A QUARTERLY NEWSMAGAZINE OF THE OHIO CHAPTER, AMERICAN ACADEMY OF PEDIATRICS FALL 2017
Ohio AAP Annual Meeting Focuses on Supporting Members and Children
All in for Kids
Annual Meeting Award
Winners
Supporting our
Membership
Value-Based
Payments
In This Issue
Issue Focus
President’s Message • 3 Annual Meeting Wrap • 5-6, 17-19, 26 Chapter Annual Report • 7-8 Membership Referral Program• 11, 25 A Deeper Dive: Bowel Management • 13 Resident Column: Global Health • 21
The Ohio AAP’s Practice of Pediatrics and Membership Pillar helps those involved in pediatric care navigate the business and operations of the practice. The pillar engages specific populations of physicians – such as hospitalists, sub-specialists, young physicians and private practitioners.
Practice of Pediatrics
Sports Shorts • 29-30
Pediatric Education Center A new resource for all of your educational needs!
Conferences Live Courses Child Health
OhioAAP.org
Online CME Online MOC Part II Archived Education
Ohio Pediatrics: A publication of the Ohio Chapter, American Academy of Pediatrics Officers: President: Robert Murray, MD, FAAP President-Elect: Michael Gittelman, MD, FAAP Treasurer: Jill Fitch, MD, FAAP Immediate Past-President: Andrew Garner, MD, PhD, FAAP Delegates-At-Large: Sarah Denny, MD, FAAP Kelsey Logan, MD, FAAP Katherine Krueck, MD, FAAP Advocacy Liaison: William Cotton, MD, FAAP Hospital-Employed Physician Liaison: Christopher Peltier, MD, FAAP Chief Executive Officer: Melissa Wervey Arnold Lobbyists: Dan Jones & Danny Hurley, Capitol Consulting Group
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Fall 2017 • Ohio Pediatrics www.ohioaap.org
Ohio Pediatrics Editorial Board Members: Sherman Alter, MD, FAAP – Blue Ash Mary Ayers, MD – Cleveland Jaclyn Bjelac, MD, FAAP – Cleveland Jennifer Hardie, MD, FAAP – Lebanon Kathleen Matic, MD – Dayton Emia Oppenheim, PhD, RD, LD – Columbus Thomas Phelps, MD, FAAP – Novelty Roopa Thakur, MD, FAAP – Beachwood Greg Walker, MD, FAAP – Cincinnati Editor: Melanie Farkas Ohio Chapter, American Academy of Pediatrics 94-A Northwoods Boulevard | Columbus, Ohio 43235 (614) 846-6258
Ohio Pediatricswww.ohioaap.org • Fall 2017 2
President’s Column Robert Murray, MD, FAAP President, Ohio Chapter, American Academy of Pediatrics We Americans tend to gravitate toward simple and even simplistic solutions to address complex issues. It’s not hard to understand why. American medicine was slow to embrace the germ theory, despite convincing early evidence from European researchers. But within a few decades, one by one, causal microorganisms were identified and interventions were developed. The transformation of medicine was striking: in 1900, the top 10 killers in the U.S. were nearly all infectious diseases; by 2000, none were. Something similar happened in nutrition. In a burst of research early in the 1900s, all the vitamins were identified and the signs and symptoms associated with deficiency states were characterized. It was revolutionary time in medicine.
A similar mindset teed up dietary fat and later high-fructose corn syrup as “the cause” of obesity, salt as “the cause” of hypertension, and saturated fats as “the cause” of cardiovascular disease. Association data may give the appearance of certainty, but evidence from high-quality systematic reviews, meta-analyses, and randomized controlled trials have repeatedly overturned these simple associations. The diseases are more complicated than that.
So not surprisingly, in the 1940s when cardiovascular disease assumed the mantle of the number one killer in the U.S., the medical community searched for its single, identifiable cause. To find it, cardiovascular researchers needed to invent new methodologies (nutritional epidemiology) and statistical approaches (regression analysis). Lipid plaques in vessels appeared to cause mechanical blockage. Early epidemiology data (much of it misinterpreted, it turns out) suggested that dietary cholesterol was “the cause.” For the next 70 years, public support for the concept swept aside objections from doubters until meta-analyses of the whole body of evidence finally changed the medical mind.
Recently, it is sugars being touted as “the cause” of obesity and all its cardio-metabolic conditions. Sadly, the 20th century is a case study of how our certitude can do great harm to the nation’s nutritional status. So I wonder, are we going to do it again? I thought about all this when I watched a debate over the question, “Should 100% fruit juices be eliminated from the diets of children?” Well, maybe so if sugars are truly “toxic” and “poison.” But that means that obesity, diabetes, and cardiac risk factors are pretty simple diseases – they all arise from one isolated dietary factor. Unfortunately, once again the high-quality evidence is beginning to show that it’s more complicated than that.
Congratulations, Dr. Murray! At the Ohio AAP’s 2017 Annual Meeting, the American Dairy Association Mideast presented Ohio AAP president, Robert Murray, MD, FAAP, with a special award recognizing him for his leadership, dedication, and contributions to child nutrition. The award was a very appropriate glass cereal bowl! Pictured left to right: Karen Bakies, RD, LD, American Dairy Association Mideast; Robert Murray, MD, FAAP, President, Ohio AAP; June Wedd, Vice President, School Wellness American Dairy Association Mideast
www.ohioaap.org
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Statehouse Update Ohio Voters Reject Drug Pricing Ballot Effort In November 2017, voters shot down Issue 2 (Drug Price Relief Act) by a margin of 79% to 21%. This was a far wider margin than in 2016 when backers attempted a similar effort in California; that effort failed 54% to 46%. Issue 2, backed by the AIDS Healthcare Foundation (AHF), would have tied prices paid by state and local entities for prescription drugs to the amount paid by the U.S. Department of Veterans Affairs. Proponents argued that reference pricing would save Ohio taxpayers nearly $400 million and help drive down healthcare costs. In their statutorily required review of the measure, the Ohio Office of Budget and Management did not concur with the savings claimed by AHF and other supporters. Opposition to Issue 2 was largely funded by the Pharmaceutical Research and Manufacturers of America (PhRMA). However, many other organizations opposed the measure, including the Ohio AAP, Ohio State Medical Association, Ohio Hospital Association, numerous veterans’ organizations, the Ohio Farm Bureau, and the Ohio Manufacturers Association. The Ohio AAP, after careful consideration, determined the vaguely-worded issue would have imposed unworkable contracting requirements for state prescription drug prices and could have caused private insurance costs to rise along with providing access problems for children and their families. Following two successive defeats and millions of dollars spent on unsuccessful campaigns, it is unclear what AHF CEO Michael Weinstein will do next. For now, it does not appear any further ballot issues will be advanced in Ohio; South Dakota and Washington DC are the likely targets. Across Ohio and the nation, the issue of rising prescription drug prices continues to draw attention from policymakers and criticism from healthcare consumers. The Ohio AAP agrees the costs ought to be reined in for prescriptions. We can expect further efforts and legislation aimed at reigning in high drug costs. State Controlling Board Votes to Sustain Medicaid Expansion On October 30th, the State Controlling Board approved the release of $264 million in state funding for the Ohio Department of Medicaid (ODM). These funds represent the state share of funding for coverage of the Expansion population for State Fiscal Years 2018 and 2019. The unanimous vote by Controlling Board will allow ODM to draw down an additional $638 million in federal matching funds. The requirement that ODM seek Controlling Board approval for Medicaid Expansion funding was included in House Bill 49, the State Operating Budget for FY18/19; HB 49 was signed by Governor Kasich on June 30th. 4
Fall 2017 • Ohio Pediatrics www.ohioaap.org
The State Controlling Board is a spending oversight panel comprised of legislators and chaired by an appointee of the Governor. The board approves contracts, authorizes appropriation increases, and in limited cases approves the release of funds for certain purposes. Controlling Board was the same entity that Kasich used to expand Medicaid coverage in 2014. The Board approved a major appropriation increase for ODM following expansion of the Medicaid program through authority granted to the Ohio Medicaid Director. In addition to requiring Controlling Board approval for Expansion, HB 49 also included language prohibiting ODM from expanding coverage in the future without legislative approval.
Advocacy
This vote does not mean Medicaid Expansion is safe in Ohio. The Ohio House of Representatives could still vote to override Governor Kasich’s veto of language in HB 49 freezing Expansion enrollment in FY19; the Ohio Senate would have to follow suit. Additionally, any changes to Medicaid at the federal level, including a repeal of the Affordable Care Act, would put Expansion at risk. Finally, Medicaid Expansion has become a target for at least two Republican candidates for Governor, meaning it could be put on the chopping block in 2019 after Kasich’s successor takes office. Dangerous Fireworks Legislation Moving Through General Assembly House Bill 226, sponsored by State Representatives Bill Seitz (R-Cincinnati) and Martin Sweeny (D-Cleveland), was introduced in May and passed the Ohio House of Representatives last month by a vote of 83-14. The measure would legalize the discharge of consumer fireworks beginning in 2020; Ohio is one of only six states that still prohibit discharge of 1.4g fireworks. HB 226 would also establish a study committee comprised of fire safety officials, fireworks industry reps, and healthcare advocates including a pediatrician to make further recommendations to Ohio’s fireworks laws. The Ohio AAP, along with many other child safety and public health advocates, continues to oppose HB 226. The bill is likely to receive hearings in the Ohio Senate in December before the legislature wraps up work for the year. Danny Hurley, Lobbyist Thank you to all of our members who made calls, held meetings, testified on issues or took part in other advocacy efforts to promote the health and well-being of Ohio’s children! Ohio Pediatricswww.ohioaap.org • Fall 2017 4
2017 Ohio AAP Annual Meeting We Are All In for Children On October 27, 2017, 291 attendees gathered at the Crowne Plaza Hotel in Dublin, Ohio to hear an exciting Keynote Address from Mark Del Monte, JD, a National AAP leader. Mr. Del Monte provided an update on how pediatricians can advocate for children with the AAP Blueprint for Children, which highlights specific policy recommendations for the federal government to align its activities to promote healthy children, support secure families, build strong communities, and ensure that the United States is a leading nation for children. During his talk, Mr. Del Monte highlighted the importance of social media, and even provided special recognition for the many Ohio pediatricians who took to social media in support of children’s health Keynote Address with Mark Del Monte during the summer and fall of 2017. He reminded attendees that while advocacy victories are often hard fought, the results are worth it and every voice matters! Mr. Del Monte also entertained questions from the audience pertaining to topics like reimbursement, gun control and CHIP. Finally, he challenged ALL Ohio AAP members to become engaged in advocacy through many avenues, including supporting the Advocacy Pillar, advocating for child health at the state level by meeting with legislators in Ohio, using social media to share your political views as they pertain to pediatric issues, connecting with the Ohio AAP on social media at https:// www.facebook.com/aapohio/ or @OHPediatricians on Twitter, or by contacting Melissa Wervey Arnold at marnold@ohioaap.org and by having your voice heard for Ohio’s children. The inaugural Hospitalist Track at Annual Meeting 2017 successfully b r o u g h t t o g e t h e r physicians representing hospitalist from all regions Hospitalist Oral Presentation of Ohio. The Keynote Session presented by Dr. Samir Shah was attended by 30 physicians, and set the tone for a weekend of discussion focusing on how the Ohio AAP can assist hospitalists in collaborative learning and implementation of best practices to improve patient outcomes. Throughout Annual Meeting, www.ohioaap.org
hospitalists shared ideas and innovations, including how the Ohio AAP has supported QI projects in Ohio hospitals and the first Hospitalist Abstract and Poster session, which awarded $500 in prizes. Attendees will be invited to join future discussions on projects or meeting tracks for 2018. To become involved in Ohio AAP Hospitalist activities, please contact Hayley Southworth at hsouthworth@ohioaap.org. Kristen Shemory, Esq. joined the resident track for a highly informative session on negotiating contract agreements. The discussion included great insight into the process of contracting, specifically the areas in which there is greater ability for new hires to negotiate. Ms. Shemory shared tips ... continued on page 6
The Ohio AAP Annual Meeting - What Have I Been Missing? A lot!! Thirty years as an Ohio Pediatrician in Chesterland, Ohio has given me much to remember, much to embrace, much to learn and most importantly much to be thankful. I had always thought of attending the Ohio AAP Annual Meeting but often found myself occupied. This year was to be different. I made the call, signed the form and cleared my schedule. Here are my highlights....Registration was easy, and I was greeted by the Ohio AAP team along with 43 exhibitors willing to answer any questions. People in Ohio know People in Ohio! From conversations with new and old friends from Northern Ohio to learning about how other practices work on obesity prevention in a format driven by pediatric research over the years along with an insightful Keynote reminding us we are all in this for the children. I even started my venture with Patenting at Mealtime and Playtime MOC II and IV. There was so much more going on to choose from over the two days as well as the 7th Annual Casino Night FUNdraiser. We are OHIO, We are pediatric providers, We are children-centered and we make a difference one child at a time!! Mark your Calendars for September 21-22, 2018 - I will be there! Thomas Phelps, MD, FAAP CCF Community Pediatrics, Chesterland, Ohio Ohio Pediatrics • Fall 2017
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Annual Meeting ...continued from page 5 for ensuring the contracts entered into are “win-win” situations for both hiring entities and residents. Ms. Shemory encouraged residents to ask questions regarding policies and contract language, to be responsive to administrators and staff, and to be timely in completing all paperwork and provided additional tips for succeeding. Shark Tank 2017 ideas were top notch! We had six oral presentations with fantastic ideas addressing health across levels of social determinants from the built environment to clinical care. Dr. Margot Lazow presented Shark Tank Oral Presentations her winning idea on “Development of an Interactive Virtual Tour of a Local Impoverished Neighborhood: Can this Impact Pediatric Physicians’ Perspectives and Practice?” Poster presentations offered another opportunity to learn of the many ideas of pediatricians and medical students across the state. Kelsey Maag and Katelyn Carlson’s poster titled, “Quality Improvement Projects: A Medical Student’s Role and Perspective” received recognition for the work they’ve done with quality improvement projects. As part of the Ohio AAP’s continuing focus on the needs of children at risk for injury and abuse, the Child Abuse and Neglect Prevention Maintenance of Certification (MOC) Part II Child Abuse & Prevention Self-Assessment was MOC Part II Self-Assessment presented on Friday to an audience of over 60 attendees. This self-assessment prepares primary care pediatricians to better identify and address children who may have already experienced injury or abuse, or to use prevention strategies for those at risk. The assessment also guides pediatricians on topics that require referral in comparison with those that can be addressed in a primary care office, including how the Safe Environment for Every Kid (SEEK) screening tool can help physicians recognize and refer for abuse risks. The Ohio AAP is currently accepting practices to use the SEEK tool as part of Wave 2 of the Injury Prevention Plus SEEK Learning Collaborative, which launches in January and will offer sleep sacks, cabinet locks, books, and other incentives for patients of participating practices. The program also provides MOC Part IV credit and options to earn MOC Part II; to enroll or learn more, visit http://ohioaap.org/SEEK or contact Hayley Southworth at hsouthworth@ohioaap.org. The Opioid Crisis in Ohio Panel discussion included a multidisciplinary panel of experts highly engaged in the opioid crisis in Ohio. The session included an in-depth discussion of the increase in discharge rates for Neonatal Abstinence Syndrome 6
Fall 2017 • Ohio Pediatrics www.ohioaap.org
(NAS) in Ohio over the past 15 years. A variety of topics related to opiate use were explored including: non-pharmacologic and pharmacologic treatments for NAS, prevention of opioid use Opioid Crisis in Ohio Panel Discussion with adolescent patients, and caring for babies with NAS in the foster care system. The second day kicked off with breakfast Saturday, a full ballroom of providers listened to updates from Richard Tuck, MD, FAAP District V Chair and Colleen Kraft, MD, FAAP incoming AAP President. Jill Castle, MS, RDN presented Introducing Solids: The Pros and Pitfalls of Modern Feeding in a plenary session during Annual Meeting. Ms. Castle emphasized the importance of feeding in the first few years of life as a critical window for meeting high nutrient needs, establishing steady growth, self-feeding, and transitioning to a variety of foods. Ms. Castle demonstrated the progression of introducing foods to babies through the first year of life and the impact repeated exposure of foods can have on a child’s acceptance of different foods. The Parenting at Mealtime and Playtime (PMP) MOC II Session was presented by Dr. Amy Sternstein and Dr. Liz Zmuda. The discussion highlighted the role of pediatricians in obesity prevention Obesity Prevention and management regarding MOC Part II Self-Assessment how pediatricians can assist parents in building strong nutrition foundations with their children. The extensive resources available through Ohio AAP were reviewed and shared. The Ohio AAP PMP team discussed the upcoming quality improvement program and its benefits to joining. Registration for the quality improvement program can be found at: http://ohioaap.org/pmp-wave-5 or you may contact Renee Dickman at rdickman@ohioaap.org. Following highly requested presentation at other AAP Chapter meetings over the past 18 months, the Injury Prevention Self-Assessments returned to Ohio AAP Annual Meeting. During the session the most common causes of morbidity and mortality for children birth-4 and adolescents were examined, including how pediatricians can increase discussions on risks parents or patients are taking. Presenters Mike Gittelman, MD and Sarah Denny, MD provided guidance for attendees to begin incorporating the Ohio AAP’s injury prevention tools and resources in practice immediately. In addition to these assessments, the Ohio AAP’s robust injury prevention initiatives include three MOC Part IV programs which are open for participation. For more information, contact Hayley Southworth at hsouthworth@ohioaap.org. ... continued on page 26 Ohio Pediatricswww.ohioaap.org • Fall 2017 6
Annual Report 1%
Financial Overview Revenue: $2,227,000 Expenses: $2,080,000
3%
10%
Grants/Contracts Dues Meetings/Exhibitors Other
86%
Only 9% Administrative Overhead 264 Million Media Impressions
Media Coverage: $230,000 in advertisment value New Website Features: • Family Resources • Searchable Education Repository • New Program Page Format • Advocacy Alerts
Collective Engagement = Advocacy Wins Protecting the Bureau of Children with Medical Handicaps (BCMH) Preventing Reimbursement Cuts for Primary Care Providers
Putting passion and ideas into action to educate and advocate on behalf of Ohio’s children. www.ohioaap.org
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The Ohio AAP Trains Providers to Achieve Impressive Results
1,197
8 QI
providers trained
Programs Program Wins
532,862
children impacted
HPV QI Program: Increased first dose of HPV vaccination by Good4Growth Program:
74%
Injury Prevention Program:
50%
for those over 15 yrs.
of providers implemented maternal depression screenings.
48%
increase in discussion on injury and abuse risks.
EASE Project: Observed safe sleep environment and family education increased by
39%.
The Ohio AAP Gratefully Acknowledges Our 2017 Foundation Donors $5,000 and Above Honda of America $3,000-$4999 Anthem, I,nc. Paramount Healthcare $1,500-$2,900 Ohio Children’s Hospital Association Jill Fitch, MD, FAAP $500-$1,499 Tara Abraham and Accel Inc. Belly of the Whale Ministries Andrew Garner, MD, PhD, FAAP and Rev. Sharon SeyfarthGarner Center for Cognitive & Behavioral Therapy (Dr. Kevin & Melissa Wervey Arnold) William Cotton, MD, FAAP and Patty Davidson, MD, FAAP Elizabeth and Paul Dawson, Dawson IT Solutions Sarah Denny, MD, FAAP and Mark Denny, MD John Duby, MD, FAAP and Sara Guerrero-Duby, MD, FAAP Bonnie and Mike Gahn Carol Hall The Thad Matta Family Nationwide Children’s Hospital Up to $499 Andrew Beauseau Tracy Vanden Branden, MD, FAAP Mercy Brew, MD, FAAP James Bryant, MD, FAAP Norman Christopher, MD, FAAP Matt Deitimeyer 8
Fall 2017 • Ohio Pediatrics www.ohioaap.org
Alex Dubin, MD, FAAP Kevin Farrell Otilia Fernandez, MD, FAAP Mike Gittelman, MD, FAAP Kathleen Grady, MD, FAAP Theresa Hutchings John and Mary Kelleher Carol Klinger Robert Klinger, MD, FAAP Kriste Kotten Katherine Krueck, MD, FAAP and James Krueck Kang Lee, MD, FAAP Mike Miller Robert Murray, MD, FAAP Gary Noritz Chris Peltier, MD, FAAP Jessica Potts Jonathan Price, MD, FAAP Todd Ratcliff Mark Redding, MD, FAAP Kathleen Roberts Jo Ann Royhans, MD, FAAP Elizabeth Ruppert, MD, FAAP Brian Schneider Toshi Shinoka, MD, PhD Holly Solomon John Sotos, MD, FAAP Hayley and Anthony Southworth Charles H Spencer, MD, FAAP Amy Sternstein, MD, FAAP Gerald Tiberio, MD, FAAP and Claire Tiberio Richard Tuck, MD, FAAP and Cynthia Tuck Denise and Steven Warrick, MD, FAAP
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Saving, protecting and enhancing children's lives
ohiochildrenshospitals.org • 614-228-2844
www.ohioaap.org
Ohio Pediatrics • Fall 2017
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Annual Meeting Payment Reform Panel
Annual Meeting panel focuses on value-based payment and its effects on pediatric care. The Ohio Chapter, American Academy of Pediatrics (Ohio AAP) hosted a timely panel discussion on value-based payment and its effects on pediatrics during its Annual Meeting on Friday, October 27, 2017. The panel discussion and question and answer session included the Director of Medicaid, Barbara Sears; President Practice of Pediatrics and CEO of the Ohio Association of Health Plans. Miranda Motter, and was moderated by Melissa Wervey Arnold, CEO, Ohio AAP. Comprehensive Primary Care Program Many of the questions at the panel were centered around the Comprehensive Primary Care program, or CPC, which is a payment initiative that brings together payers, providers and other healthcare stakeholders to broadly transform the Ohio health delivery system to achieve better health, better care, and cost savings. The program had been on the state budget chopping block earlier in 2017. After a robust advocacy effort by the Ohio AAP, our member pediatricians, and partner organizations, CPC remained in the budget. The funding allowed the program to continue for existing participants and for others that meet the qualifications (more than 5,000 Medicaid patients and national certification). At the panel discussion, Director Sears noted that in 2017, the CPC program had 111 participating practices and impacted 437,000 children. Director Sears said the goal is to connect all Ohioans Barbara Sears, Director to comprehensive care Ohio Department of Medicaid and they hope to bring on additional practices in 2018, despite the budget constraints. Sears also said 32% of the CPC episodes of care, which are bundles of services around a problem or procedure, are relevant to pediatrics. Members brought forth to the panel a discussion around the larger debate that one of the core values provided by pediatrics is prevention and early intervention, which sometimes makes caring for children more complicated and/or resourceintense. Furthermore, many times there are factors largely out of the control of physicians that impact patient outcomes, which are most notably social determinants of health and issues related to parent behaviors. Because of this, there was a large discussion around the need for risk adjustment
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to payment to pediatricians based on the complexity of care. Director Sears and Ms. Motter both agreed this is a missing component in current payment reform and they would like more discussion on this topic with the Ohio AAP.
Miranda Motter, President & CEO, Ohio Association of Health Plans
Director Sears and Ms. Motter also both highlighted the need for practices to begin looking at their current business model and determine what changes are needed to adapt to payment reform. Ms. Motter noted the importance of including the health plans in these conversations and looking to the plans for guidance and assistance. Children’s Health Insurance Program Federal funding for the CHIP program expired on September 30, 2017 and, as of this publication, had not yet been renewed. The panel agreed that if CHIP is not renewed altogether, it will cause a budget crisis in Ohio. HEDIS Measures Some attendees questioned why there are not more HEDIS measures around pediatric measurements, and how important it is to add more measures around prevention. HEDIS stands for Healthcare Effectiveness Data and Information Set and is a tool used by more than 90 percent of America’s health plans to measure performance. Both Director Sears and Ms. Motter predicted HEDIS will start to include more preventative measures as we move toward more quality measures overall. Summary
The Ohio AAP is committed to working with our members to continue to educate them on best practices in payment reform as well as bring forth concerns to the administration and health plans. If you have concerns you would like the Ohio AAP to look at around payment reform, please contact Melissa Wervey Arnold, CEO at marnold@ ohioaap.org.
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Membership: What’s in it for you? Kelsey Logan, MD, FAAP, Christopher Peltier, MD, FAAP, Jonathan Price, MD, FAAP The Practice of Pediatrics and Membership of the Ohio AAP focuses on specific populations of physicians – such as hospitalists, subspecialists, early career physicians, and private practitioners – and is starting a new effort to communicate with those physicians on the benefits of membership. The Chapter learned in its 2016 membership survey that while many current members value their membership, but it may be difficult to share everything the Chapter has to offer with colleagues. Unlike many state AAP Chapters, the Ohio AAP works to secure funding for programs. This effort has allowed the Chapter to keep membership dues low. Dues account for just 10% of the Chapter budget. The varied sources of funding streams have allowed the Chapter to reach hundreds of pediatricians with education, quality improvement programs, advocacy, events and much more. Advocacy The Ohio AAP advocates for Ohio pediatricians and children at the statehouse year-round. This year was a very busy year for advocacy cochairs William Cotton, MD, FAAP and Sarah Denny, MD, FAAP; Ohio AAP CEO, Melissa Wervey Arnold; and the Chapter’s dedicated lobbyist, Danny Hurley. Their time spent in meetings were focused on many issues including protecting scope of practice, discussing the importance of immunizations, protecting pediatricians when Medicaid rate cuts were on the horizon, and many other topics. (You may read more in the Statehouse Update on page 4). The Advocacy team created a new webpage (www.OhioAAP.org/pillars/ advocacy) that lists important updates including a State Legislation Watch list, updates on recent advocacy efforts, goals of the pillar, and ways to take action. The Chapter also advocates for members in other ways including with www.ohioaap.org
payers at the Pediatric Care Council (see page 24). Education & Programs The Child Health Pillar recently launched a very exciting website update as well – the Pediatric Education Center. This is a collection of education provided by the Chapter, organized by category, author(s) and type of credit (MOC Part II and CME). This site contains years of education, all available in a searchable format. Archived items are also included and new items will be added as they become available. The site is a compliment to the current quality improvement programming available through the Chapter, which now offers three formats in their Maintenance of Certification (MOC) Part IV programs to meet the various needs of practices and providers in Ohio. • Collaborative Learning: The Institute for Healthcare Improvement (IHI) breakthrough series is a collaborative learning model in which practices learning from each other and from topic experts. • Practice Coaching: The practice coaching or practice facilitation model brings a more personalized approach to QI, with a practice coach working directly with a practice to bring them personalized education and change strategies. • On-Demand Learning: Complete a quality improvement program all-online, at your own pace. The Chapter is currently recruiting for the Smoke Free for Me Learning Collaborative (see page 16) and the Injury Prevention Plus SEEK Program (see page 15). In addition, several other QI
Practice of Pediatrics
programs are currently underway, Pillar Leaders: Kelsey Logan, MD, FAAP Christopher Peltier, MD, FAAP Jonathan Price, MD, FAAP Staff Lead: Melanie Farkas mfarkas@ohioaap.org including Wave 5 of the Parenting at Mealtime and Playtime Program and Ohio QI2U-MenB. You may find more about all of the Chapter’s programs at www.OhioAAP.org. Parent/Caregiver Resources The Ohio AAP unveiled another exciting website update in September, the new Good4Growth Parent Resource Page. This webpage is packed with trusted, helpful information on a wealth of child health topics and was provided through a partnership with the Cardinal Health Foundation. “We have valued our collaboration with the Cardinal Health Foundation and Dianne Radigan over the past several years,” said Robert Murray, MD, FAAP, president of the Ohio AAP. “Their support has now allowed us to create a one-stop-shop not only for our member pediatricians to access and share with their patients – but for parents and caregivers to access when they aren’t able to ask their pediatrician directly.” The team at the Ohio AAP worked to compile current and historical resources created for the Chapter programs and members, determine
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Ohio AAP Launches Parent Vaccine Advocacy Group
Factual resources provided for parents to share online The Ohio Chapter, American Academy of Pediatrics (Ohio AAP) announced the launch of Ohio Parents Advocating for Vaccines (Ohio PA4V) at the Annual Meeting on October 27, 2017. Ohio PA4V is a parent-led group advocating for vaccines and spreading accurate information about the disease burden, safety and effectiveness of vaccines. “There is so much misinformation online about the safety and efficacy of vaccines, and often people overlook the reality of how many families have been harmed by vaccine preventable diseases,” said Melissa Wervey Arnold, CEO of the Ohio AAP. “We want to bring those stories to the forefront and talk about why vaccines continue to be so important.” Ohio PA4V will be centered around a social media campaign designed to spread factual information and share real-life stories that will help parents understand the importance of vaccines. Ohio AAP has created a website for the group (http://www.OhioAAP.org/OhioPA4V), which includes a collection of factual information about vaccines that parents can share with their friends and family. “I know most parents in Ohio do the right thing to protect
their kids and get them vaccinated,” said Samantha Bennett, Ohio PA4V co-chair and a survivor of bacterial meningitis. “As a survivor and a parent, I am excited to join other parents in continuing to spread the facts and encouraging all parents to vaccinate their kids!” “I feel passionate about vaccines and this project because I work with so many families who have questions about vaccines and they want access to accurate information that they can share with others,” said Dr. Denise Warrick, cochair of the group and a pediatrician in the Cincinnati area. “I also recognize the need for parents to be empowered to make educated decisions with accurate health information. I want to help them have their voice heard about their experiences and enthusiasm for protecting their families.” PA4V is a free group that parents can join to share the facts and share their stories. Over the next six months, PA4V will be collecting stories from families who not only vaccinate, but also families who have been impacted by vaccine preventable diseases. Parents may get involved by going to the new website (http://www.OhioAAP.org/OhioPA4V).
Thanks for 10 Years, Liz! The Chief Operating Officer of the Ohio Chapter, American Academy of Pediatrics, Elizabeth Dawson, recently celebrated ten years with the organization. During her time at the Chapter, Dawson grew Annual Meeting 17 times larger than when she started and obtained Continuing Medical Education accreditation. She also actualized the live format for Maintenance of Certification Part II, developed two mobile applications and led the Chapter in developing a new practice coaching model for quality improvement. “Liz is a one of the reasons the Chapter has grown into what it is right now,” said Melissa Wervey Arnold, Ohio AAP CEO. “She has had a hand in the incredible growth of our programs and funding, the training of our staff and everything else we do. Thank you, Liz, and we can’t wait to see what next year brings us!”
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A Deeper Dive
Column Coordinators: Gregory Walker, MD, FAAP, Jaclyn Bjelac, MD, FAAP
A Structured Bowel Management Program for Treatment of Children with Moderate to Severe Functional Constipation
Andrea Wagner MSN, CPNP Stephanie Vyrostek BSN, RN Marc Levitt, MD Center for Colorectal and Pelvic Reconstruction, Nationwide Children’s Hospital In this article, we discuss the levels of severity of functional constipation and the bowel management strategies that can be used to reduce constipation and fecal incontinence in children. First, we will discuss the spectrum of severity of functional constipation. Then, we will review the different types of fecal incontinence, pseudo incontinence versus true fecal incontinence. Finally, we will review strategies clinicians can use to reduce fecal incontinence through the use a formalized bowel management program. Functional Constipation Mild to Moderate and Severe Functional constipation is a common problem in pediatric patients, and one that pediatricians are often asked to evaluate, accounting for 3% of outpatient visits and 10% to 25% of referrals to pediatric gastroenterologists (3, 6). Constipation can have several etiologies; however, most children who present with constipation have no underlying medical disease as a cause for the constipation. Mild to Moderate constipation can typically be treated with changes to diet, stool softeners, osmotic laxatives and behavior modifications. Those children who suffer from moderate-to-severe constipation will www.ohioaap.org
require more aggressive treatments with stimulant laxatives and water soluble fiber therapy, or a rectal enema regimen. Untreated or intractable constipation can lead to severe dilation of the rectum, fecal impaction and overflow fecal incontinence or encopresis. Fecal incontinence or soiling can have debilitating and devastating consequences on a child’s quality of life and social acceptance. True Fecal Incontinence versus Pseudo Incontinence There are two types of fecal incontinence, true fecal incontinence and pseudo incontinence, and they require different management strategies. Children with true fecal incontinence have an underlying anatomic or pathologic cause for fecal soiling. This population can include children with anorectal malformations (ARM), Hirschsprung disease (HD), and children who have spinal cord problems or injuries. Children with true fecal incontinence have a very limited potential for bowel control, and cannot have voluntary bowel movements. There are structured bowel management programs used to treat children with true fecal incontinence, which rely on a mechanical emptying of stool with rectal or antegrade enemas. In contrast to true fecal incontinence, children with pseudo incontinence do not have an underlying structural or functional abnormality and therefore have good potential for bowel control. Fecal incontinence or encopresis in a child with severe functional constipation falls into the category of pseudo incontinence. In these children, the chronic constipation leads to overflow of stool and soiling. A structured bowel management program developed initially to treat patients with true fecal incontinence
can be also applied to patients with intractable functional constipation and pseudo incontinence (4, 6). These children may benefit from a regimen with a stimulant laxative or may need rectal or antegrade enemas as a first line mechanism as a bridge to trying a laxative therapy in the future. Bowel management Bowel management is an outpatient program used to treat fecal incontinence. The clinician selects an appropriate treatment modality, either oral stimulant laxatives or a once daily rectal or antegrade enema. The therapy is adjusted throughout the course of the week according to the patient report and daily abdominal radiograph findings. Whether using an oral stimulant laxative or rectal enema washout, the goal of treatment is to stimulate a daily bowel movement and empty the colon. The child will then not have another bowel movement or soiling for 24 hours until the next treatment and will thereby be clean and able to wear normal underwear. The week begins with a contrast enema. This image provides information regarding the shape and size of the colon. Additionally, the speed at which a child evacuates contrast, as seen on subsequent abdominal radiographs, can provide valuable information regarding colonic motility. The contrast also cleans the colon of residual stool, giving the patient an empty colon to start the week of treatment. If after a contrast enema the patient still has a significant fecal burden, an at home bowel clean out is given prior to starting an enema regimen or laxative trial. The colon must be radiographically clean prior to starting the program. ... continued on page 31 Ohio Pediatrics • Fall 2017
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Ohio Pediatrics www.ohioaap.org • Fall 2017 14
Foundation Focus Foundation Pillar Raises Support for Firearm Safety Through Final 2017 Activities
The Ohio AAP Foundation Pillar introduced “Store It Safe” in early 2017, a new community safety program focusing on decreasing unintentional injuries from unsecured firearms (see below). After nearly a year of exciting results and data, the Pillar will use the end of this calendar year to raise funds to support the continued purchase and distribution of gun boxes to Ohio families. Fall is often one of the most successful fundraising times for the Foundation Pillar, and this continued in 2017. Casino Night returned to Ohio AAP Annual Meeting, providing attendees at the educational conference with an opportunity to network, play Casino games, and support the initiatives of the Chapter. Nearly 100 attendees joined the event, raising over $6,000 - enough funds to purchase 400 gun boxes!
The Chapter also participated in Giving Tuesday, with funds raised during that day supporting firearm safety as well. Opportunities to support any program at the Ohio AAP are still available; in addition to firearm safety, support can be directed to bike helmet safety, safe sleep, early literacy, or any other Chapter initiative. As a 501c3 organization, all donations to the Ohio AAP are tax deductible to the fullest extent, making an excellent opportunity to support programs that directly benefit Ohio’s children through end of year giving. Donations can be made to the Ohio AAP by visiting http:// ohioaap.org/donate-now/ or by contacting the Chapter at (614) 846-6258 for more information.
Child Abuse and Injury Prevention Programming Expands in 2018, Participant Resources Still Available
Physicians around Ohio have been improving injury prevention in practice with the Ohio AAP since 2012, and in 2017 a new program began offering another way to keep kids safe through injury prevention screening and anticipatory guidance. The Injury Prevention Plus SEEK (Safe Environment for Every Kid) program launched a pilot wave in July 2017, and is currently recruiting practices for a second wave starting in January 2018.
Participating practices receive training on the use of a hybrid screening tool, which addresses the most common risk factors for intentional and unintentional injuries, as well as psycho-social risk factors, for families with children age 5 and under. In the pilot wave, discussions on these factors have shown preliminary increases of up to 40% for families who identify risky behaviors. Wave 2 of the program will focus more directly on ensuring families receive and utilize resources for any areas where families need assistance. The resources provided to each family vary by identified need, but will include up to $1,000 in products as well as assistance with referral for risk factors including: • Sleep sacks and board books for families of infants at risk of unsafe sleep environments • Cabinet locks to decrease child access to medicine and dangerous substances • Referral information for social determinants of health like food insecurity, maternal depression, domestic or community violence, and drug or alcohol abuse www.ohioaap.org
Wave 2 of the Injury Plus SEEK Program will begin with a Learning Session on Tuesday, January 30, 2018, and will use a quality improvement model combining practice coaching with collaborative and online learning to allow participants to complete the program during the times that work best for their schedules. ABP MOC Part IV credit (25 points) and opportunities for MOC Part II and CME will be available. Interested physicians are encouraged to contact Hayley Southworth at hsouthworth@ohioaap.org or visit http://ohioaap.org/SEEK by January 15 to register.
Congratulations, Team Injury, for receiving the Promising Practice Award from the Ohio Injury Prevention Partnership. The award recognizes outstanding community-based programs aimed at reducing injury in children. Our injury prevention team, Sarah Denny, MD, FAAP, Mike Gittelman, MD, FAAP, Jamie Macklin, MD, FAAP, Hayley Southworth and Heather Maciejewski, were honored for the Safe Sleep Messaging research project!
Hayley Southworth (left), project manager, and Michelle Vargas (right), ODH Safe Sleep Consultant
Ohio Pediatrics • Fall 2017
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Pediatricians Should Address Vaping Melinda Mahabee-Gittens, MD, FAAP Cincinnati Children’s Hospital Medical Center The harmful effects of tobacco smoke exposure on infant’s health are well known. However, given the popularity of electronic nicotine delivery systems (ENDS), pediatricians are being asked about the safety of these products. ENDs include electronic cigarettes, vape pens, vaping devices, e-cigars, and e-hookah. ENDS are different than conventional cigarettes which burn tobacco to generate smoke. ENDs heat a liquid that contains nicotine, flavoring chemicals, and propylene glycol or glycerol to create a vapor that is inhaled. Nicotine is the major psychoactive ingredient in ENDs solutions and as in conventional cigarettes, it is highly addictive and toxic. Since there is a range of nicotine content in ENDS solutions, it’s difficult to assess how much nicotine is present. Liquid nicotine vapor inhaled into the user’s lungs has numerous toxins and carcinogens including formaldehyde and tobacco-specific nitrosamines. ENDs are not safe to use during pregnancy as nicotine in ENDs can cross the placenta and has harmful effects on fetal and postnatal development. Additionally, ENDs-aerosol is not harmless “water vapor,” as secondhand exposure to aerosol emissions of both exhaled ENDs and from the aerosol
generated from the device could be harmful. Dangerous toxicants and carcinogens founds in ENDS emissions include nicotine, polycyclic aromatic hydrocarbons, and volatile organic particles. Additionally, children can be exposed to thirdhand aerosols which is the residual aerosol that remains on surfaces and in dust after ENDS use. Thirdhand aerosol contains nicotine and other harmful toxicants that can harm children. Finally, the liquid nicotine used to refill ENDS is highly concentrated and toxic. Children who are exposed on their skin, or who inhale or ingest the liquid, are at risk of nicotine poisoning; in very high doses nicotine can be lethal. Thus, pediatricians should screen and provide counseling about ENDs including: 1. Counseling about the harms of use and exposure to ENDS; 2. Emphasizing that ENDS use is not: recommended, FDAapproved, or scientifically proven as a way to decrease or quit smoking; 3. Referring all ENDS users to tobacco cessation counseling and pharmacologic treatment programs; and 4. Recommending that children must be kept away from contact with ENDS and ENDS solutions.
The Ohio AAP’s new “Smoke Free For Me” Learning Collaborative is working with primary care practices to build upon the provider/family relationship by addressing caregiver and family member smoking or vaping early in a child’s life during well visit appointments. The program is launching in January 2018. Contact Kristen Fluitt, program manager, at 614-846-6258 or kfluitt@ohioaap.org for more information.
For more information, call 614-722-2145 or go to www.cppdocs.org. 16
Fall 2017 • Ohio Pediatrics www.ohioaap.org
References available upon request.
Ohio Pediatrics www.ohioaap.org • Fall 2017 16
pher, MD, FAAP Norman Christo ppert, MD, FAAP, Elizabeth Spencer Ru ard cian of the Year Aw Outstanding Pediatri
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Charles Spencer, MD, FAA Leonard P. Rome Award
O. N. Ray B
ignall, II, MD, FAAP William H. C otton Pediatrician Advocate A ward
Congratulations to our 2017 Award winners
Steven Wexberg, MD, FAAP Arnold Friedman, MD, FAAP Community Pediatrician Award
U.S. Senator Sh errod Brown (D ) Antoinette Parisi Ea ton, MD, FAAP Advo ca cy Aw ard (award accepted by his aide, Ellen Short)
KEYNOTE: Mark Del M onte, JD, Chi Senior Vice ef Deputy, President, A dvocacy & Ex Affairs, Amer ternalk ican Academ y of Pediatri cs
4
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Opioid Crisis in Ohio Panel Disc
291 Attendees
45 First-Time Attendees First-Ever Hospitalist Track
Up to 40 MOC Part II Point
43 exhibitors
5 MOC Par Presentatio
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Colleen Kraft, MD, FAAP President-Elect, American Academy of Pediatrics Saturday Breakfast
ts Casino Night Fundraiser
Richard Tuck, MD, FAAP District V Chair Saturday Breakfast
Practice Advice at your Fingertips Jonathan Price, MD, FAAP The Ohio Chapter continues to host an online advice tool to help pediatric practices assist each other about everything from coding and payment problems to employee issues. The Practice Management listserv is available by having a pediatrician, practice manager, billing manager, or other practice person sign up to start posting and receiving messages from the group. We find that the most common practice problems brought to our attention at the chapter office have already been solved in the experience of other practices. The listserv assists linking the experience of one practice with the unsolved problem of another. Melanie Farkas, the staff lead for the Practice of Pediatrics pillar, monitors your postings on the listserv. Common billing and payment problems are brought to the attention of Frank Combs and Jon Price, co-chairs of the Pediatric Care Council to see if correspondence with a given health plan or a discussion with several participating plans would be helpful. Some of our chapter members are already active on the AAP national version of this endeavor, the SOAPM (Section on Administration and Practice Management) listserv, for advice from peers from around the country. We recommend that if you do so, please post the same message on our state listserv. Some local problems have local answers and other Ohio practices can share their solutions. To remain compliant with our interpretation of antitrust laws the listserv cannot be used to deal with complaints about specific dollar amounts of payments by insurers. It is acceptable to deal with complaints expressed in more general terms, such as when payment for this or that product is below its acquisition cost. This year we learned, for instance, that there is a discrepancy among payers
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Fall 2017 • Ohio Pediatrics www.ohioaap.org
which code for application of fluoride they will pay. Some issues needed the Pediatric Council’s investigation, such as payment Practice of for face to face prolonged service codes, Pediatrics for influenza testing products, for ADHD services for families of state employees, to name a few. We look forward to your participation. Contact Melanie Farkas at mfarkas@ohioaap.org to join.
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Resident Update
Column Coordinators: Kathleen Matic, MD, Mary Ayers, MD
Global Health Issues Made Relevant for the Ohio Pediatrician
Nicole Mensah, MD, PGY3 Rainbow Babies and Children’s Hospital The American Academy of Pediatrics (AAP) has taken an active role in advocating for the attainment of “optimal physical, mental, and social health and well-being for all children around the world.” As such, the AAP provides resources tailored to improving neonatal health, immunization compliance, and natural disaster preparedness both here and around the globe. Understandably, it can be easy to ignore health-related issues affecting other nations when our own healthcare system is in such flux. However, diseases tend not to respect international borders. Human migratory patterns and travel have the potential to impact pediatric health practices here in the United States. Aware of this phenomenon, the United Nations established the 8 Millennium Development Goals (MDGs) in 2000: an initiative to eradicate poverty, hunger, improve maternal and child health, combat diseases such as HIV/Aids and Malaria, and ensure environmental sustainability by 2015. Overall, we were moving in the right direction: The global under-five mortality rate has declined from 90 to 43 deaths per 1,000 live births between 1990 and 2015. In addition, 84 % of children worldwide received at least one dose of measles-containing vaccine in 2013, up from 73% in 2000. Lastly, 71% of births globally were assisted by skilled health personnel in 2014, up from 59% in 1990. The efforts of the UN resulted in much success, however by 2015 there was still progress to be made. In response, the United Nations established the 17 Sustainable Development Goals (SDGs), www.ohioaap.org
which they hope to achieve by the year 2030. The SDGs cover a wide-range of vital, sometimes controversial, issues impacting the globe including, but not limited to, sustainable energy practices, promotion of economic growth, and commitment to gender equality. Goal #3: Ensure healthy lives and promote well-being for all at all ages is most obviously relevant to Pediatricians. Nevertheless, these goals cannot be achieved if they are each thought about in isolation. The intersection between health, poverty, access to resources, and environmental sustainability is an important consideration. As a resident who is training in Ohio, it can be difficult to appreciate how these global topics can be relevant in our local practices. Yet, it is important to realize that immigrant children are cared for by pediatricians throughout the state every day, and the numbers are only rising. The foreign-born share of Ohio’s population increased from 2.4% in 1990 to 4.1% in 2013, and according to the U.S. Census Bureau, Ohio was home to 477,337 immigrants in 2013. Underlying malnourishment, previous exposure to toxic stress (i.e. war), and suboptimal health literacy can make caring for these patients more challenging, especially if we as physicians are ignorant to global health initiatives. There are many resources available to Residents designed to make caring for refugees or foreign-born patients more manageable. These include: 1. The U.S Committee for Refugees and Immigrants: This is a nationwide network that assists uprooted families now living in the US. Ohio is home to three agencies located in Cleveland, Lima, and Akron. Physicians can easily direct their patients to this resource if they are in
need of employment opportunities, subsidized goods, or assistance with English language skills. Visit http:// refugees.org/ for details. 2. The AAP Immigrant Child Health Toolkit: Notably a very easy to navigate resource which provides practical ways for pediatricians to address common issues related to immigrant child health in a culturally-sensitive manner. It also provides a list of state-bystate Legal Aid Services which help patients navigate the complexities of immigration law. Visit https://www. aap.org/en-us/about-the-aap/ Committees-Councils-Sections/ Council-on-Community-Pediatrics/ Pages/Immigrant-Child-HealthToolkit.aspx for more information 3. The Centers for Disease Control and Prevention (CDC): Their section on immigrant and refugee health is a comprehensive site where practicing resident physicians can find and distribute patient information handouts that have been translated into multiple languages. It also provides information regarding international vaccination schedules, which can be used as a reference for determining patient immunization catch-up schedules. See https://www.cdc. gov/immigrantrefugeehealth/ resources/index.html for details. All in all, resident pediatricians training in Ohio play an essential role in the lives of this very vulnerable patient population. We should feel empowered to contact political representatives, advocate at the local, state and federal level to oppose de-funding of UN operations, and remember that success can only be met if there is persistent intergovernmental coordination and cooperation. References available upon request.
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UnitedHealthcare Community Plan is proud to support the Ohio Association of Child Caring Agencies. We’re happy to provide services and support to organizations all across Ohio. From Community Grants and grant writing support, to educational programs for their membership, we are proud to partner with groups who help serve vulnerable populations.
For more information about our programs, or to learn about working with us, please call us at:
1-800-895-2017 or visit UHCCommunityPlan.com
©2017 United Healthcare Services, Inc. All rights reserved.
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Ohio Pediatrics •www.ohioaap.org Fall 2017 22
Firearm Safety Focus of November Media Campaign The Ohio AAP extended media efforts on firearm safety in November as part of Store It Safe Awareness Month. During this month the members of the Partnership for Safety of Children Around Firearms and Chapter partners from all across Ohio committed to share messages encouraging safe firearm storage with families, and increasing discussions of firearm safety by all healthcare professionals. Store It Safe Awareness Month was inspired partially by data collected by the Ohio AAP that shows healthcare professionals are the number one choice for families who would like information on safe firearm storage. Additional data demonstrates that many pediatricians do not discuss injury prevention because they lack confidence and training on the subject. The tools available for this campaign can be used throughout the year to improve knowledge for this topic. One goal of the Ohio AAP Injury Prevention program is to keep kids safe through increasing these discussions. Store It Safe Awareness Month focused on three key messages, which Ohio AAP members can incorporate into
practice now to help keep kids safe from unintentional firearm injuries. 1. Store it Safe! Ensure all firearms are secured in a lock box when not on the body of the owner. 2. Talk to kids about firearm safety – even if there isn’t a firearm in their home or if all firearms in the home are secured. 3. Ask about the presence and storage of firearms in homes children will be visiting – Asking Saves Kids! If you have any questions about this program, contact Hayley Southworth at hsouthworth@ohioaap.org.
Planning for Summer Meals Service Can Start Now Hayley Southworth, MS
As winter approaches in Ohio, now is also the time for hospitals around the state to start making plans to help children in the summer of 2018 through the USDA’s Summer Food Service Program (SFSP). This program is designed to help the high number of children who experience food insecurity, which can be exasperated by the loss of free school breakfast and lunch during the summer. Ohio AAP President Robert Murray, MD, FAAP began an educational campaign over 2 years ago to encourage children’s hospitals to consider becoming SFSP sites after learning of a successful model for this program implemented in Arkansas Children’s Hospital.
Since the start of this effort, two Ohio children’s hospitals have initiated summer meals programs: Toledo Children’s in 2016, and Rainbow Babies in 2017. Both programs have received extremely positive feedback, as the manager of the program at Rainbow Babies shared. Jennifer Walker manages a variety of programs serving the Cleveland area and communities, and described the SFSP as an addition that “just made sense with the mission of Rainbow Babies.” After a well received program in 2017, the hospital has plans to continue next year. Walker stated that a large part of their success resulted in a strong partnership with Sodexo, the food service provider for the hospital.
As part of this campaign, the Ohio AAP has met with more than eight hospitals in the state to provide education on how the SFSP can be used in their institutions to combat food insecurity during one of the most crucial times of the year for many children. The SFSP is designed to allow organizations a flexible method of providing food for children up to age 18, with options for open sites inviting all community kids to attend or closed sites for those already visiting the hospital. A reimbursement system provides payment for each method that covers costs for food and some operations, allowing hospitals to incorporate summer meals into existing food services with minimal investment.
Walker’s advice to others who may be interested in starting a SFSP program at their hospital or organization is to look for a similar opportunity. Once food service providers already have experience and a system for summer meals programs, hospitals can benefit from faster and more efficient implementation. By beginning these discussions now, hospitals can be prepared to launch their programs as soon as school releases - when children will need their help the most. The Ohio AAP is also available to assist hospitals in making connections with administrators for the SFSP in Ohio. Contact Hayley Southworth at hsouthworth@ohioaap. org for more information.
www.ohioaap.org
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Your Pediatric Council Jonathan Price, MD, FAAP
The Ohio Chapter’s Pediatric Care Council, our dialog group including pediatricians, medical directors of health plans, and chapter staff, successfully dealt with a number of issues in 2017. Our members told us that the Medicaid managed care plans resolved discrepancies in how pediatricians should code and bill administration of vaccines. Likewise, Anthem/ Wellpoint restored pediatricians as payable providers of ADHD services to the state employees they cover. Caresource corrected non-payment for a brand of influenza diagnostic tests. Some plans corrected non-payment for prolonged face to face services as well.
So far, most such quality measures were designed to apply to adult medicine rather than pediatrics. Without our advocacy, it could therefore become easier for all the Practice of other primary care disciplines to score well Pediatrics as “quality providers” by virtue of how many measures they meet and thereby get Tier 1 status over most pediatricians. Likewise we will advocate for patients of small independent practices in rural areas so they do not face higher copays than those of large practices in larger cities that enjoy lower costs via economies of scale.
Looking ahead, the Chapter will be monitoring payers’ design and implementation of alternatives to fee-for-service payments. These alternative payment models will be part of our future as pediatricians. In many of these models, payers rate providers according to their performance on the quality measures they devise and according to how expensive to the insurance plans these providers are. They then steer newly covered families to the high performing or low cost practices by listing those practices as “Tier 1” and rewarding visits to them with lower copays or lower out of pocket costs for the patients. Those practices are also listed first for prospective patients to see on the insurance plans’ websites when they search for local providers.
In anticipation of these changes, pediatric practices can serve themselves well by checking how they are listed on various payers’ websites for consumers and contemplate joining one of the large purchasing collaboratives in Ohio.
New Opioid Rules Go into Effect The Ohio Chapter, American Academy of Pediatrics was proud to stand with Ohio Gov. John Kasich and many other organizations on August 30, 2017 to announce “Take Charge Ohio: Manage Pain, Prevent Medication Abuse” to address Ohio’s opioid epidemic.
Meanwhile the Council will monitor payment and coverage issues that come to our attention on the Ohio Practice Management listserv. (See article on page 20)
In recognition of
DR. BOB MURRAY
a true champion
Thank you for your leadership, dedication and contributions to child nutrition
The program rules went into effect on August 31, 2017 include: • Doctors can prescribe only 7 days of opioids for adults in acute pain • Doctors can prescribe only 5 days of opioids for children The rules do not apply to prescriptions written for chronic pain or for cancer, palliative and hospice care or for medicines that assist with addiction treatment. The regulations will require doctors, dentists, physician assistants and others who prescribe the drugs to include the diagnosis or procedure code on all opioid prescriptions beginning Dec. 29, 2017. That information will be used to track whether people are being overprescribed. Medical professionals will face sanctions if there are problems. 24
Fall 2017 • Ohio Pediatrics www.ohioaap.org
Ohio Pediatrics •www.ohioaap.org Fall 2017 24
Ohio AAP Receives AAP District Award Several Ohio Chapter leaders attended the AAP District V Meeting in Ottawa, Canada on August 11, 2017 and were honored to receive a special achievement award for the Chapter’s spread of Maintenance of Certification (MOC) Part II work. The Chapter has 12 online MOC Part II Self-Assessments and has presented several live across the country. Members may find the online eduation in our new Pediatric Education Center at www.ohioaap. org. Pictured: Back: Michael Gittelman, MD, FAAP; Robert Murray, MD, FAAP Front: Judith Romano, MD, FAAP; Gerald Tiberio, MD, FAAP; Melissa Wervey Arnold; Richard Tuck, MD, FAAP Membership ... continued from page 11 whether they were still valid, and then built a website to house all of the information. Resources are offered by age group along with some additional special topics including parent videos and sports-related information.
Thousands of procedures. Just one focus: kids.
“We have a number of programs that have sunset – like asthma and autism – but have really great information that can still be shared. We are so happy to have this new opportunity to educate parents,” said Dr. Murray. The new webpage, located at OhioAAP. org/parent-resource-page, breaks down resources by age groups. Visitors to the site can click on a child’s age group to view downloadable flyers, links and videos.
Akron Children’s surgery team offers a wide range of specialty procedures, including:
As the largest pediatric healthcare provider in northern Ohio,
Abdominal surgery
through discharge and home care. With many minimally
Hernia repair
invasive procedures available using laparoscopic, endoscopic
Soft tissue repair
and needlescopic techniques, we strive to make surgery less
Thoracic surgery
invasive and scars smaller.
Tumor surgery
Akron Children’s surgery team performed more than 15,500 surgeries last year. In every case, our sole focus is to provide support for kids and their families, from presurgical appointments
For more information, referring physicians can call 330-543-1040.
New Membership Referral Program With the Chapter growing in so many areas, you can share all of these exciting developments with a colleague, early career physician, or resident with whom you work! We invite you to go to www. OhioAAP.org/refer-a-member and fill out the short online form to refer a colleague to become a Chapter member. The Ohio AAP will then reach out to the colleague with information on membership. If they become a member, you will receive FREE entry to our 2018 Annual Meeting!
akronchildrens.org
Email Melanie Farkas at mfarkas@ ohioaap.org with any questions. ach7138-06_SurgeryAd_AcademyPed_v01AR_20160822.indd 1
www.ohioaap.org
8/22/16 4:56 PM
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Inaugural Meeting of the Ohio AAP’s Senior Section On Saturday, October 28, during Annual Meeting, the newly formed Ohio AAP Senior Section convened its first meeting chaired by Charles Deitschel, MD, FAAP and Emanuel Doyne, MD, FAAP. The meeting was attended by 15 individuals interested in being involved in the future plans for this Practice of group. The history of the evolution of the Pediatrics group over the past two years was discussed and an update was given concerning the activities of the AAP Section on Senior Members. Pillar leaders and staff described the work of each group and introduced possible opportunities for senior involvement. In addition, members of the Early Career Physician Group, Jennifer Kusma, MD, and Denise Warwick, MD, FAAP, suggested a number of ways their group would like to interact with the senior section. Future activities will now include: 1. A winter newsletter 2. A check list to be sent to over 80 members to allow them to choose from a menu of potential activities to be involved with to allow them to use their experience and expertise to continue to improve the health and safety of all children 3. Resources available for seniors about “Physician Wellness”
4. Perhaps the planning of social events including educational opportunities (art museums; museums of natural history etc.) 5. Members were invited to submit articles to either the senior section of the chapter or to the Senior Bulletin of the Section on Senior Members in the areas of medical history, retirement issues, career advice, and humor. Contact Melanie Farkas at mfarkas@ohioaap.org if you would like to join the Ohio AAP’s Senior Section.
Annual Meeting ...continued from 6 For children identified with a mental health problem, fewer than 1 in 8 (or 12.5%) receive treatment. More shocking is that only 50% of children with clinically significant problems are detected. During the MOC Part II Session “Mental Health Issues: Early Identification and Intervention for Hospitalists,” Rebecca Baum, MD, FAAP, challenged the hospitalists and primary care providers in the room to improve these statistics by screening children and adolescents for mental health concerns. She shared a list of recommended screening tools – by child’s age – that can be used to assess children from birth to 21 years of age for developmental, emotional and behavioral concerns. To review the information shared during this session, and to earn MOC Part II Self-Assessment credit, visit http://ohioaap. org/MOCPartII/BMW to complete the SelfAssessment.
improve outcomes
increase patient satisfaction
decrease patient costs
The Ohio AAP Child Health Pillar is busy planning next year’s meeting, which will be held at the Crowne Plaza Dublin on September 21-22, 2018. Stay tuned for topics and registration details. See pages 17-19 for pictures of the conference and to celebrate the 2017 Ohio AAP Award winners. Contact Elizabeth Dawson at edawson@ohioaap. org with any questions. 26
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Ohio Pediatrics •www.ohioaap.org Fall 2017 26
Collaboration to Prevent Childhood Obesity Launches Wave 5 In October 2017, the Centers for Disease Control and Prevention released new findings of the prevalence of obesity in the United States. The prevalence of obesity among U.S. youth (age 2-19) was 18.5% in 2015-2016. Among preschoolage children (2-5 years), the prevalence of obesity was 13.9%. [Hales 2017] The Ohio AAP and the Ohio Department of Health are collaborating to encourage prevention and early intervention of childhood obesity through its Parenting at Mealtime and Playtime (PMP) program. This program aims to enhance the ability for pediatricians to provide age-appropriate preventive care and anticipatory guidance, assess “risk” for weight gain, and intervene at an early age for obesity management. You are a vital component to reducing childhood obesity! By joining the PMP quality improvement program, you will
To Accept or Not Accept the Children of Vaccine Refusing Parents Ben Almasanu, DO
This article first appeared in Primary Care Matters, a regular column of MedStat, a monthly publication by Nationwide Children’s Hospital for its medical staff members. It was printed with permission. To accept or not to accept the children of vaccine refusing parents? That was the question my five partners and I asked ourselves in 2015 amidst the aftermath of the mumps and measles epidemics of the previous year. Historically, our office had maintained a somewhat liberal approach; we welcomed families whether they strictly adhered to the Advisory Committee on Immunization Practices (ACIP) vaccination schedule, elected to modify this timetable, or decided to refuse immunizations for their children altogether. Grounded in the belief that it was our responsibility not just to administer potentially life-saving immunizations but also to provide education on their benefits, we felt uncomfortable turning away families who didn’t see eye to eye with us when it came to shots for their kids. Optimistically (and perhaps somewhat naively) we believed that by fostering long-term relationships with families, we could build trust and gradually enlighten vaccine-averse parents. Certainly, given time and adequate evidenced-based information, we posited, families would come to share our belief in the importance, safety, and efficacy of childhood immunizations which represent the core of our preventative medicine practices. Although taking this somewhat permissive stance naturally appealed to our inclinations as nurturing, nonwww.ohioaap.org
be part of a group of your peers in exploring opportunities for improving nutrition and physical activity assessments in your practice. This virtual program will offer resources developed by program experts, a familyfriendly mobile app, new handouts on issues you encounter, and more! With completion of the MOC IV program, you will receive up to $500 in products for your practice. This includes the very popular “MyPlate” and MyPlate placemats that are highly popular with patients! You will also receive 25 MOC Part IV points, if you are eligible. Register at http://ohioaap.org/pmp-wave-5. For more information, please contact Renee Dickman at 614-8466258 or rdickman@ohioaap.org. confrontational pediatricians, in retrospect, it did have negative consequences. We often found ourselves spending inordinate time and emotional energy in combating the potent messaging of the anti vaxxer movement. Discussing the inaccuracies of countless websites and popular media reports became exhausting. After all, we queried parents, who knows more about immunizations — your child’s pediatrician or Oprah Winfrey and Jenny McCarthy? Though we were successful in changing the hearts and minds of some, the majority of strongly vaccine-averse parents seemed largely unmoved by our educational efforts to debunk myths such as the linkage of vaccines with autism. The acceptance of vaccinating families who chose to modify or delay the evidence based vaccine schedule also presented some unique challenges. There was often confusion when parents deviated from their already altered schedules (“We’re not going to stick with Dr. Bob’s’ schedule anymore”) or when they failed to return in the expected time frame for catch-up vaccines. Our nurses and medical assistants were often left in the lurch. Vaccine schedule modification also placed us as physicians in the awkward position of having to arbitrarily advise parents on which vaccines were most important at a given visit. How ought a self-respecting pediatrician respond to parental insistence that their child only get one shot at a well check when several are due? “Doctor, should we go with the DtaP or Pneumococcal for Johnny today?” When my partners and I discussed revising our vaccine policy, we framed our deliberations in terms of our practice’s broader responsibilities. The still fresh memory of vaccine preventable disease outbreaks in Ohio served as an impetus for us to embrace change. These epidemics reminded us of our duty to protect patients and families in our waiting room. On an even larger scale, we recognized that our policy decisions could significantly influence the health of the broader community. ...continued on page 31 Ohio Pediatrics • Fall 2017
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Shriners Hospital for Children— Cincinnati: The region’s Cleft Lip and Palate treatment destination Facial clefts occur in nearly one out of 600 births in the United States, and are the most common birth defects treated by pediatric plastic surgeons. Clefts of the lip and palate are complex conditions, which affect not only the child’s appearance and self-esteem, but also a child’s ability to breathe, speak, hear and eat properly. In 2018, Shriners Hospital for Children—Cincinnati will celebrate its 50th year of serving children with a familycentered philosophy, fostering an environment that keeps parents and families close to the child and actively involved in treatment and recovery. Shriners Hospital for Children—Cincinnati is a designated Cleft Lip and Palate Team by the Cleft Palate Foundation and the American Cleft Palate and Craniofacial Association. At Cincinnati Shriners Hospital, treatment for Cleft Lip and Palate (CLP) is a signature service, along with its cuttingedge burn treatment. Each child’s unique physical, social and psychological needs will be addressed by a team of professionals throughout treatment, recovery and beyond. Treatment of cleft lip and palate is not a “one and done” fix. As a child grows, adjustments will need to be made throughout his or her life. Cincinnati Shriners Hospital understands this and will be involved in every aspect of a child’s development throughout the growth period. Issues related to self-esteem, hearing, speech, learning and appearance are all significant, so the team generates a multidisciplinary team report for review by other health professionals treating the child. Here is a timeline of typical CLP treatment at Cincinnati Shriners Hospital: Infancy The plastic surgeon repairs the cleft lip shortly after birth, usually at 2 to 3 months of age, or by 12 months of age - prior to the child’s first spoken words. Many children with clefts develop hearing problems as a result of chronic ear infections. If left untreated it will create speech and language problems. The audiologists 28
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and otolaryngologists assess the child’s ears. At the time of the cleft repairs, tubes may be placed in the child’s ears to help treat the infections and maximize hearing sensitivity. In addition, many infant children may also have their gum repaired with a bone graft, depending on the circumstances, sometime after the lip repair and before the repair of the cleft palate. Childhood Each child’s speech development is routinely assessed by the speech and language pathologist. If treatment is needed, the speech pathologist works with the parent, the child and a local speech pathologist. Sometimes, additional surgery is needed when speech therapy alone does not improve the child’s ability to speak normally. Surgery involves improving the function of the palate and pharynx (throat) where the air needed for sound is directed. Before the child begins school, any significant residual cleft deformities involving the lip and nose are surgically corrected to help minimize the psychological effects of the cleft deformity. Pediatric dental and orthodontic services begin to play a more important role with the development of teeth during the later years of childhood. Surgery to restore the residual cleft in the dental arch is frequently done at this age. ...continued on page 35
Caring for kids?
ECHO Autism echoautism.com
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Sports Shorts
GUIDELINES FOR PEDIATRICIANS
What is an Athletic Trainer?
A Valuable Team Member for Pediatricians Athletic trainers (ATs) are healthcare professionals who render service or treatment, under the direction of, or in collaboration with, a physician, in accordance with their education and training and the states’ statutes, rules and regulations. The AT skillset encompasses a variety of patient care services including injury and illness prevention, wellness promotion and education, emergent care, examination and clinical diagnosis, therapeutic intervention, and rehabilitation of injuries and medical conditions. The education and training required to become an AT includes graduation with a bachelor’s or master’s degree from an accredited professional athletic training education program recognized by the Commission on Accreditation of Athletic Training Education (CAATE). Using a medical based education model, students complete extensive clinical learning requirements and follow competency-based training in both the classroom and clinical environment. Coursework and formal instruction in the following is required by the CAATE: • • • • • •
Clinical Examination and Diagnosis Acute Care of Injury and Illness Therapeutic Rehabilitation and Interventions Psychosocial Strategies and Referral Healthcare Administration Evidence-based Practice
Athletic trainers must pass a national examination to become certified by the Board of Certification (BOC) as well as obtain licensure in the State of Ohio to be eligible to practice athletic training. To maintain certification (BOC) and Ohio licensure, ATs must complete ongoing continuing education requirements. ATs are recognized by the American Medical Association (AMA) as healthcare professionals, and the AMA has further recommended athletic trainers in every high school to keep America’s youth safe and healthy. In 2003, the American Academy of Pediatrics reinforced this concept, endorsing an inter-association consensus statement which identified an athletic health care team, centered on ATs, as essential to appropriate medical care for secondary school aged athletes. ATs work in a variety of employment settings including high schools, colleges, universities, professional sports teams, hospitals, rehabilitation clinics, physician offices, corporate
Lisa Kluchurosky MEd, AT, ATC
and industrial institutions, the military, public safety and the performing arts. When ATs work in a physician practice setting, these practices often experience improved physician efficiency and increased patient satisfaction, as they return more quickly and safely to their pre-injury level of activity. Unlike “personal trainers” or “athletic directors,” ATs have passed a secure national exam after completing a bachelor’s degree from an accredited institution, obtained licensure in the State of Ohio, and have mandatory continuing education requirements. Additionally, over 70% of ATs possess a masters or doctorate degree. In a secondary school setting, ATs provide daily acute and emergent care to student-athletes at practices and sporting events. They also deliver rehabilitation and injury prevention services along with wellness promotion and education to keep students healthy and active. In recent years, as increasing attention has been directed toward the dangers of concussion. The Centers for Disease Control and Prevention has recommended that all suspected concussions be evaluated by an experienced healthcare professional. The American Academy of Neurology has recognized that concussion assessment is a core competency of ATs, and specifically recommends that “an athletic trainer should be present at all sporting events, including practices, where athletes are at risk for concussion” (October 2010 Position Statement). In 2017, Ohio passed a law related to Sudden Cardiac Arrest referred to as Lindsay’s Law which mandates any athlete who complains of, or experiences, syncope must be pulled from activity until cleared by a qualified practitioner. Additionally this law requires education of coaches, parents and athletes related to the recognition of sudden cardiac arrest. ATs are valuable resources for schools in recognizing such medical issues and ensuring proper medical care is received. Finally, the patient-centered medical home promotes teamwork – comprehensive coordination and collaboration with community-based partners – to deliver care that is timely and responsive to patient needs. ATs, similar to school nurses, provide prompt care to children and adolescents in the school setting, decreasing time away from the classroom, thereby promoting academic advancement along with safe physical activity. When pediatricians and other PCPs collaborate with ATs working in secondary schools on patient care, it enables better continuity and enhanced outcomes for patients.
This information is available on the Ohio Chapter, American Academy of Pediatrics’ website at www.ohioaap.org
www.ohioaap.org
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Sports Shorts
GUIDELINES FOR PARENTS
What is an Athletic Trainer?
Peace of Mind for Parents of Student-Athletes
Lisa Kluchurosky MEd, AT, ATC
Athletic trainers (ATs) are healthcare professionals who provide patient care services or treatment, under the direction of, or in collaboration with, a physician, in accordance with their education and training and the states’ statutes, rules and regulations. The AT skillset encompasses a variety of patient care services including injury and illness prevention, wellness promotion and education, emergency care, examination and clinical diagnosis, therapeutic intervention, and rehabilitation of injuries and medical conditions.
performing arts. When ATs work in a physician practice setting, these practices often experience improved physician efficiency and increased patient satisfaction, as they return more quickly and safely to their pre-injury level of activity. When ATs work with employees in an industrial or public safety setting, their focus is on prevention of injury to keep workers on the job by avoiding unnecessary common injuries, and in getting them back to work as quickly as possible by using the athletic healthcare model when an injury does occur.
The education and training required to become an AT includes graduation with a bachelor’s or master’s degree from an accredited professional athletic training education program recognized by the Commission on Accreditation of Athletic Training Education (CAATE). Using a medical based education model, students complete extensive learning in both the classroom and clinical environment in the areas of clinical evaluation and diagnosis of injury and illness, rehabilitation, injury prevention, wellness, and healthcare administration.
In the secondary school setting, ATs provide daily acute and emergency care to student-athletes at practices and sporting events. They also deliver rehabilitation and injury prevention services along with wellness promotion and education to keep students healthy and active. ATs advocate for student-athletes by keeping their long term health in mind when directing their care.
Athletic trainers must pass a national examination to become certified by the Board of Certification (BOC) as well as obtain licensure in the State of Ohio to be eligible to practice athletic training. To maintain certification (BOC) and Ohio licensure, ATs must complete ongoing continuing education requirements. ATs are recognized by the American Medical Association (AMA) as healthcare professionals, and the AMA has further recommended athletic trainers in every high school to keep America’s youth safe and healthy. In 2003, the American Academy of Pediatrics reinforced this concept, endorsing a consensus statement which identified an athletic health care team, centered on ATs, as essential to appropriate medical care for secondary school aged athletes. Unlike “personal trainers” or “athletic directors” ATs have passed a secure national exam after completing a minimum of a bachelor’s degree from an accredited institution, obtained licensure in the State of Ohio, and have mandatory continuing education requirements. Additionally, over 70% of ATs possess a masters or doctorate degree. ATs work in a variety of employment settings including high schools, colleges, universities, professional sports teams, hospitals, rehabilitation clinics, physician offices, corporate and industrial institutions, the military, public safety and the
Some specific examples of AT responsibilities in the school setting are: • • • • • •
On-field management of life and limb-threatening injuries such as fractures, cardiac arrest & neck injuries Diagnosis of concussion and oversight of concussion return to play progressions Rehabilitation of injuries such as ankle sprains, muscle strains and stress fractures Supervision of an athlete’s functional progression back to sport Preventative services such as taping, padding and teaching injury prevention exercises Helping parents navigate the health care system and coordinate care with other medical providers
Finally, ATs are trained in the team based healthcare model. Comprehensive coordination and collaboration with communitybased partners to deliver care that is timely and responsive to patient needs is the focus. ATs, similar to school nurses, provide prompt care to children and adolescents in the school setting, decreasing time away from the classroom, thereby promoting academic advancement along with safe physical activity. By collaborating with pediatricians and other PCPs on patient care, ATs working in secondary schools facilitate better continuity and enhanced outcomes for patients.
This information is available on the Ohio Chapter, American Academy of Pediatrics’ website at www.ohioaap.org
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Vaccine Refusing Parents ...continued from page 27 Unanimously, the six of us concluded that the status quo of tacitly condoning refusal or alteration of the accepted vaccine schedule was no longer tenable. The time had come for us to send a strong and clear message that in our practice, vaccination is non-negotiable. In order to implement this change in policy, we have been very forthright in communicating with patients. Our reception staff has been instructed to inform the parents of all new patients that our office does not allow for declining or delaying vaccines. We have also made this a standard talking point in presentations delivered to prospective families at our monthly prenatal meetings. Additionally, we provide copies of our practice specific and corporate vaccine policy statements. We made exceptions for existing patient families who had elected to modify the vaccine schedule prior to the implementation of this new policy. ‘Grandfathered’ in, these parents are asked to sign a waiver form declaring that they have chosen to go against the recommendations of their health care Bowel ... continued from page 13 Treatment modality: Enemas or laxatives? The clinician should consider whether the patient has true fecal incontinence or pseudo incontinence when selecting the treatment modality for bowel management week. Patients with true fecal incontinence benefit from a rectal or antegrade enema regimen. Patients with pseudo incontinence typically respond very well to stimulant laxative and water soluble fiber therapies, but may benefit from rectal or antegrade enemas for a period of time depending on any dilation of the rectum and recto-sigmoid that may impair rectal sensation. They also get clean quickly and enjoy that state, which sets them up for success when they try future laxative therapy. Prior studies have shown, over the course of one week, 89-95% of patients stopped soiling and were able to wear underwear as opposed to diapers or pull ups. After six months to one year of a daily rectal enema regimen, the child has regained a more typical bowel movement pattern of one stool per day at the time of the enema, and therefore may have decrease size of rectum and recto sigmoid, which will allow for return of normal rectal sensation. These children can then effectively transition to oral stimulant laxative and water soluble fiber therapy. For the patients who cannot tolerate a rectal enema, due to behavioral concerns, an antegrade route (cecostomy or Malone appendicostomy) can be offered. For those children with significant colonic dilatation or redundancy who need a large dose of laxatives or who do not respond to high dose laxatives, a partial colon resection guided by colonic manometry can be offered. Program Details: Enemas and Laxatives Enemas: A normal saline enema regimen (usually 15-20ml/kg) is prescribed to the patient. Glycerin or castile soap are added to the saline for additional stimulation. Children are instructed to administer the enema slowly over 5-10 minutes, hold the solution in for 5-10 minutes, and sit on the toilet to evacuate www.ohioaap.org
provider and that they understand and assume responsibility for the potential harm that might result from their decision. The response to our policy has been overwhelmingly positive based on the feedback we have received from parents — many of whom have stated they respect our stance and appreciate knowing their children’s exposure to vaccine preventable diseases has been limited. We did not experience a mass exodus of existing patients from our practice, and we do not feel that our policy shift hindered our ability to attract new patients. In fact, there has been no discernible down-side to our decision. We have not abrogated our ongoing responsibility to provide education about vaccines, but find that our experience in sharing information about immunizations is much more pleasurable than it was previously. We and our patients’ families now share common ground when it comes to immunizations; they are safe and effective tools to keep kids healthy — the goal of every parent and pediatrician.
stool for 30 minutes. The type of stimulant, volume, and concentration are adjusted daily during the week as needed according to the patient’s tolerance, report of symptoms or soiling, and abdominal radiograph findings. This goal of treatment is to keep the child clean between enemas. Laxatives: Senna or Bisacodyl based stimulant laxatives are the first choice for treatment based on their ability to provoke the colon to contract and empty stool burden. Stool softeners or osmotic laxatives are avoided because they make the stool soft, but do not provoke stool to empty. The laxative dose is determined from interpretation of the contrast enema. The patient is observed for 24 hours after laxative administration. If the child does not stool within 24 hours, they are instructed to administer an over the counter rectal enema to evacuate rectal stool burden. After the enema, the laxative dose is increased. In contrast, if the patient stools multiple times and the abdominal radiograph does not have significant stool burden, the laxative dose can be decreased. Water soluble fiber is prescribed in conjunction with laxatives to add bulk to the stool and to decrease the occurrence of watery stools. The laxative and fiber dosages are adjusted daily during the week as needed according to the patient’s tolerance, report of symptoms or soiling, and abdominal radiograph findings. The goal of treatment is one to two, formed bowel movements per day and no soiling accidents. Summary Whether on laxatives or enemas, the bowel management week treatment plan is considered successful when the child is emptying their colon daily, the abdominal radiographs reveal no stool burden in the rectosigmoid colon, and the child has no stool accidents or fecal soiling. Clinicians can use the principals of bowel management to successfully treat moderate to severe functional constipation in patients with true fecal incontinence or pseudo incontinence. References available upon request. Ohio Pediatrics • Fall 2017
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Three Things to Keep in Mind When Delivering a Diagnosis of Down Syndrome Kari Jones, President & CEO, Down Syndrome Association of Central Ohio (DSACO) Stephanie Santoro, MD, FAAP, Chair, DSACO Medical Advisory Committee Chair Down syndrome may be familiar to most physicians and genetic professionals, but many families do not have experience with Down syndrome prior to having a child diagnosed.1 Parents receiving a postnatal diagnosis report (1) being frightened or anxious after learning the diagnosis, (2) that their physicians talked little about the positive aspects of Down syndrome and (3) that they were rarely provided enough up-to-date printed materials and information. •
•
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Ohio Down syndrome advocacy groups worked to pass Ohio House Bill 552, which was signed into law in 2014, and requires that medical professionals provide a fact sheet about Down syndrome. Available at: https:// www.odh.ohio.gov/odhprograms/cmh/dsyndrome/ Down%20Syndrome.aspx Although families may have had a brief conversation about suspected Down syndrome while in the hospital, many leave the hospital without resources and information provided to them because the diagnosis had not yet been “confirmed”. In 2016, the Down Syndrome Association of Central Ohio (DSACO) conducted a parent survey focusing on parents with children with Down syndrome born in the past 12 months. Overall, few parents reported positive experiences at the time of diagnosis and over half had not received written information. DSACO also found that many children with Down syndrome are diagnosed postnatally, approximately 66%, despite increased availability of prenatal testing such as cell-free fetal DNA. These two facts suggest that an infant’s pediatrician may be the first person to discuss the diagnosis of Down syndrome with a family. Ultimately, to ensure families undoubtedly have information and support, we encourage pediatricians to share resources with any family who has recently received a Down syndrome diagnosis. While the Ohio Department of Health Down Syndrome Fact Sheet does cite local resources, your local Down Syndrome Association likely has a lot to offer as well. For example, DSACO’s website, www. dsaco.net, has a Resources tab specifically designed for medical professionals in addition to resources available to families. To find which local association is in your area, visit www.downsyndromeohio.org.
Overall, families report positive feedback about the importance of genetic counseling, the utility of talking through the specific details of chromosome testing, and access to legally-mandated state information sheets. Sharing information in a direct manner, while also focusing on a plan for next steps is critical. In addition to the information you provide to families about Down syndrome, we encourage you to make a referral to one of these clinics—or one in your area—for supplemental care if needed. For more details, practice guidelines recommend how to best deliver a diagnosis of Down syndrome.2-5 References: 1. Skotko B. Mothers of children with Down syndrome reflect on their postnatal support. Pediatrics. 2005;115(1):64-77. 2. Bull MJ. Health supervision for children with Down syndrome. Pediatrics. 2011;128(2):393-406. 3. Sheets KB, Crissman BG, Feist CD, et al. Practice guidelines for communicating a prenatal or postnatal diagnosis of Down syndrome: recommendations of the national society of genetic counselors. J Genet Couns. 2011;20(5):432-441. 4. Skotko BG, Kishnani PS, Capone GT. Prenatal diagnosis of Down syndrome: how best to deliver the news. Am J Med Genet A. 2009;149A(11):2361-2367. 5. Skotko BG, Capone GT, Kishnani PS. Postnatal diagnosis of Down syndrome: synthesis of the evidence on how best to deliver the news. Pediatrics. 2009;124(4):e751-758.
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Ohio Pediatrics •www.ohioaap.org Fall 2017 32
The AAP 2017-2018 Agenda For Children
This wellness initiative was further enhanced by the PEDS 21 2017 NCE session held on Friday afternoon, 9/15 , in Chicago. Here the focus was on leading change in physician health and wellness, the relationship among burnout, job satisfaction, quality care, and patient safety. Specific strategies were presented for physicians, their practices, and their organizations.
Richard H. Tuck, MD, FAAP District V Chairperson
Each year the AAP Board reviews and updates the “Agenda for Children� which identifies specific strategic initiatives to advance during the year. At the September Board meeting, two specific focus areas were added to the current Agenda for Children, and information was provided on moving these initiatives forward. Please refer to the Agenda diagram on this page. Physician Wellness and Resilience is a major concern for pediatricians and the American Academy of Pediatrics. It is now a new strategic priority. Without healthy pediatricians, we cannot optimally promote the health and welfare of the children we serve. Burnout is prevalent at all career stages, from trainee to retiree. Nearly half of medical students, residents, and practicing physicians report symptoms of burnout.
The second strategic initiative now included in our Agenda for Children is Addressing Bias and Discrimination. Calling this issue out is a critical first step in addressing this pervasive challenge for children, families, and pediatricians. A task force has been developed that will: 1. Make the case that bias and discrimination affect child health 2. Develop education for pediatricians/trainees on bias and effective strategies to promote inclusion 3. Develop resources for parents on how to support their children to develop empathy and resilience
Our Chief Medical Officer, Dr. Fan Tait, convened a July meeting with representatives from major organizations representing pediatricians including the Association of Medical School Pediatric Department Chairs, American Pediatric Association, American Board of Pediatrics, American Pediatric Society, Society for Pediatric Research, Look for your AAP to lead the way for both the new important Association of Pediatric Program Directors, and Federation Physician Wellness and Resilience; and Addressing Bias and of Pediatric Organizations to: Discrimination strategic priorities. 1. Identify physician health and wellness initiatives in leading pediatric health care organizations 2. Build consensus on the unique tM needs of pediatricians and dedicated to the health of all children pediatric providers 3. Determine and prioritize needs and opportunities for future initiatives. M ty The group will continue working Addressing Bias and together to: Discrimination 1. Determine how pediatrics initiatives can be linked to Physician Health and Wellness other specialty based initiatives 2. Determine factors of burnout Poverty and Child Health relative to pediatrics 3. Determine definition of wellbeing for pediatrics and Quality Access Finance appropriate measures 4. Identify resources by topic area or target audiences Planning 5. Refine messaging for pediatrics Implementing Pr 6. Further investigate partnership s c Integration/Integrated ofe i opportunities within the key atr ssion i d e themes while building a 5-year of P plan
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AAP Agenda for Children 2017-2018
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2017 Ohio AAP Annual Meeting Exhibitors Champion for Children $5,000 and Higher
Advocate for Children $2,500
Friend of the Children $1,000 Child Injury Prevention Alliance-Grow Up Safe
Special thanks to Advantage Print Solutions for printing the meeting program!
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Ohio AAP Welcomes New Members Edward Alten Jessica Backstrom Sara Bode, MD Markus Buchfellner Erin Burrier Kylie Bushroe Christian Carwell Melody Chiu Kimberly Churbock, MD Chad Coe, MD Emilia Connolly, DO Kimberly Cooper, DO Terrence Cronin, MD Peter de Blank, MD Perry Dinardo Mary Gaugler Amrit Gill, MD Martie Gravitt, MD Rebecca Hamilton, PNP
Kit I Ho, MD Rebecca Kelley, PA Kristin Lambert-Jenkins Justine Latremouille Stephanie Lauden, MD Nikki Lawson Coral Li Molly Marshall Mark Mccollum, MD Christiane Mhanna Lauren Misik Yolanda Moore-Forbes, MD Sariha Moyen McKenzie Nelson Lindsay Newburn Nicholas Nguyen, MD Mark Occhionero Leeann Pavlek, MD Stephanie Royer, MD
Aaida Samad Tara Sardesai Alexandra Schoenberger Nadine Schwartz, MD Amina Smajlovic, MD Kinnari Sorathia John Spencer, MD Habeeb Suara Shira Toister Cole Turner Joy Um Courtney Vaughn Prasoon Verma, MBBS Carolyn Vespoli Nora Vish, MD Lukasz Weiner, MD Mark Wells Justin Wildemann
Shriners ...continued from page 28 Adolescence While nearly all cleft children will need braces (orthodontia), a smaller number of children will need orthognatic (jaw) surgery. In these children, the growth of the upper jaw remains behind the lower jaw and the face develops a sunken appearance as the child grows into adolescence. The surgery involves repositioning the jaws to improve the child’s bite and appearance. The plastic surgeon carefully plans the surgery with the dental specialists (dentist, orthodontist and prosthodontist) to achieve the best results. Once the facial bones are in correct relationship to each other, the final nose and lip surgery are completed. For children who have previously endured trauma, such as children who have joined their families via adoption, Cincinnati Shriners Hospital has a pediatric psychiatrist on staff help children and the families. The clinicians are also willing to review medical information for a family considering adopting a child from outside the U.S. with cleft lip and palate treatment needs. Although Shriners Hospital for Children— Cincinnati will accept children without a physician referral, physicians and other health professionals can refer a child for treatment by calling its referral department at 855-206-2096 or helpachild@shrinenet.org. www.shrinershospitalcincinnati.org www.ohioaap.org
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Ohio Chapter, American Academy of Pediatrics 94 Northwoods Blvd. Ste. A Columbus, Ohio 43235-4721
Calendar of Events January 18, 2018 • Planning, Implementation and Performance (PIP) Committee Meeting Ohio AAP Office, Columbus February 2, 2018 • Winter Executive Committee Meeting Ohio AAP Office, Columbus March 8, 2018 • Pediatric Care Council Ohio Association of Health Plans Office, Downtown Columbus April 20, 2018 • Spring Education Meeting Ohio University College of Osteropathic Medicine Dublin Campus May 2018 • Bike Helmet Awareness Month Statewide August 10, 2018 • Glow Ball Fundraiser Blackhawk Golf Course, Galena September 21, 2018 • 2018 Casino Night Fundraiser Crowne Plaza, Dublin September 21-22, 2018 • 2018 Annual Meeting Crowne Plaza, Dublin
Dues Disclosure Statement Dues remitted to the Ohio Chapter are not deductible as a charitable contribution, but may be deducted as an ordinary and necessary business expense. However, $40 of the dues is not deductible as a business expense because of the Chapter’s lobbying activity. Please consult your tax advisor for specific information. This statement is in reference to fellows, associate fellows and subspecialty fellows. No portion of candidate fellows nor post-residency fellows dues is used for lobbying.