first time. On his retirement as chair of the FPS/Chapter Legislative Committee in 1995, Bob Stempfel was honored by the Florida Legislature with a joint resolution of the House and Senate recognizing his outstanding contributions to child health. In 1997 Dick Boothby, a continuously involved pediatrician from Jacksonville, delivered an account of the history of the Florida Regional Perinatal Program, of which he was the first chairman. He recounted that in the early 1970's at which time there were 5 neonatologists in the state, the infant mortality rate was 19 per thousand live births. With a grant of $50,000 from the Florida Regional Medical Program, a multi-disciplined steering committee was formed to improve the care of high risk newborns. The five neonatologists in the initial committee were Drs. Eduardo Bancalari, Miami, John Curran, Tampa, Don Eitzman, Gainesville, Don Garrison, Jacksonville, and Ed Westmark, Pensacola. At the time of Dick Boothby's report (1997), there were over 100 neonatologists (perinatologists), and an infant mortality rate of 7.5 in 1995. 1998, the new Title XXI program, the State Children's Health Insurance Program (SCHIP) is implemented. Florida was one of the first to have its plan of implementation approved by the Federal Government.G [To be continued in next issue] Note: If you are a Fellow of the American Academy of Pediatrics, you are automatically a member of the Florida Pediatric Society/Florida Chapter of the American Academy of Pediatrics, and you automatically receive The Florida Pediatrician. If you have not already done so, please pay your annual Florida dues, billed through the Academy Office. G REGISTRATION Have you registered yet for the Annual Meeting in Orlando, June 20-22, 2003? Important Business CME Credit The CATCH Corner David L. Wood, M.D. North Florida Regional CATCH Facilitator University of Florida/Jacksonville It is with great pleasure that, C.A.T.C.H. as the new North Florida Regional CATCH Coordinator, I write my first Catch Corner for Florida Pediatrician. Now is the time to think about a CATCH grant!!! I want to encourage all pediatricians and pediatric residents in Florida to consider submitting a CATCH grant this year. The CATCH Planning Funds grant cycle l begins in mid-May. New Applications (including on-line) will be available in May. Submitted applications must be postmarked no later than Friday, July 26, 2002. Award recipients will be notified by the end of January 2003. See the following website (on the AAP website under Community Pediatrics) for more information: http://www.aap.org/visit/catchgrants.htm The resident grants have two annual cycles: one that starts in May with a due date of July 25, 2003 and a second cycle that starts in November with a due date of the last Friday of Jan. 2004. If you have any questions or just want to bounce ideas off someone, talk to your local District CATCH Facilitator. The state of Florida is divided into 8 Districts and below are the names and contact information for each District CATCH Coordinator along with the names of the counties they cover. DISTRICT I (Escam bia, San ta Rosa , Okalo osa, Walton, H olmes, Jackson, Washington, Bay, Calhoun, Gulf, Gadsden, Liberty, Franklin, Leon and Wakulla) Julia St. Petery, M.D. 1132 L ee Avenue Tallahassee, FL 32303 Phone: 850-224-8830 Fax: 850-224-8802 Email: [email protected] DIST RIC T II (Duva l, Clay, St. John s, Nassau and Bake r) David L. Wood, M.D., MPH Chief, Division of Community Pediatrics University of Florida Health Science Center/ Jacksonville 655 W est 8 th Street, 5 th Floor Jacksonville, FL 32209 Phone: 904-244-6150 Fax: 904-244-5240 Email: [email protected] DISTRICT III (Alac hua , Volusia, Flagler, Putnam, Ma rion, Citrus, Levy, Dixie,Taylor, Jefferson, Madison, Hamilton, Union, Suwanee, Columbia, Lafayette, Gilchrist and Bradford) G. Neal Wiggins, M.D. 809 North Stone Street Deland, FL 32720 Phone: 386-734-6423 Email: [email protected] DISTRICT IV (Orange, Polk, Seminole, Lake, Sumter, Brevard, Osceola, Indian River, St. Lucie and Okeechobee) Robert Cooper, M.D. Chief, Division of G enera l Acad emicPed iatrics, Nemo urs Children’s ClinicArn old Palmer Hospital for Children and W omen 89 W est Copeland Orlando, FL 32806 Phone: 407-649-9111, Ext. 48812 Fax: 407-843-8505 Email: Rcooper@ nemours.org DISTRICT V (Hillsborough, Pinellas, Pasco and Hernando) Mudra Kumar, M.D. USF Dep artment of Pediatrics 17 Davis Boulevard, Suite 200 Tampa, FL 33606 Phone: 813-272-2268 (TGH) 727-892-8266(ACH) Fax: 813-272-2269 Email: kumarm@ allkids.org DISTRICT VI (Collier, Lee, Charlotte, Hardee, Sarasota, Ma natee, H endry, Desoto , Highla nds an d Gla des) Martha Valiant, M.D. Public Health Unit Director P.O. Box 70 Labelle, FL 33935 Phone: 941-674-4056, Ext.119 Fax: 863-674-4076 Email: [email protected] DIST RIC T V II (Broward, Palm Beach and Martin) Eric Cameron, M.D. Palghat Alamedri, M.D. Memo rial Primary Care Center 4105 Pembroke Road Hollywood, FL 33021 Phone: 954-985-1551, Ext. 2021 Fax: 954-985-1434 Email: [email protected] DIST RIC T V III (Dade and Mo nroe) Gloria Riefkohl, M.D. Miami Children’s Hospital Division of Preventive Medicine Community Health Program 3100 S.W. 62 nd Avenue Miami, FL 33155 Phone: 305-663-6853 Fax: 305-669-6542 Email: [email protected] (Continued next page <) Page 23 C.A.T.C.H. (=Continued from previous page) Improving Access to the Medical Home for Children with Special Health Care Needs. There have been many CATCH projects that have focused on improving access to a medical home for children with special health care needs (CHSCN). Our own Karen Toker, MD, the prior North Florida Regional CATCH Coordinator, received a CATCH grant last year to improve access for CHSCN in the Jacksonville community. Her proposal was to organize the child health community through the local Commission for Children with Special Health Care Needs and create a plan for a system of care that would make the medical home more accessible for CSHCNs. Thus far Dr. Toker has been able to convene several community-wide organizational meetings, which have included community pediatricians and public and private providers of allied and special services for CSHCN. She is fielding a survey to assess pediatrician’s willingness to provide a comprehensive medical home for additional CSHCNs. Based on this information and other input they will write a plan and a larger grant that will allow funding for training and support for pediatricians to do case management, developmental screening and other services for CHSCN that are components of the medical home. As exemplified by Karen’s project, CATCH grants are planning grants. CATCH projects commonly provide funds to a pediatrician to mobilize their local community with the goal of improving access to health or other services for children. The CATCH grants also commonly result in a plan or proposal for a larger project. Many have been successful at having a major improvement in services for children, especially poor or disadvantaged children. Medical Home Collaborative for CSCHN. Providing access for all children to comprehensive medical homes is also major emphasis of the AAP, Title V and child health advocates. Another Medical Home-focused project is also in Jacksonville (pardon my geographic bias, but as they say…’write what you know.’ Deise will get her chance in the next Florida Pediatrician!!). The Florida Children’s Medical Services, local CMS in Jacksonville and 3 pediatric practices in Jacksonville, for a team, one of 11 State Title V agencies/pediatric practice teams chosen to participate in a national learning Page 24 collaborative developed by the National Initiative for Children’s Healthcare Quality (NICHQ), the Center for Medical Home Improvement (CMHI) and the United States Maternal and Child Health Bureau (USMCHB) Division of Services for Children with Special Healthcare Needs. The collaborative is a tremendous opportunity to learn and identify how we, as primary care providers for CHSCN, can support and improve on our provision of the comprehensive medical home. The three practices participating in the collaborative are Dr. David Weiss, a pediatrician in solo private practice; Dr. Olin B. “Chip” Mauldin, of the University of Florida Pediatric Center at Andrew Robinson Elementary School; and Dr. Sandra Morales, of the University of Florida Pediatric Center at San Jose. In addition to the physician/leaders, each practice team will consist of an office staff member and a parent of a child with special health care needs. The teams will work together for twelve months during which they will attend three two-day Learning Sessions, participate in action periods between Learning Sessions and maintain continuous contact with the collaborative faculty members, each other and the collaborative organizations. The offices will assess their own provision of the medical home as defined by the Center for Medical Home Improvement (www.medicalhomeimprovement.org). I encourage all of you to take the test! When I took the test with our residents we found outthat we have a lot to learn and do in our clinics to improve our provision care to CHSCN. As part of the process the Title V programs will seek to improve their understanding of community-based primary care practice as it relates to children with special health care needs and how they can better support pediatricians’ practices. “The Learning Collaborative … goals are consistent with the Healthy People 2010 objective that every child with special health care needs will receive comprehensive care in a Medical Home.” according to Phyllis Sloyer, Director of Florida’s CMS Network and Related Programs, “The second purpose of the collaborative is to foster strong relationships between Title V (CMS) programs and the primary care communities within the state.”G Add-a-Pearl ...from Chu ck W eiss [Here are 10 questions from Chuck. Try them! Answers on Page 27 ] OBESITY AND “TYPE 2"DIABETES CONTROL Questions and Answers 1. Two years ago the UK Childhood Cancer Study found what researchers called “weak evidence of borderline statistical significance”that breast feeding reduced childhood cancer risks. The repeat survey of 3376 mothers with children who died of cancer found no evidence of the claim. T F The International Diabetes Foundation (IDF) states that primary care physicians/pediatricians need to manage their patients blood glucose levels much m ore aggressively if the global explosio n in type 2 diabetes prevalence is to be slowed.1 Many doctors are “too com place nt“ about the nee d for close co ntrol of glucose levels. Unfortunately, this lack of motivation is being p assed on to patients. It is inapp ropriate to say to a pa tient you’ve just go t mild diabetes and you don’t nee d insulin. Diabetes specialists try to reduce pe ople’s bloo d glucose lev els to norm al, acco rding to the ID F. They mu st convince their colleagues that they should do that and at the same time treat all the heart disease risk factors just as seriously. All should be treated aggressively. Type 2 diabetes affects 22.5 million European adults and acco unts for 10 % o f the European he alth care bud get. Professor Albe rti, IDF President* says the increasing rates of type 2 diabetes in adolescents and children are particularly worrisome. “ . . ., unless they’re dealt with meticulously, are going to die of heart disease of kidney failure in their 30's . . . .now we are see ing it in fat white childre n.” . . . studies show that reducing the blood glucose control 2. In a recent report by Harris Interactive, 110 million people look for health information online, and 90 percent of those surveyed want to communicate online with their physicians. T F 3. Most Florida Pediatricians have and use the Online Doctor-Patient Communication tool. T F 4. Throat clearing can be the first sign of pediatric asthma. T F 5. Doctors are “too aggressive” about type 2 diabetes control . T F 6. Increasing rates of type 2 diabetes in adolescents is particularly worryissome. T F 7. Depression in adolescence does not influence risk of obesity. T F 8. Some academic researchers report a high prevalence of impaired glucose tolerance in severely obese children and adolescents T F 9. Soft drinks are the major source of caffeine in caffeine consumption and altered sleep patterns in teenagers. It may be reasonable to limit the caffeine content and restrict the type of beverages promoted to teenagers. T F 10. The administration of vaccines containing thiomersal does not appear to raise blood mercury concentrations above safe levels and ethylmercury seems to be eliminated rapidly via the stools. T F marker Hb1c by just 1% cuts the risk of MI by 14% and the risk of eye and kidney da mage by nearly 45 %. Typ e 2 diabetes is largely a consequence of an unhealthy lifestyle and it is preventable. Other serious risks of adolescent obesity: Depression2 Adolescents with depression are at increased risk for the development and p ersistenc e of obesity. 2 A depressed mood present at the first interview, based on a modified Center for E pidemiolo gic Studies Depression Scale more than doubled the risk of obesity at one-year follow-up as well as the risk of developing obesity among those who initially were not obese. This suggests that if you treat depression in adolescents you may stave off the onset of obesity or prevent an o bese child fro m be com ing mo re ob ese. These supporting data are the result of a joint study of Banders University and the Cincinnati Children’s Hospital Medical Center. They gathered data jointly on 9,000 adolescents who were in grades 7-12 when first interviewed in 1995. In this cohort, the number of obese parents was the strongest correlate of obesity at the baseline. Clinicians should “talk to young people, not just their parents” and “encourage parents to talk to their kids about feelings, and to definitely not make light of them. Self-esteem of Obese Children Below That of Peers3 A study has found a startling level of despair among obese children, with many rating their quality of life as low as (See Pearls, page 27 <) Page 25 President (= continued from page 3) Women’s Nonetheless, we did make some significant progress. The Medicaid fee increase, although modest, has moved reimbursement closer to being acceptable for some services, but there is still more to do. We have had some success with legislation aimed at making the environment in Florida safer for children, but there is still more that can be done. We have begun to streamline the KidCare program to make it friendlier to families and pediatricians, but there is still more that must be done. To strengthen our position, we have reached out to other child and family advocates within the state to build a broad-based coalition to address these challenges successfully. All members of the coalition have a common goal: access to affordable, quality pediatric care for all of Florida’s children. Each member of the coalition is dedicated to improving the administrative structure of the KidCare program to make it seamless for families and Pediatricians. Each member of the coalition sees Pediatricians as the best qualified to deliver that quality care to children. And each member of the coalition understands that full access to quality care will not occur in Florida until Pediatricians are adequately and appropriately reimbursed from all components of the KidCare program. In closing, I want to thank all of you for your active participation in the Chapter, but most of all, I want to thank you for allowing me to be your President. ( = continued from page 13) advocate and violence folks have the opportunity to communicate with providers and improve awareness in the community. The organization helped recruit new mental health service providers in the community, collaborated with Juvenile Justice in conducting a public forum with families and adolescents and obtained grants for the teenage pregnancy prevention through the library program. The library also received funds for a reading enhancement program. The best part was, in my opinion, the celebration of children this past March. Franklin's Promise presented the Franklin County Board of County Commissioners' with a resolution supporting children, community initiatives serving children, and declaring Thursday March 20th Children's Day. The Board adopted the resolution acknowledging that every dollar used to fund children's initiatives is a dollar well spent and a significant investment in the future of the community, the state and the nation. On Children's Day in the playground of Chapman Elementary School in Apalachicola, about eighty-seven children attended to two hours of fun and games. Volunteers from Franklin's Promise manned the booths. The celebration was a great success. And I expect continuing success on the part of the community through the initiative of Franklin's Promise, Inc. G With warmest regards, REGISTRATION Richard L. Bucciarelli, M.D.G Have you registered yet for the Annual Meeting in Orlando, June 20-22, 2003? Important Business CME Credit The “Ticked Off” Column. If you are really “ticked off” about something in your practice or about medical economics in general, write about it and send it in. reasonable complaint will find its way into print!G Page 26 Any Resident Pearls ( = continued from page 14) ( = continued from page 25) Top Ten Reasons why you should become a member of the Resident Section 10) To receive free journals and other resources available to AAP members 9) To use the resident section web page www.aap.org/sections/resident 8) To learn how the AAP affects legislation through a health policy elective at the national AAP office 7) To get INVOLVED in the community whether by service, advocacy, or politics 6) To lobby for children’s issues 5) To learn about new job opportunities 4) To meet life-long mentors and colleagues 3) To meet and build relationships with residents from across the country 2) To participate in the Florida Chapter AAP Annual Meeting ** June 20-22nd in Orlando** THE TOP REASON….. 1) To participate in the national conference **This year it’s in New Orleans! October 31st-November 5th** G Add-A Pearl that of young cancer patients on chem otherapy. The JAM A offers a sobering glimp se of what life is like for an obese youngster. They are teased about their size, have trouble playing sports and suffer physical ailmen ts linked to their weight. An obesity researcher, Kelly Brownell, who runs a Yale University weight disorder center, said the increasing prevalence of obesity hasn’t mad e it any less stigmatizing. In the study, 106 children, age five to 18 were asked to rate their well-being on physical, emotional and social measure s. Obe se youths scored an average of 67 points out of 100. 16 points lower than a group of 400 mo stly normal weight children. The obese childre n’s scores were similar to the quality of life self-ratings from a previously published study of about 100 p ediatric cancer p atients. Girls and boys in the study ap peared to be eq ually adversely affected by ob esity. On the average the typical 12-year-old youngsters were 5 -foot = 1 and 174 pounds . Obesity related ailments were common, including fatty liver disease, obstructive sleep apnea, diabetes and ortho ped ic problems caused by excess weight. Even in the absence of this conditions, \, children and parents reported a low quality of life. Rep ortedly parental assessmen ts rated their child rens’ wellbeing even lower than the childs’ self-ratings. The only hope for relief today, is the experimental (un licensed) drug Sibutrime. In studies, thus far, it has provided what might be considered useful weight control, reductions in hunger and body mass index. (BMI) Side effects require more safety and efficacy data before the drug may b e used outside of experim ental settings. from Chuck W eiss ( = questions on page 25) Add-a-Pearl Answers from Chuck Weiss 1. True Ref: Br J Cancer 2003; 88:000-000 2. True Ref: Harris Interactive Poll 3. False Ref:Harris Interactive Poll 4. True Ref: N Engl J Med 2002; 348:1502-1503 5. False Ref: Intl Diabetes Foundation, April News release 6 True Ref: Intl Diabetes Foundation, April News release 7 False Ref: Pediatrics, 2002; 109:497-504 8 True Ref: N Engl J Med 2002; 346:802-810, 854-855 9 True Ref: Pediatrics 2003; 111: 42-46 10 True Ref: Lancet 2002; 360: 1737-1741 G Impaire d Gluc ose Tolerance Common in Obese Children and Ado lescents. 4 Researchers at the Yale University School of Med icine report a high prevalence of impaired glucose toleranc e in severely obese children and adolescents. Among 55 obese children, 25% had impaired glucose toleranc e, as did 21 % o f the 112 o bese adolesce nts. In addition 4% of the adolescents were diagnosed with silent type 2 diabetes. “Despite all our best efforts, prevention of childhood obesity eludes our grasp,“ comment of a U niversity of Michigan research physician, in a journal editorial. “Even with successful weight loss, the rate of relapses is high. I believe that a more effective strategy is to identify those obese children who are at high risk for diabetes and to target them for intensive weight-loss treatment,” he advised. “Oral glucose-tolerance testing appears to be an excellent method for reliably identifying obese children who are at high risk for diabetes.” 1. Reuters 2002-05-29 9:31:23 2. Pediatrics Sept 02 3. JAMA, April 9, 2003 4. N Engl J Med 2002; 346:802-810, 854-855 G Page 27 Paid Advertisement PROS (=continued from page 8) routine well child check up season (April – August) is upon us. We need your help now!! Are you interested in testing some new, brief screening and counseling tools for violence prevention and reading promotion? The project involves minimal paperwork and last only 2 – 4 weeks. Its results will lead to new recommendations on how we as pediatricians provide guidance on these and other safety & developmental issues. We are actively enrolling practices in PROS CARES (Child Abuse Recognition Experience Study). Clinicians complete a postcard size survey when seeing children presenting with an injury and a longer survey if the child has a high likelihood of abuse. Outcomes are then monitored. By collecting this information from many practices across the nation, we expect a pattern to emerge that will help inform our decision-making. New projects in the pipeline include identifying timing of pubertal changes in boys, creating tools to help clinicians update immunizations, and improving the effectiveness of anticipatory guidance. Keep an eye out for future developments. If you are interested in working on a PROS study at any level (enrolling patients to designing projects), contact us at [email protected] or call 800-433-9016, extension 7626. Further, please contact me if you are interested in having a 12-minute slide presentation about PROS at your local hospital or pediatric society meeting. Respectfully submitted, Lloyd N. Werk, MD, MPH, FAAP Email: [email protected] 407-650-7177G TAMPA OPPORTUNITY Ne w ly Created Position! Se e pa tients in our state-o fthe-a rt facilities Saturday and S und ay 1p-11p and 2 -3 we ekdays 5p-11p . Your d ays are for hobbies, fun, or just relax ing! AHP works in conc ert with the patient’s prim ary care physician. Must be BC Pediatrician w ith at least 3 yrs expe rience. Fast p aced e nviron me nt, full benefits package and excellent compensation. To become a p art of this exciting, unique practice, email your C V to HR @ afterhourspediatrics.com or fax your CV to 813.622.7589. Visit us on the web at http ://ww w .afterho urspediatrics.c om . EO E M /F/D /V Reach out and Read (= continued from page 8) parents and enticing the interest of the children. The ROR Florida Coalition will support the activities of individual sites in Florida through technical assistance and training, legislative advocacy, fundraising, and expanded visibility. You can learn more about Reach Out and Read at www.reachoutandread.org. The partnership between the FPS Foundation and the ROR Florida Coalition promises to promote the healthy development of young children in Florida. Can the statewide presence of the Florida Pediatric Society Foundation similarly help an organization you work with? Respectfully submitted, Lloyd N. Werk, MD, MPH, FAAP Nemours Foundation Lee Sanders, MD, MPH, FAAP University of Miami Page 28 Managed (= continued from page 15) Examples include: • CPT code 17250 - chemical cauterization of granulation tissue (proud flesh, sinus or fistula); with E&M services; • CPT code 536 70 - catheterization, urethra; simple; with E&M services (Please note the complaint received was concerning CPT code 53670 that has been deleted in the 2003 CPT Book and replaced with CPT code 5 1701 - insertion of non-indwelling bladder catheter (e.g., straight catheterization for residual urine) and CPT code 51702 - insertion of temporary indwelling blad der catheter; simple (e.g., Fo ley) • CPT code 69210 - removal imp acted cerum en (sep arate procedure), one or both ears; with E&M services; and • CPT code series 99381 - 993 97 - preventive medicine services with E& M services. There has been a lack of recognition or improper assignment of Mod ifier –59 which was developed for the Med icare National Correct Coding Initiative explicitly for the purpo se of identifying services not typically performed together. Modifier –59 is appended to indicate that under certain circumstances the physician may need to indicate that a procedure or service was distinct or independent from other service s performed on the same day. Highmark has also repeatedly failed to recognize various CPT co des: Examples include: • CPT code 99050 - services requested after office hours in addition to basic service; and • CPT code 99058 - office services provided on an emergency basis; and • CPT code 99215 - office or other outpatient visit for the evaluation and management of an established patient; downcoded to CPT code 99214 - office or other outpatient visit for the evaluation and management of an established p atient. The undersigned medical associations have received com plaints concerning Emp ire B lueC ross BlueS hield's inapp ropriate bundling of CPT code series 99381 - 99387 and 99391- 99397 - preventive m edicine services with ap propriate CPT code series 99201 - 99205, and 99211 - 99215 – office / outpatient E& M services: This practice is inco nsistent with CPT guidelines and conventions as stated within the CPT B ook. “If an abnormality/ies is/are encountered or a preexisting problem addressed in the p rocess of performing this preventive medicine evaluation and management service and if the problem / abno rmality is significant eno ugh to require additional work to perform the key components of a problem-oriented E&M service, then the appropriate Office / Outp atient code 99201 - 99215 should also be reported. Modifier –25 should be added to the Office / Outpatient code to indicate that a significant separately identifiab le Evaluation and Management service was provided by the same physician on the same day as the preventive medicine service. The app ropriate preventive medicine service is additionally reported.” Downco ding, bundling and lack of recognition of CPT modifiers by BCBSK S: Mo difier –25 has been denied for the purpose of bundling. Examples include: • CPT code 90471 - immunization administration (includes percutaneous, intradermal, subcutaneous, intramuscular and jet injections); one vaccine (single or combination vaccine / toxoid ); with preventive medicine E&M services; and • CPT code 90472 - immunization administration (includes percutaneous, intradermal, subcutaneous, intramuscular and jet injections and/or intranasal or oral administration); two or more single or combination vaccines / toxoid s); with preventive medicine E&M services. Instead of rewarding physicians and non-physician healthcare professionals for providing necessary patient care efficiently during the same visit, BCBS KS is penalizing physicians and non-physician healthcare professionals for providing quality, efficient care to patients that is consistent with current medical guidelines and standards. The undersigned medical associations are opposed to health plan payment policy that requires a patient to come back for a subsequent visit for necessary care wh en this treatment could have been provided during the original visit as this practice jeopardizes quality patient care and safety, and threatens the patient-physician relationship. 3. PROMPT PAY BROCHURES As part of its Campaign to Promo te Timely Payment, the A M A is working with state medical associations to develop prompt payment brochures that are state-specific. Brochures were developed to educate both physicians and patients about their state's prompt payment laws. Click on the links below to see samples of the brochures developed by the FMA and the AMA: < h t t p : / / w w w . a m a assn.org/ama1/pub/upload/mm/36 8/floridapatientbro2.pdf> Florida Every pediatrician who deals w ith managed care should be regularly accessing the A AP .org M emb ers O nly Cha nnel to study the information under reimb ursem ent activities. 4. ME DICA ID ISSUES As of this time, any Florida Medicaid changes are unclear. It appears that circumcisions will no longer be covered. The prop osed fee increase is promised but not as yet delivered. I welcome questions concerning managed care issues at [email protected]. Page 29 GENERAL PEDIATRIC UPDATE IX and FLORIDA CHAPTER AAP ANNUAL BUSINESS MEETING and FLORIDA PEDIATRIC ALUMNI ASSOCOATION, INC. ANNUAL MEETING JUNE 20-22, 2003 HILTON IN THE WALT DISNEY WORLD RESORT LAKE BUENA VISTA, FL FEATURING E. STEPHEN EDWARDS, MD, FAAP PRESIDENT, AAP Annual Meetings include Florida Pediatric Alu,mni Association, Inc., University of Miami/Jackson Memorial Hospital Pediatric Alumni, and University of South Florida Pediatric Alumni APPROVED FOR 12.5 CATEGORY I CME CREDITS For More Information, contact Florida Pediatric Society at 850-224-3939 or visit us on the web at www.fcaap.org REGISTER NOW REGISTRATION FORM GENERAL PEDIATRIC UPDATE IX June 20, 21, and 22, 2003 Hilton in the Walt Disney World Resort, Lake Buena Vista, FL Name: (Please Print) Mailing Address: City, State, Zip: Phone: ( ) E-Mail Address: I will be attending the following: Friday, June 20 Welcome Dinner $10 - spouse $5 - per child Saturday, June21 Florida Chapter AAP Annual Business Meeting. and Alumni Luncheons (No Charge) Saturday, June 21 Reception (No Charge) ______#Adults_____#Children ______#Attendees ______#Adults______#Children Saturday, June 21 Florida Pediatric Alumni Assoc. Dinner (Charge for this dinner to he determined) ______#Adults Saturday, June21 Children’s Dinner (Charge for this dinner to be determined) ______#Children SCIENTIFIC SESSIONS - Friday. Saturday. and Sunday Please check appropriate category for registration ______FPS/FCAAP Member - $150 registration fee ______Non-Member - $250 registration fee (includes a one-year membership to FPS) ______Resident - No Charge ______Emeritus Fellow - No Charge Enclosed is my check made payable to the Florida Pediatric Society in the amount of $______. Please mail this form and check to: The Florida Pediatric Society 1132 Lee Avenue Tallahassee, FL 32303 The Hilton in the Walt I)isnev World Resort is holding a block of rooms for our meeting. The room rate is $115 plus tax (Junior Suite is $155 plus tax). Please call 1-800-782-4414 and mention the Florida Pediatric Society Meeting. The deadline for reservations is May 20, 2003. Reach Out and Read - Florida Book Drive: Bring a new or gently used children’s hook (suitable for ages 6 months to 5 years old), All books will be distributed to young indigent children to promote reading and early child literacy. For further information, please contact us at (305) 243-3619. Upcoming Continuing Medical Education Events THE FLORIDA PEDIATRICIAN will publish Upcoming Continuing Medical Education Events planned. Please send notices to the Editor as early as possible, in order to accommodate press times in February, May, August, and November. Program: Dates: Place: Credit: Practical Pediatrics May 16-18, 2003 Anchorage Marriott Downtown, Anchorage, AK Hour for hour (up to 16.5 hours), for Category 1 for AMA Physician Recognition Award Sponsor: American Academy of Pediatrics Inquiries: American Academy of Pediatrics, (800) 4339016, ext 6796 or 7657 Program: Dates: Place: Credit: Program: Pediatrics Symposium: Update 2003 Dates: May 24-26, 2003 Place: Sandestin Beach Hilton Golf and Tennis Resort, Destin, FL Credit:: Hour for hour (up to 29 hours), for Category 1 for AMA Physician Recognition Award Sponsor: Medical Educational Council of Pensacola/Sacred Heart Children’s Hospital Inquiries: Call (850) 477-4956 Program: Dates: Place: Credit: 27 th Annual Florida Suncoast Conference June 27-29, 2003 Trade Winds Island Grand Resort, St. Pete Beach Up to 13 hours for Category 1 for AMA Physician Recognition Award Sponsor: University of South Florida and All Children’s Hospital Inquiries: Terra Sroka, (727)892-8584 Program: Dates: Place: Credit: Practical Pediatrics August 29-31, 2003 Seattle, Washington Hour for hour (up to 16.5 hours), for Category 1 for AMA Physician Recognition Award Sponsor: American Academy of Pediatrics Inquiries: American Academy of Pediatrics, (800)433-9016, ext 6796 or 7657 Practical Pediatrics October 10-12, 2003 Toronto, Ontario, Canada Hour for hour (up to 16.5 hours), for Category 1 for AMA Physician Recognition Award Sponsor: American Academy of Pediatrics Inquiries: American Academy of Pediatrics, (800)433-9016, ext 6796 or 7657 Program: Dates: Place: Credit: Practical Pediatrics November 14-16, 2003 Tempe, Arizona Hour for hour (up to 16.5 hours), for Category 1 for AMA Physician Recognition Award Sponsor: American Academy of Pediatrics Inquiries: American Academy of Pediatrics, (800)433-9016, ext 6796 or 7657 Page 32 The Florida Pediatrician c/o USF Department of Pediatrics 12901 Bruce B. Downs Boulevard MDC Box 15CE Tampa, FL 33612 Non-Profit Org. U.S. Postage PAID Permit No. 1632 Tampa, Florida