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FOCUS TOPICS PEDIATRICS

SERVING A 24 COUNTY AREA, INCLUDING BIRMINGHAM, HUNTSVILLE, MONTGOMERY & TUSCALOOSA ON ROUNDS PEDIATRICS

Back to School with COVID As summer break began, it seemed like the worst of the pandemic was behind us. ... 9

Pediatric Kidney Stone Prevention Clinic Kidney stones are on the rise in children ... 10

What Physicians are Seeing in Children’s of Alabama Emergency Department “we are still seeing too many serious injuries from children riding ATVs. ... 12

Pediatric Rehabilitation Medicine at Children’s “Kids come to us with a wide array of diagnoses, and we work to help them to flourish.” ... 13

Tracking Instances and Impact of COVID-19 Among Pediatric Cancer Patients How would the new COVID-19 pandemic impact the pediatric cancer population? ... 16

New Technologies Bring National Standard Spine Care to Birmingham By ann B. deBelliS

A procedure for relief of severe back and leg pain is improving outcomes for patients. A minimally invasive surgical (MIS) procedure called Transforaminal Lumbar Interbody Fusion (MIS TLIF) relieves pain caused by disc degeneration, spinal stenosis, and spinal instability. Daniel Kim, MD and his colleagues at Southlake Orthopedic Spine Center at Grandview Medical Center are using some of the latest technologies to provide evidence-based best care for their patients. “My goal is to provide national standard spine care in Birmingham. We (CONTINUED ON PAGE 3)

Surgeon Daniel Kim, MD, left, uses single position MIS fusion to save time in the operating room.

St. Vincent’s Bariatric Surgery Center Helps Patients Achieve a Healthier Life By laura Freeman

Which procedure is lower risk— gallbladder surgery or a gastric sleeve? “Even physicians are often surprised when I tell them a bariatric sleeve procedure is lower risk the way we do it today,” Ascension St. Vincent’s surgeon Katie Novitski, MD said Bariatric surgery has come a long way since the early days of big incisions and complex after care. “With laparoscopic robotic surgery, only a small incision is necessary,” Novitski said. “Using the DaVinci system, I can visualize the abdomen in 3-D. The robot is attached to a specially

Bariatric surgeon Katie Novitski, MD

designed bariatric operating table that moves with it, so it’s easier to keep the patient in the best position. You don’t have to stop and reset everything, which saves time. We can usually complete a sleeve

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procedure in a half hour or less.” Patients with comorbidities like diabetes may opt for a bypass procedure. “It’s a more involved surgery, but in some cases it virtually eliminates type 2 diabetes symptoms,” Novitski said. She also does bariatric revision surgery. “Patients who have a gastric sleeve may decide to switch to a bypass if they have another issue such as reflux or diabetes, or one of the older procedures may need a touch up,” she said. If anyone thinks bariatric surgery is taking the easy way out, it isn’t. “Many of our patients have been struggling with serious obesity their entire life,” (CONTINUED ON PAGE 4)


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New Technologies Bring National Standard Spine Care to Birmingham, continued from page 1 already have good spine care, but newer technologies can elevate the existing programs,” Kim says. The MIS TLIF procedure is generally used to treat sciatica and back pain, most commonly caused by degenerative disc disease and subsequent pressure on the lumbar nerves. It is also an adaptation of a posterior lumbar interbody fusion used to stabilize the spine by restoring disc height and fusing the vertebrae together to alleviate nerve compression, eliminate instability, and maintain spinal balance. Common indications for TLIF include severe foraminal stenosis requiring facet joint removal and recurrent disc herniation, asymmetric collapse, among others. “The concept of minimally invasive is to be normal anatomy sparing. It doesn’t necessarily have to do with the size of the incision, but it is the least trauma to the ligaments, muscles and joints, everything that controls the spine,” Kim says. “At the same time, it ensures that the goals for the surgery will be the same as an open surgery procedure.” Kim performs the MIS TLIF procedure with robot assistance. “Formerly, TLIF was performed with a big midline incision and often we would have to peel the muscles off of the midline,” he says. “This new procedure helps with healing

and preserving stability by maintaining natural anatomy while freeing up the nerves. I am able to work through a small tube that allows for sparing muscles and ligaments with the same decompression and interbody insertion. We approach from the patient’s back so we can clean out the disc space. We then place an interbody pacer, which supplies decompression and bone healing.” As part of his MIS portfolio, Kim also performs cervical disc arthroplasty, minimally invasive posterior cervical decompression, MIS lumbar decompression, as well as robot assisted singleposition lateral interbody fusion. The single-position MIS fusion saves time in the operating room. “Patients are not under anesthesia as long, and it saves them from being in a prone position for a longer time,” Kim says. “I can better ensure the safety of the procedure for these patients. However, not everyone is a candidate for these minimally invasive procedures.” In addition to the MIS TLIF and other minimally invasive methods, Kim plans to introduce endoscopic spine surgery for decompression procedures, surgeries that are commonly performed in Asia and Europe. “In many places, the endoscopic procedure is standard-of-care for a cer-

tain disc herniation, because you use a sub-centimeter incision with minimal muscle or bone damage,” he says. “The cannula is the size of a ballpoint pen, and you can remove disc herniations using an endoscopic camera through which you can visualize nerves and structures. There is a steep learning curve, but this technology can be advantageous for our patients in the right setting.” “Each of the procedures reduces blood loss and hospital stays. Naysayers may argue that at one year, most studies on any of these techniques have general equivalence. They often do, but I think the early outcomes matter as well. People want to feel good at their sixweek visit, and I think that being mindful about the collateral damage during surgery helps.” Kim is grateful for the guidance of the group of surgeons at Southlake Orthopedic Spine Center as well as his fellowship training at the Twin Cities Spine Center. “I am a product of my training, and I am lucky to be here, where I can continue to learn from these surgeons. They believe in ‘conservative management first,’ and take the holistic patient into consideration,” he says. “My philosophy is that we must preserve what God gave us as much as possible, but always make sure you achieve your surgical goals.”

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New Technologies Bring National Standard Spine Care to Birmingham, continued from page 1 said Aimee Rothe, BSN, RN, CEN, who serves as the director of Ascension St.Vincent’s Metabolic and Bariatric Surgery program. “They have been down the diet road all too often. Some have lost more than a hundred pounds more than once, only to end up back where they started or even farther behind,” Rothe herself has walked many a mile in her patients’ shoes, having struggled through years of dieting before achieving a major weight loss. She understands because she has been there, and she teaches her nurses and patient navigators so that they empathize with what their patients are experiencing. Why would a patient choose a bariatric surgery center rather than a surgery center that does bariatric procedures? “Everything in the center is geared to bariatric patients,” Rothe said. “When they come here, they don’t have to worry about whether there will be a chair they can fit into. All our chairs are designed for bariatric patients. Many patients have mobility problems, so the center is in an easy access location and the services they are likely to need are nearby. “Patients usually have the same nurses and staff who they get to know. When patients come here, they can be confident they will be treated with respect.” Novitski said “Another advantage is that all the health professionals here

(left to right) Bariatric dietitian Molly Neill, RD, RDN, MS with program director Aimee Rothe, BSN, RN

are passionate about the work we do. I trained in general surgery, but bariatric surgery is my primary interest. It gives me the opportunity to save both lives and quality of life.” Physicians and health care professionals in other areas, especially those who have never struggled with their own weight, can find it hard to know what to do with patients facing severe obesity. And they may have difficulty understanding why the patient has so much trouble controlling their weight with diet and exercise. Until recently, most efforts

to lose weight ended in frustration for both the patients and the providers. “The specialists who care for our patients have experience with this population and in interpreting the differences obesity may make in their care,” Novitski said. To be considered for bariatric surgery, patients must have a BMI of 40 or more, or 35 if they have a co-morbidity that could benefit from surgery. They should be at least 18 years old and may be up to 60 or older, depending on their physical condition.

“All our patients go through a thorough health screening, including evaluation by a cardiologist and pulmonary specialist. If there are indications of sleep apnea, we may also order a sleep study,” Novitski said. “One of the most important presurgery evaluations is a psychological screening.” Rothe said, “Obese patients tend to have a disturbed relationship with food and may use eating as a coping mechanism for stress. When emotional eating is no longer an option, we want them to have better ways of coping in place to deal with difficult times. “Also, going from eating like everyone else to only being able to eat a small volume that has to be reserved for high nutrition foods is a major adjustment in lifestyle. We have to be confident that they will be able to do it. We also look for a commitment to learning about nutrition and activity to help them succeed and get what their body needs to stay healthy.” Post op support includes nutrition and conditioning classes and a support group where patients can exchange ideas with others who are on the same journey. “I make sure every patient has my mobile number and knows they can call or text me any time,” Rothe said. “One patient called me to say she had just touched her toes for the first time in years.”

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CVA & BBH Help Organize International Conference with Effective Online Format Viewership Increased Across the World as Word Spread By laura Freeman

Sometimes necessity is the driving force for creative thinking that leads to something even better. When the pandemic closed borders early last year, many international medical conferences were forced to cancel. For most people hosting a first-time conference, the prospect would have been daunting. But with a little high-tech help and an agile move online, the initial ICARUS endovascular conference was able to go on as scheduled in Warsaw and reach an audience around the world. Internationally noted interventional cardiologists from Cardiovascular Associates and Brookwood Baptist Health helped to organize the event and participated in programming. Working behind the scenes, they saw how much online presentation technology could do and they put those insights to work planning an even better online conference for 2021. Originally from Poland and now based in Birmingham, Jan Skoronski, MD MBA, is one of the foremost interventional cardiologists in peripheral, coronary and structural heart disease. He is an early adopter of lifesaving technologies and has been involved in extensive clinical research into new devices and procedures. He was also a primary influence in

Jan Skoronski, MD (left) of CVA and Grzegorz Oszkinis, MD (center) of Medical University of Opole, Poland, served as Course Directors.

launching the ICARUS conference. “The types of endovascular procedures we are presenting and equipment we are demonstrating in case studies aren’t as familiar in many parts of the world as they are in north America and western Europe,” Skoronski said. “ICARUS is an important first step in making the benefits of these procedures available everywhere. As a free conference available online, it eliminates the barrier of travel expenses and restrictions on how many people can participate. “To communicate effectively in an online format, we have to consider that our viewer may be watching in an environment where other things are compet-

ing for attention. Our viewer’s eyes are also accustomed to seeing sophisticated content on screen. Computer generated special effects in movies, TV, gaming and online presentations have set a higher bar. It’s not enough to put an expert in front of a microphone, turn on a camera, and let the speaker talk. We had to engage the audience and hold their attention to communicate the points we want to convey.” The first thing Skoronski did to prepare for a more dynamic 2021 conference was to change the presenting format. Instead of experts giving long speeches, he limited the time for opening remarks to the essentials necessary to cover the key points of a teaching case.

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Then the presentation moved into interactive mode, with real-time questions and answers with the audience, discussion of the cases between experts, and in one case a debate between a vascular surgeon and an endovascular cardiologist on how they might approach the same case differently and the advantages each choice could offer. Another part of the engagement strategy included a professional host, multiple cameras, and a set and graphics comparable to a TV news show. The strategy paid off. The number of viewers continued to rise steadily as the conference went on and word of the event spread. All over the globe, health professionals were listening in their choice of English, Polish or Russian. They were watching from eastern and western Europe, north and south America, Africa and as far away as Siberia and China. Programming included an international lineup of some of the most highly regarded interventional cardiologists in the field presenting some of their most challenging and unusual cases. From the United States, participants included leading interventional cardiologists from Houston and Birmingham. Known for his groundbreaking work in the development of the first FDA approved coronary stent, Gary Roubin, MD of Cardiovascular Associates was a panelist in the carotid session. “The ICARUS conference was one of the first endovascular online events during the pandemic in 2020. The organizers created an even better version in 2021,” Roubin said. “We had great discussions and reviewed some really great cases. This is one of the most engaging conferences in current medical education.” Skoronski also participated in discussions and a third physician from Cardiovascular Associates, Matthew Sample, MD, FACE, used a teaching case to demonstrate a technology that is still new to much of the world. “After abdominal surgery, a woman in her 80s was complaining of shortness of breath,” Sample said. “The problem was an embolism in her pulmonary artery. In the past, we might use blood thinners, watch it and hope for the best. The problem with that approach is that it gives the clot more time to cause difficulties and it extends the time the patient has to stay in the hospital. “In this case, I used the INARI FlowTriever system with a microcatheter that allowed me to grasp the clot and remove it. The patient did well and the problem was resolved quickly. In cases where a clot has moved into a vessel that is too small to (CONTINUED ON PAGE 8)

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Birmingham Medical News


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Training Against Cyber-Attacks

Takes On Life.

Arielle has a severe blood disorder called sickle cell anemia hemoglobin SS. While her condition is high risk and complex, she manages her disease well with medication and a monthly red blood cell exchange at the Alabama Center for Childhood Cancer and Blood Disorders at Children’s of Alabama. Our team of over 300 dedicated pediatric healthcare professionals is committed to exceptional patient care and innovative research – and driven to find cures for kids like Arielle.

By Kelli C. Fleming

We are seeing more and more attacks that could have been The COVID-19 panprevented had an employee demic over the past 18 been properly trained and months has impacted almost known what to look out for. For every area of our pre-COexample, phishing scams where VID, “normal’’ lives---workperpetrators send e-mails with ing from home, a demand on attached malware to individutoilet paper, and a decline in als, appearing as if they came the workforce, just to name a from a legitimate sender, are on Kelli C. Fleming few. Almost no industry has the rise. Cyber-security trainbeen spared when it comes ing can help employees identify to the impact of the pandemic. suspicious e-mails and protect against these As a result of the pandemic, cybertypes of scams, among others. attacks are on the rise in almost every inCyber-security training should dustry, reaching unprecedented numbers not take a one and done approach, but following the 2020 lock-down. As workers rather should be ongoing and periodic. suddenly transitioned to a remote enviCyber-security training can be conducted ronment and management became more internally by someone within the IT defocused on merely surviving day-to-day partment, or externally by a contracted than spending dollars on IT security, the third-party. I recommend a combination doors opened for perpetrators to seize new of both, utilizing the expertise and trainopportunities. One report I read indicates ing programs of a third-party in conjuncthat, with regard to the frequency of rantion with the institutional and operational somware attacks, there were 93 percent knowledge of someone in-house. more attacks in the first half of 2021 than While employees should always be in the first half of 2022, while the numtrained upon hire, they should also be ber of global cyber-attacks increased by trained periodically thereafter. I recom29 percent. Unfortunately, this “perfect mend cyber-security training at least one storm” has resulted in massive amounts a year. If there is a significant shift in techof personal information being breached, nology, a change in policy/procedure, or as well as millions of dollars being spent on an increased threat, additional, more fremitigation, response, and recovery efforts. quent training may also be warranted. For healthcare providers, the situation Whenever training is conducted, becomes even more dire, as a ransomware whether internally or externally, the trainattack can not only disrupt business operaing should be documented. The documentions and impact the bottom law, but can tation should include the date the training also have a negative impact on direct pawas conducted, the employees that were tient care. Even with up-to-date backups, trained, the topics discussed, and a copy of it can take several hours or days to get a any training materials that were utilized. system back up and running following a If a breach incident occurs, this training ransomware attack, and most providers, documentation will become extremely imand the patients they serve, will feel a negaportant in the course of the investigation. tive impact as a result of such delay. In light of the current environment, One of the easiest and cheapest ways all healthcare providers should be conto prevent cyber-attacks is to train your ducting appropriate, periodic cyber-seemployees. Yes, implementing two-factor curity training as a first line of defense authentication and investing in computer against attacks. security and protection measures are imKelli Fleming is a Partner at Burr & Forman LLP portant, but supplementing those measures and practices exclusively in the firm’s Healthwith effective employee training will drascare Practice Group. Kelli may be reached at (205) 458-5429 or kfleming@burr.com. tically reduce the likelihood of an attack.

CVA & BBH Help Organize International Conference, continued from page 6

To learn about Arielle’s story and how you can help, visit ChildrensAL.org/committedtoacure

8 • SEPTEMBER 2021

Birmingham Medical News

introduce the catheter, it wouldn’t be an option, but it can make quite a difference in the right cases. I enjoy sharing what I’ve learned with cardiologists in other parts of the world so they can use these skills to help their patients.” Archives from 2021 will soon be on YouTube for review, and work is already underway in planning the next ICARUS

online conference for 2022. “We hope to continue improving each year,” Skoronski said. “If we can start getting the pandemic under better control, perhaps we can have a hybrid event. People could be watching online while a studio audience asks questions and participates in discussions.”


PEDIATRICS

Back to School with COVID By Cindy Sanders

As summer break began, it seemed like the worst of the pandemic was behind us. After a year of virtual learning, parents, teachers and students were all looking forward to returning to the classroom. Unfortunately, the Delta variant has allowed COVID-19 to take root again just as school starts. Amid tussles over mask mandates and vaccine hesitancy, COVID-19 has begun to quickly spread in unvaccinated populations, which includes all children under the age of 12 and many teens who are eligible but remain unvaccinated. In a two-week period at the beginning of last month, Alabama saw more than 6,000 new pediatric COVID cases in children ages five to 17, nearly five times as many as the same time period last year. Forbes reported that Alabama has set a new state record for children hospitalized with COVID with 50 children hospitalized across the state. At least nine were on ventilators. In addition, information from the Alabama Department of Public Health showed at least 113 children had been seen with multisystem inflammatory syndrome in children (MIS-C). As parents seek answers, pediatricians are stepping up to dispel myths and share the facts on vaccination efforts and mitigation measures. VACCINES & CARDIAC CONCERNS Stuart Berger, MD, FAAP, chair of the Section of Cardiology and Cardiac Surgery for the American Academy of Pediatrics (AAP), spoke with the Birmingham Medical News to address MIS-C and parent concerns over reports of myocarditis or pericarditis linked to vaccination in children 12 and up. “There seems to be an association with the MRNA vaccination and myocarditis,” he said. “It’s been seen typically in the 16 to 24 age range and in boys more than girls. However, it’s relatively uncommon to see it, and when it is presented, it’s very, very mild. The children who have been diagnosed haven’t been very sick, and the inflammation has gone away fairly quickly. Thus far, it has not required any treatment other than one to two days of pain management such as non-steroidal anti-inflammatory drugs.” Typically, the self-limiting condition requires no intervention at all outside of rest and OTC pain relievers as needed. “This is in stark contrast with myocarditis that can be seen from an acute COVID infection or in association with MIS-C,” said Berger, who is the division head of Cardiology at the Ann & Robert H. Lurie Children’s Hospital of Chicago. “Those patients can be very sick

Anna Morad, MD, FAAP

Stuart Berger, MD, FAAP

and often end up in the hospital and can get a very severe form of myocarditis requiring treatment and a fairly intense therapy for a period of time. “Many of those patients can require therapy in the Intensive Care Unit and can have morbidity and mortality if they get this. Data is also being gathered on possible residual issues these children could face over the long term. “In my experience with seeing COVID and MIS-C in young patients and my experience in seeing patients post-vaccine, it is a no-brainer to me that getting the vaccine is critical and what is best for every individual and for society in general.”

Without masks and other mitigation measures, in-person learning could quickly become another victim of the Delta surge. Within two weeks of returning to class, several districts in Georgia and Mississippi have already returned to remote learning. Florida’s Hillsborough County, which includes Tampa, has already seen more than 10,000 students be isolated or sent home to quarantine. “Masks have become politicized, but they should simply be viewed as an effective strategy to prevent the spread of COVID-19,” Morad said. “While

parents have become passionate about their children’s ‘right’ to be mask-free, most kids aren’t terribly bothered by wearing them.” While most children do recover, hospitalizations and deaths do occur. “The mortality rate for children is not as high as for adults,” Morad said. “But these are children. We should not be talking about mortality among children. No child deserves to have a vaccine-preventable disease because people around them refused to wear masks or get vaccinated.”

MITIGATING RISKS Anna Morad, MD, FAAP, president of the Tennessee Chapter of the American Academy of Pediatrics (TNAAP), said AAP guidelines call for masking children in the school setting. With low vaccination rates throughout the south, the bulk of people entering these schools will be unvaccinated. Even if more were vaccinated, Morad said most schools don’t have a robust system in place to determine vaccination status. And evidence continues to mount that vaccinated individuals with breakthrough infections can spread the Delta variant more easily than initially thought. As important as it is to keep kids and teachers well, it’s equally important to keep them in class. Many students had a tough time last year emotionally, socially and academically. “Kids do well with routine, and with having their peers around them,” Morad said. “Virtual learning has a disproportionate impact on kids who don’t have reliable internet access or a parent who can’t be home during the day to help.” Birmingham Medical News

SEPTEMBER 2021 • 9


PEDIATRICS

Pediatric Kidney Stone Prevention Clinic by Jane

Ehrhardt

Kidney stones are on the rise in children, especially ages 12 to 18. According to Pediatric Annals, the incidence is increasing by six to 10 percent each year. “Most of the time, kidney stones are the result of what people do to their body,” says Pankaj Dangle, MD, pediatric nephrologist in the division of pediatric nephrology at Children’s of Alabama. “Too much salt and sugar is a bad combination, along with processed food, junk food, sweet sodas, candies, especially if you’re not drinking enough water.” Neither obesity nor genetics play much of a role among the 70 or so patients who come through Children’s pediatric nephrology unit each year. The strongest prevention found so far is a balanced diet and plenty of water, which turns out to be challenging to maintain among teens. “It’s difficult to get high school or college kids to drink lots of water, just because of peer pressure,” Dangle says. The reason for the escalation in pediatric cases seems to point to societal changes in the past few decades, including grocery store options and kids being more mobile. “At this age, kids have more choices in what they eat and drink with more access to pro-

10 • SEPTEMBER 2021

Pankaj Dangle, MD

cessed foods and fast food. Most of them eat garbage, even after suffering through their first bout of painful kidney stones,” Dangle says. One of his 18-year-old female patients has returned several times. She would continue to eat only chicken nuggets and drink soda despite knowing that would likely lead to another episode. “She would starve herself,” Dangle says, “because of body image issues, then only eat nuggets and drink cola to get by because she knew it would maintain her weight. Compliance is an issue with this age group, which is why the stones come back once you have one.” Around half of patients this age will face kidney stones again within 12 to 18 months

Birmingham Medical News

after an attack, which is why Dangle spearheaded an effort to establish a multidisciplinary pediatric kidney stone clinic at Children’s. The only one of its kind in the Southeast, the clinic includes Dangle, pediatric nephrologist Michael E. Seifert, MD, in the division of pediatric nephrology at UAB, and Children’s clinical nutritionist Perrin Tamblyn Bickert, MS, RD, LDN, CLC. “We meet with the families to educate them about changing food preferences,” Dangle says. “It’s hard to change a lifetime of dietary habits and we find that the families are more receptive when the information comes from three specialists. This is important because prevention is better than any cure in medicine.” The teens and their families get the same message from three medical professionals at once, driving home the importance of change, the consequences of inaction, and help moving through those steps. Bickert, one of only two pediatric renal nutritionists in the state, not only formulates a dietary plan, but works with the family to mitigate any instigators of stone formation, such as oxalate, which derives from potatoes, a common food among teenagers. She even identifies for the families which meals offered on their school

lunch menus would best serve their child. The clinic began about three years ago. “The numbers are getting better,” Dangle says of those teens and families adapting to new lifestyle plans and returning for follow-ups with the clinic group. “30 to 40 percent of the patients are making the recommended changes.” Though proven to help convince families to alter their unhealthy ways, the bigger problem is convincing families to commit to the clinic meetings. “Once you pass a stone and you’re asymptomatic, and you don’t have pain so a lot of people don’t show up,” Dangle says. With no symptoms returning until the next attack perhaps more than a year apart, the usefulness of the ongoing support is not understood. Pediatricians and primary care providers can help prevent kidney stones as well. Parents often have no idea their child can get kidney stones and how much diet and water intake influence their formation. “Providers can play a big role by honing in about fluid intake, especially in summertime,” Dangle says. “A lot of people think that sports drinks are great and are better than water, but they have to be mindful that they’re also full of sweetness.”


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Birmingham Medical News

SEPTEMBER 2021 • 11


PEDIATRICS

What Physicians are Seeing in Children’s of Alabama Emergency Department By Laura Freeman

When asked what conditions she encounters most, Alicia Webb, MD, a Pediatric Emergency Physician at Children’s of Alabama, says “we are still seeing too many serious injuries from children riding ATVs. They aren’t designed for someone small with a child’s motor skills and judgment. So many turnovers cause devastating injuries or death. “In terms of illness, the top three reasons patients come to our emergency department are the same that pediatric emergency facilities are seeing across the country—respiratory problems, seizures and psychological issues, particularly in adolescents. “One surprise this summer is the high numbers of younger children with respiratory syncytial virus (RSV). This infection tends to occur in babies and toddlers. It’s usually mild, but it can cause lung issues. We typically see this virus during the cold months, and we don’t know why it’s showing up in summer. With winter ahead, we’re concerned about the potential for more infections.

Alicia Webb, MD

“What complicates matters is that parents are often afraid it is Covid-19 and they bring their children to the ED to be tested. It’s very, very important that parents know not to come to the ED for that. Get in touch with your pediatrician or check the Alabama Health Department website for a list of locations where you can get a test. “With the COVID surge, our waiting room has been very crowded and waiting times are longer than usual. You don’t want to be sitting a long time in a waiting room with a sick baby around other sick children who may be positive for a variety of illnesses.

Children’s of Alabama Emergency Department

“You should come to the ED if your child develops serious symptoms. Watch for difficult breathing, dehydration, fever, seizures and other symptoms that indicate something serious might be going on.” It appears that the pandemic is having an affect on other health issues. “Before the pandemic we often saw inju-

ries from abuse against children,” Webb says. “Now, with isolation and financial uncertainty, increasing stress may take a toll. Pandemic related stress is also having an effect on children who tend to have anxiety, depression and other mental health issues.” Another concern is that the pan(CONTINUED ON PAGE 15)

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PEDIATRICS

Pediatric Rehabilitation Medicine at Children’s by Jane

Ehrhardt

“It’s hard to do the elevator pitch for this specialty,” says Drew Davis, MD, one of the three physicians in Children’s Division of Pediatric Rehabilitation Medicine (PRM). “We’re the function people,” adds Cynthia Wozow, DO, another member of the PRM team. “Kids come to us with a wide array of diagnoses, and we work to help them to flourish.” Their patients face a range of conditions that will impact them for a lifetime and can strike at any age, such as cerebral palsy, musculoskeletal conditions, and limb deficiencies. “We meet everybody where they come, no matter when they come in or how,” Wozow says. Not all are from a congenital onset. Some cases come from abrupt, traumatic injuries to the brain or spine, occurring at any age. “Their life was going a certain way and then everything changed in an instant. We walk through this traumatic life change with them,” Wozow says. Wozow brings a powerful influence to many patients, having been a patient at Children’s herself just a few decades ago when diagnosed with cerebral palsy at age eight. “There wasn’t a medical rehabilitation division here then, but I had

Cynthia Wozow, DO

Drew Davis, MD, FAAPMR, FAAP

surgical intervention here and then subsequently acute therapy rehabilitation,” she says. “And that’s how I met the current therapist who’s still here.” She grew up telling her mother that she would be happy to work with kids with cerebral palsy. “It was my entire world,” she says. “I realized early on I wanted to use my story to influence others. Most people view a cerebral palsy diagnosis as a person who may need assistance in throughout their life and a quality of life that is not what they would want it to be. That’s not always the case.” Just this week, Wozow was with a new patient’s family that had just received a diagnosis of cerebral palsy, when the mother asked Wozow if she

had the disease. When Wozow affirmed that she did, the father simply said, “wow.” “In that moment, he knew that there were going to be good things about his child’s life,” Wozow says. These days, the PRM department serves such a universal need at Children’s that the three doctors—the only three physicians in Alabama who are board certified in pediatric rehabilitation medicine—are asked to participate on a multitude of hospital clinics. Wozow sits on clinics for general rehab, brachial plexus injuries, musculature dystrophy, surgical spasticity, and gastroenterology and rehabilitation. “Ours is not a one-and-done situation. We take a comprehensive approach

because we follow patients through childhood up to age 21,” David says. “Some patients begin under our care while still in the neonatal intensive care unit. Premies are at high-risk for cerebral palsy so we’re involved early on in the course of their life to support their development. “Treatment plans are unique to each patient. We take an individualistic and holistic approach. We know the range of options, but it depends on if that child would benefit most from oral medications, injections, or a procedure, some are reversible and some are not. And it depends on the timing in terms of age and where they are developmentally.” If the patient has muscular tightening at age five and is still not walking, the PRM physician knows whether relaxing the muscles in that particular patient can enhance that movement or take some of the progress already made. “Other teams may come in for the acute hospitalization, but we’re the lifelong cheerleaders,” Wozow says. Beyond the medical aspects of treatments and spasticity management throughout development, the department, which also includes a researcher, nurse clinicians, (CONTINUED ON PAGE 15)

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The Whitehead family would like to thank Dr. Joseph Esparaz of Children’s Hospital as well as Whole Foods manager Jason Stonicher and his staff for all they did to try to help save Kenneth Whitehead. These were ordinary people going about their daily lives who did not hesitate to try and help save a life. We are truly thankful for their actions that morning, which bring us great comfort during this difficult time.

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Birmingham Medical News

CMS Proposes Reversing Trump Administration Decision By Zachary Trotter Manning Russell

and

In yet another reversal by the Biden Administration of a Trump-era policy, the Centers for Medicare & Medicaid Services (CMS) recently released a proposed rule reversing the Trump Administration’s decision to eliminate the inpatient-only service list (IPO List) over a three-year period. This proposed change will reinstate 298 procedures onto the IPO List, and remove hundreds of procedures from the list of procedures (the ASC List) authorized to be performed in an Ambulatory Surgery Center (ASC). As part of the Calendar Year 2021 Hospital Outpatient Prospective Payment System (OPPS) and ASC Payment System Final Rule (the “2021 Final Rule”), the Trump Administration previously “finalized a policy to eliminate the IPO list over a three-year period, removing 298 services from the IPO List in the first phase of the elimination” and “add[ing] 267 surgical procedures to the ASC [List].” The IPO List is a list of procedures for which Medicare will only make payment when the services is provided in an inpatient hospital  setting. The Trump administration had pursued the elimination of the IPO List, touting multiple benefits including giving patients more options for their healthcare; potentially lowering costs for both patients and payors by performing more procedures in outpatient settings; and allowing patients to recuperate at home, rather than in an inpatient facility. The CMS proposed rule now seeks to reverse course on these changes. To support that decision, CMS reported that the agency had “received a large number of stakeholder comments throughout the CY 2021 rulemaking cycle and following issuance of the final rule with comment period that opposed the elimination of the IPO List, primarily relating to patient safety concerns, stating that the IPO list serves as an important programmatic safeguard.” CMS assets that its new proposal will “reinstate the criteria (which related to patient safety) for adding a procedure to the ASC List” in place prior to the Trump Administration changes. Beyond simply reversing the Trumpera changes, the CMS proposal also attempts to prevent future administrations from making sweeping changes to the

Zachary Trotter

Manning Russell

IPO List by “codify[ing] the longstanding criteria for removal of procedures from the IPO [L]ist to make clear in regulatory text how [CMS] will evaluate future procedures for removal.” Moreover, the CMS’ proposal will “reinstate the criteria (which related to patient safety) for adding a procedure to the ASC List” in place prior to the Trump Administration changes. If finalized, these proposed changes will have a significant impact on the types of procedures ASCs may perform and could result in a rebalancing of surgical volumes between hospitals and ASCs. In addition, CMS is soliciting comment on several policy modifications, including whether CMS should maintain the longer-term objective of eliminating the IPO list or maintaining the IPO list but continuing to systematically scale the list back so that inpatient-only designations are consistent with current standards of practice. The deadline for interested parties to submit comments on the proposed changes is Sept. 17, 2021. CMS is expected to publish the final rule in November of 2021.


What Physicians are Seeing in Children’s of Alabama Emergency Department, continued from page 12 demic is causing delays and interruptions in routine care that may lead to future emergencies. “When parents put off pediatrician visits, they may be missing vaccinations that could lead to an outbreak of preventable diseases like measles,” Webb says. “Also, children in Alabama have high rates of diabetes and asthma. If developing symptoms are missed, they may not be detected until there’s a lifethreatening emergency.” As of press time, Children’s of Alabama has adequate rooms to move admitted patients from the emergency department, but numbers are trending upward. “We’re getting calls from across Alabama as well as surrounding states asking for beds,” Webb says. “The delta surge is creating a desperate situation throughout the region. We are specially equipped and trained to care for children, and young patients referred to us are arriving by plane, helicopter, ambulances and in some cases their parents are driving hundreds of miles.” The unfamiliar environment of a hospital can be frightening for a child who is sick and uncertain about what is happening. To ease their fears, Children’s’ of Alabama has a child life team that works with children when they are admitted and spends time with them to

help them and their parents understand what’s going on and what to expect. Pediatrics has benefitted from the same advances in technology and treatment as other fields of medicine, but Webb says there is a simple tool that will likely determine what happens next in the our children’s health. “As of now, masks are the only defense we have for children under 12, so wear them and teach children when and how to wear them,” she says. “In addition to reducing the risk for COVID19, they also help to prevent flu, colds, RSV and can be protective against some of the allergens that could trigger an asthma attack. “If your child is old enough to qualify for the vaccine, please get them vaccinated. The Delta surge seems to be hitting younger people harder than previous variants. Children can and do die from this and could develop long term health problems. “We’re always listening for news of advances that will make vaccines available for all children, but as of now, we don’t know how long that will be. We have to build a circle of protection around them with masks, washing hands, social distancing and making sure everyone around them who qualifies for vaccination does their part.”

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Pediatric Rehabilitation Medicine at Children’s, continued from page 13 and office staff, connects families with resources throughout the state for anything from helping to navigate school issues to assessing driving capabilities after a brain injury to vocational services to pinpoint skillsets for moving on to college or the workforce. “We also know the justification that works for insurance for why our patients need therapy and equipment,” Wozow says. “We know how to get those types of things accomplished.” The demand for the team’s expertise is extensive. “In a typical week, there are 80 inpatient kids admitted in intensive rehab who are sick enough or injured enough for a prolonged hospital stay,” Davis says. Despite the need, only 308 physi-

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cians in the nation were board certified in pediatric rehabilitation medicine by 2019. “There are not many pediatric rehabilitation providers on the whole. There are some states around us who don’t have any,” Wozow says. “We are limited by our numbers, so there’s a constant conversation about how to improve that issue.” Wozow encourages providers to refer children to the group as soon as they see any concerns. “Our group is uniquely trained not only in rehabilitation as a whole, but in how those unique diagnoses affect those kids over a lifetime,” she says. “By being involved earlier, we can anticipate possible future concerns and as well as meet current needs.”

Every Tuesday, we’ll feature healthcare professionals discussing important medical topics.

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PEDIATRICS

Tracking Instances and Impact of COVID-19 Among Pediatric Cancer Patients By Emily Johnston, M.D., MS & Julie Wolfson, M.D., MSHS

A pediatric oncologist colleague of ours from Cornell Medical Center in New York posted a question to Facebook on March 23, 2020: How would the new COVID-19 pandemic impact the pediatric cancer population? We were asking ourselves the same question here at Children’s of Alabama. As social distancing and virtual meetings became the norm, we put our heads together – nearly 1,000 miles apart – to figure out how best to provide ongoing care for our oncology patients. The result is the Pediatric COVID19 Cancer Case (POCC) Report, a national registry of pediatric cancer patients diagnosed with COVID-19. It’s designed to better help our fellow clinicians provide vital care during an evolving pandemic. The first edition of the report was dated April 29, 2020, just a few weeks after the idea was presented, a timeframe unheard of for getting studies approved by an Institutional Review Board (IRB). We reported 12 documented cases of COVID-19 among pediatric cancer patients across the country, representing six institutions. The initial goal was a biweekly update, sharing real-time information with our colleagues about what COVID-19 looked like in our patient population so that as the pandemic waves moved across the country, they would have a better sense of how to treat their patients. More than a year later, 1,000+ pa-

Julie Wolfson, MD, MSHS

Emily Johnston, MD

tients are in the registry from 95+ participating sites, representing more than half of the pediatric oncology sites in the country. While those numbers bring mixed emotions – it’s unfortunate that so many kids with cancer in this country were affected by COVID-19 – we are motivated knowing that we are contributing to the clinical care of these kids, serving as a clearinghouse of information for other institutions. The POCC uncovered some important early findings in children with cancer. Specifically, children with cancer and COVID-19 are getting sick: 65 percent of these children are symptomatic; 30 percent are admitted to the hospital, a rate five times higher than the general pediatric population; 10 percent are admitted to the ICU; four percent are intubated, and two percent die due to COVID-19. Approximately half had

their cancer therapy changed due to COVID-19. Looking through a disparity lens, we see that kids with cancer who have public insurance, are from a Hispanic background and have other comorbidities like sleep apnea or diabetes are also more likely to face a COVID-19 infection – mirroring the risk factors for COVID-19 in the adult population. When a child with cancer tests positive for COVID-19, we have to consider delaying the time-tested protocols for their cancer treatment. We know from the registry that almost half of the documented patients have had their cancer therapy changed due to a COVID19 illness. Early in the pandemic, we were all learning how best to safely approach the scheduled treatments. Is it safe to continue chemotherapy during a COVID-19 infection? Are they too sick from COVID-19 for sedation for their

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imaging, procedures and surgery? Working with our anesthesia and radiology teams, we had to decide how important the treatment was or determine the impact of delaying until the child’s quarantine period was over. Delayed treatment could lead to higher risk of relapse, diminished support over time from family and friends, additional FMLA approvals from parents’ employers and prolonged isolation to keep the child and family members from being exposed to the virus during the course of cancer treatment, at a time when families are already under stress from their child’s illness. As we face new variants that are more likely to affect children, we encourage all who are eligible to get one of the available COVID-19 vaccines. Immunocompromised children like our cancer patients may mount some kind of response from the vaccine but may not have full protection. For the most vulnerable patients, it’s important that close family members get vaccinated as well to protect those who aren’t old enough to get vaccinated themselves. It’s a conversation we’re having with every one of our patient families, similar to our approach with the annual flu vaccine. The POCC is a labor of love for both of us as well as for our pediatric oncology colleagues across the country. This registry serves as a snapshot in time so that we have the data and can look back and understand the impact that the pandemic had on young cancer patients. And while we don’t expect to face another pandemic of this magnitude in our careers, we are better prepared to understand how best to support and care for our patients. September is National Childhood Cancer Awareness Month and Sickle Cell Disease Awareness Month. More than 90 percent of Alabama’s children with these illnesses receive treatment at the Alabama Center for Childhood Cancer and Blood Disorders at Children’s of Alabama, where more than 300 pediatric healthcare professionals provide exceptional patient care, education and research. Emily Johnston, MD, MS is an Assistant Professor in the University of Alabama at Birmingham Division of Pediatric Hematology and Oncology; Alabama Center for Childhood Cancer and Blood Disorders at Children’s of Alabama Julie Wolfson, MD, MSHS is an Assistant Professor at the University of Alabama at Birmingham Division of Pediatric Hematology and Oncology; Member, Institute for Cancer Outcomes and Survivorship; Alabama Center for Childhood Cancer and Blood Disorders at Children’s of Alabama


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Bipartisan Legislation to Support ACOs and Fix Rural Glitch By Cindy Sanders

In July, major healthcare organizations signed a letter of support for the recent reintroduction of a bipartisan bill to support accountable care organizations (ACOs) and other alternative payment models (APMs), while also addressing an unintended consequence of the ACO formulary, known as the ‘rural glitch,’ that punishes rural hospitals even when they achieve savings. The Value in Health Care Act 2021 was reintroduced in the U.S. House of Representatives on July 20 by Reps. Peter Welch (D-Vermont), Suzan DelBene (DWashington), Darin LaHood (R-Illinois) and Brad Wenstrup (R-Ohio). That same day, 14 healthcare stakeholders praised the bill, which looks to increase shared savings rates, update risk adjustment rules, eliminate an artificial barrier to participation, fix the rural glitch and restart the ACO Investment Model. The bill also extends the five percent Advanced APM incentive payments for an additional six years and authorizes a study looking at overlap between Medicare alternative payment programs. Additionally, The Value Act mandates the Government Accountability Office produce a report on health outcomes and racial disparities comparing Medicare patients cared for by ACO participants with those cared for by traditional Medicare programs. The bill comes as participation rates

Suzan DelBene (D-Washington)

Darin LaHood (R-Illinois)

Stakeholders Supporting the Value Act A broad coalition of healthcare stakeholders have voiced approval for the reintroduced act. Those signing onto the letter of support were: • America’s Health Insurance Plans • America’s Physician Groups • American Academy of Family Physicians • Association of American Medical Colleges • American College of Physicians • Federation of American Hospitals • American Hospital Association • Health Care Transformation Task Force • American Medical Association • Medical Group Management Association • America’s Essential Hospitals • National Association of ACOs • American Medical Group Association • Premier A section-by-section summary of the Value in Health Care Act 2021 is available through NAACOS. Go to our website at BirminghamMedicalNews.com for a direct link to the summary.

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have declined over the past few years. There were 477 ACOs participating in the Medicare Shared Savings Program at the beginning of 2021, compared to a high of 561 in 2018. Since launching in 2012, ACOs had seen steady growth up until late 2018 when the Trump-era ‘Pathways to Success’ policies took effect.

“Since 2012, Medicare ACOs have saved $8.5 billion in gross savings and $2.5 billion in net savings,” Allison Brennan, vice president with the National Association of ACOs (NAACOS), said during a virtual briefing on The Value Act. “Unfortunately, we have seen a decline in the number of ACOs, providers

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and beneficiaries covered. The policies enacted in late 2018 and early 2019 that sped up the risk profile and cut the share of savings available to ACOs seem to have impacted participation. On balance, I think it has had the effect of chilling new ACO growth. “The reintroduced bipartisan bill once again incentivizes ACO growth as participants would get to keep more of the savings they help generate. It also gives ACOs three years before they must take on risk and provides some upfront funding for those who need help in setting up their ACO.” Sponsor Rep. DelBene cited the importance of finding cost savings while improving care coordination and quality. “Our healthcare system should be as healthy as we want our patients to be,” she sais. “The need for this level of care was made clear by the pandemic. Across our health system, we should be incentivizing care coordination and quality. ACOs show the ability to do that.” Fixing the Rural Glitch The Value Act and a separate bill introduced in the U.S. Senate last fall – The Rural ACO Improvement Act (S.2648) and companion bill in the House (H.R.5212) – focus on making financial targets more equitable in rural areas. Introduced by Sens. Catherine Cortez Masto (D-Nevada) and Pat Roberts (R-Kansas), the bill changes the benchmark calculation so rural ACOs aren’t punished for their location in areas that are more sparsely populated. In 2017, the Centers for Medicare and Medicaid Services began aggregating spending from other providers in the ACO region to calculate an ACO’s benchmark. The adjustment was created to reward ACOs with costs below the regional mark and includes an ACO’s own beneficiaries in the calculation. In rural areas, however, ACOs often either had no peers for comparison or were penalized by making up the bulk of the market, thus being compared to themselves. With a lower spending benchmark, rural ACOs often receive smaller savings bonuses compared to their urban counterparts where there are more providers and patients in the pool. To address the unfair adjustment, both bills look to remove an ACO’s assigned patients from the regional comparison to get a truer picture of whether the ACO is creating cost savings compared to other providers in the area. While all ACOs will benefit from the change, the issue is known as the rural glitch because rural ACO participants have been negatively impacted the most by the current spending target methodology. “When ACOs lower their spend(CONTINUED ON PAGE 19)

18 • SEPTEMBER 2021

Birmingham Medical News


Professional Liability Factors That Affect Your Malpractice Insurance Rates By Blair Voltz

When physicians are looking into a malpractice insurance policy to purchase, there are several factors to consider that are as important as price. To start with, the financial stability of the insurance company is critically important. A.M. Best Company, established in 1899, rates the strength of insurance companies, their long-term viability, and their ability to pay their financial obligations. A.M. Best also gives a forward-looking outlook, which is a predictor of the company’s nearto-midterm expected development (expressed as a rating of Positive, Stable, or Negative). A.M. Best rates by both size of the company and financial strength. The A.M. Best rating represents a comprehensive analysis consisting of a quantitative and qualitative evaluation of balance sheet strength, operating performance, and business profile of an insurance company. Best rates companies on the following scale: RATING

RATING RATING SYMBOL NOTCHES

Exceptional AAA (none) Superior AA +/Excellent A +/Good BBB +/Fair BB +/Marginal B +/Weak CCC +/Very Weak CC +/Poor C +/-

You want to be insured by a company that has at least an A rating. There are too many companies to choose from, than to pick one that is rated BBB or lower. As an insurance Consultant and Licensed Agent, I could never recommend any company with less than an A rating. This is especially important for hospitals, as many hospital contracts for construction and equipment leasing require the hospital to be insured by an A rated company or higher. Next, you should review the insurance policy, commonly referred to as the Form. Does the Form/Policy ade-

quately cover the insured? Does it favor the insured, or does it favor the insurance company? There is language in all policies that usually favor the insurance company. The insured needs to have it pointed out where these are, as many times the form limitations can leave a physician or hospital in a tenuous position when they discover, usually the hard way, what those items are, such as limits, deductibles, aggregate deductibles, exclusions, etc. This is where it helps to have an independent Consultant/Agent who is working for you, rather than the insurance company, to point out these things before you make a decision. A great example of this is the socalled Hammer clause in some policies that practically forces the physician to settle a case if that is what the insurance company wants to do. I could never recommend a policy if it contains a Hammer clause, yet I know of Alabama physicians who are insured by a company that has the Hammer clause in their policy. On the other hand, a Consent-to-Settle clause favors the insured and puts them in charge of the decision of whether to settle or fight. Most physician-owned companies will have a consent to settle clause in their policy. This leads to another factor to be aware of. What is the insurance company’s defense philosophy? Do they look forward to defending an insured who is facing a lawsuit or do they prefer to settle? This is more important to physicians than to hospitals because hospitals have larger deductibles and are willing to settle the case to avoid negative publicity. On the other hand, if a physician settles a case, it stays on his record for the rest of his career. Any judgement or settlement over $25,000 must be reported to the National Practitioner Data Bank where it remains. Even worse, with every application a physician has to complete for the rest of her career, she will have to answer the question “have you ever been notified of a malpractice lawsuit, claim, or incident?” If the answer is “yes”, then the physician has to provide all of the details and the result. It is much better to say the case was dismissed or defense

Bipartisan Legislation to Support ACOs and Fix Rural Glitch, continued from page 18 ing, Medicare spending for the entire region also falls,” NAACOS President Clif Gaus, ScD said. “These bills correct an unintended flaw that penalizes those who make up the bulk of their market. Our health system needs to find ways to incentivize the adoption of alternative payment models like ACOs.” Value Act sponsor Rep. LaHood,

who represents a mostly rural area, said supporting value-based efforts in healthcare is critical to ensuring access and coordination. “As we continue the transition to value-based care, there are always challenges to address and ways to improve. The Value in Health Care Act is a common-sense proposal to do that.”

Blair Voltz

verdict obtained at trial than to try to explain that you wanted to defend it but the insurer settled. You want a company that is going to fight for you so you won’t have a stain on your record. Be careful though: many companies will give lip service to defending you, but will not do it when the time comes. Also when looking at a policy, you should consider the business model/ownership of the company. A publicly traded insurer can be under pressure from Wall Street and stockholders to make growing profits. Or is it a Risk Retention Group (RRG) where a number of insureds have come together to insure each other? (RRG’s have notoriously unfavorable terms for physicians, limited coverage limits, and notoriously bad track records.) Or is it a Mutual company?

The type of company it is will have a direct impact on the price of the policy. Stock companies will usually have higher rates due to the financial pressures to make money for the stockholders. Mutual companies on the other hand do not have to make profit for the stockholders or impress Wall Street, and Mutuals usually pay a dividend back to the policyholder. The A.M. Best rating, policy form, the defense philosophy, and the business model/ownership of the insurance company are all very important factors in choosing a professional liability carrier. Only when all these factors line up in favor of the insured should the physician look at the premium. Unfortunately, I know physicians and hospital administrations who are concerned with price only, and may be insured with a company that may not be there in one way or another. Next month, I will discuss more about rate, price and Hard-Market. Blair Voltz began his career in medical professional liability in 1987, spending the next 25 years with Alabama’s largest medical malpractice carrier before establishing Voltz Professional Risk Advisors in 2011. Since then, he has helped over 200 physicians and a major hospital system improve their coverage, as well as their bottom line.

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$20M Awarded for Research in Preventing Hypertension

For Parkinson’s, the grant will advance its research on a molecule that may keep brain cells alive. The second grant will support exploratory research about how neurons stop functioning in frontotemporal dementia and ALS.

SCHEDULE

Alabama State Nurses Association Statement on Nurse Staffing Crisis

 SEPTEMBER 7 William C. Presson, ERPA of Pinnacle Plan Design Retirement Plan Issues When a Doctor Leaves the Practice  SEPTEMBER 14 Katila Farley RN of Complete Health Value Based Care Disrupting the Market  SEPTEMBER 16 Christopher Michael Clark, MD of ENT Associates Surgical Treatment of Obstructive Sleep Apnea  SEPTEMBER 21 Blair Voltz of Voltz Risk Advisors Medical Malpractice Rates and Price in the Hard Market  OCTOBER 5 Marliese Delgado, PT MS of United Ability Public Accessibility for Individuals with Disabilities  OCTOBER 12 Bill Nolan of Nolan Elder Law Helping Elders Protect Savings and Navigate Challenges

Uncontrolled hypertension is a health concern in underserved communities.

The American Heart Association, has awarded $20 million in grants to five research teams, including researchers at the UAB Schools of Medicine and Public Health, to find new solutions for preventing high blood pressure. The research projects, under the RESTORE (AddREssing Social Determinants TO pRevent hypErtension) Network, will focus on hypertension prevention in underserved populations with historically the highest prevalence of this condition. The UAB team, led by Andrea Cherrington, MD, MPH, professor in the Division of Preventive Medicine, will work with 16 churches in rural Alabama where they will recruit black adults with elevated blood pressure who have not treated for hypertension to take part in one of two interventions. People from eight of the churches will receive group health education and computer tablets to access online cooking shows and exercise classes. People in the other eight churches will receive group health education, access to online cooking shows and exercise classes, plus peer support

from a trained community health worker to help set and meet diet and physical activity goals. Churches will also receive funding for community-level interventions to promote healthy foods and physical activity opportunities.

Southern Research Lab Wins $3.9 Million Grants A Southern Research neuroscience lab has received new federal grants totaling almost $3.9 million to advance its study of Parkinson’s Disease and other neurological diseases. The grants from the National Institute of Neurological Disorders and Stroke include $3.3 million to study Parkinson’s and $594,000 for research related to frontotemporal dementia, a disease that is similar to Amyotrophic Lateral Sclerosis (ALS). Both grants will support a lab led by Rita Cowell, PhD, of the Department of Neuroscience in Southern Research’s Drug Discovery Division.

Through membership surveys, the Alabama State Nurses Association (ASNA) members report that our healthcare system’s staffing challenges are perilously high. Nurse burnout and exhaustion are common. Many have elected to retire. Because Alabama’s average RN pay is less than the average pay of our 12 surrounding states, many nurses have chosen to practice elsewhere either as travel nurses or through a multi-state license. Alabama has one of the lowest CMS Medicare wage indexes in the country, and Alabama has not expanded Medicaid, which could cover the cost of compensated patients. As a result, ASNA believes that when the COVID surge is over, it will be challenging to return to healthy numbers of permanent staff unless Alabama becomes competitive with our surrounding states.

Bariatric Surgeon Joins Cullman Regional Medical Group Venkat Kanthimathinathan, MD has joined the Cullman Regional Venkat Kanthimathinathan, MD Medical Group. Venkat, who is a board-certified General, Bariatric and Minimally Invasive Surgeon, completed his medical school at JSS Medical College and his Residency in General Surgery at Loma

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GRAND ROUNDS Linda University Medical Center in California. He then went on to complete a Fellowship in Minimally Invasive and Bariatric Surgery at the University of Missouri Health Care. Venkat will treat patients age 12 and older and specializes in: Sleeve Gastrectomy; Gastric Bypass; Removal/Adjustment of Gastric Band; Revisional Bariatric surgery; Gallbladder Removal; Acid reflux Surgery; Hernia Repair; Small Bowel Resection; Colectomy; Rectum Resection; Splenectomy; Pancreatectomy; Adrenalectomy; Port placement; Emergency Surgeries; Endoscopy (Colonoscopy/EGD/ PEG Tube Placement, Balloon dilation, Stent placement). He will be providing care at Cullman Regional Metabolic and Surgical Clinic, located in Professional Office Building 3, 1800 AL Hwy 157, Suite 201.

Karl Schroeder, MD Joins Norwood Pulmonologist Karl Schroeder, MD has joined the Norwood Clinic. Schroeder, who is a Huntsville native, received his medical degree in Karl Schroeder, MD 2007 from the University of South Alabama in Mobile after receiving his undergraduate degree in chemistry from the University of Montevallo. Her completed his internal medicine residency and internship at the University of South Alabama in 2010. Following his residency, he completed a fellowship in pulmonary disease and critical care medicine at the University of South Alabama. Schroeder will see patients at Norwood’s new Grandview location, as well as the Specialty Clinic located in Fultondale.

Unsheltered Homelessness Results from a Number of Risk Factors New research from UAB and Birmingham VA Medical Center’s Stefan Kertesz, MD reports that among veterans expeStefan Kertesz, MD riencing homelessness, unsheltered experiences correlate with individual and community risk factors. Kertesz, professor with UAB’s Division of Preventive Medicine, says the study aimed to look at the causes of unsheltered homelessness in a survey of 5,406 veterans who have been homeless in the past two and a half years. “Some claim that unsheltered homelessness is an addiction problem,” Kertesz said. “I’m an addiction doctor, and I can say that is why, some of the time, a person ends up on the streets. But we wanted to offer a fuller and more evidence-based account of why some wind up homeless.” The survey examined personal and community characteristics, citing nine personal and two community factors including low income, criminal justice or jail history, poor social support, high psychological distress, medical conditions, drug problem, warm weather, and low shelter bed availability. Each one of the personal and community characteristics added moderately to the chance of a person’s having been homeless. When stacked together, the more risk factors a person had, the more likely they were to have been unsheltered in the previous six months. “Let’s depolarize the homeless discussion by using evidence,” Kertesz said. “Yes, personal vulnerabilities can help in understanding who is going to wind up unsheltered. But it’s just not one vulnerability like addiction. It’s a stack of vulnerabilities and the more you have, the greater the chance you will be without a place to stay.”

UAB Hospital-Highlands ED is First in Southeast to Receive Level 1 Geriatric Accreditation

The geriatric ED is equipped with LED lighting with bi-level dimming, non-slip flooring, wall-to-wall art, and color-contrasting walls, floors and doors.

The American College of Emergency Physicians has named UAB Hospital-Highlands Emergency Department a Level 1 Geriatric Emergency Department, the ACEP’s highest level of accreditation. This makes the UAB Hospital-Highlands Emergency Department the only accredited geriatric ED in Alabama, the first one in the southeast and just the 17th Level 1 ED in the world. “Research shows that geriatric patients do not recover as easily when they are taken out of the familiarity of their home environment,” said Brendhan Buckingham, M.D., medical director of UAB Hospital-Highlands ED. With this in mind, the geriatric ED

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offers a specialized pathway for older adults. Patients are placed in separate enclosed rooms with curtains and sound-absorbing materials to reduce noise. It is also equipped with LED lighting with bi-level dimming, non-slip flooring, handrails, and color-contrasting walls, floors and doors. Patients will also find comfortable furniture, analog clocks on the walls, and art of local scenery to remind them of the current time and location. And the facility offers a variety of resources such as delirium prevention toolkits to help reduce instances of confusion. Upon arrival to the ED, older adults will undergo an Identification of Seniors at Risk assessment (ISAR). The ISAR results assist in identifying patients who may need a more comprehensive assessment in the ED. Based on a patient’s score, a geriatric emergency nursing intervention expert (GENIE) may come in and complete additional screenings to identify any needs that must be met before the patient can be safely discharged. The GENIE nurse will share the screening results with the medical team to determine an appropriate treatment plan. GENIE nurses assist with coordinating a range of services needed at home, including physical therapy, home health, social work services and medical equipment delivery. GENIE nurses also conduct follow-up calls to ensure the patient is getting the needed treatment. This accreditation was a three-year effort led by UAB’s Department of Emergency Medicine in collaboration with the Division of Gerontology, Geriatrics and Palliative Care, Rehabilitation Medicine and Therapy Services, pharmacy services, social work services, and nursing.


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Birmingham MGMA Honors Debbie West In August, the Birmingham MGMA chapter honored Debbie West who is retiring from her position as Practice Administrator for Birmingham Pediatrics. West began her career 42 years ago with a small private practice in Trussville before she was recruited to Pediatrics East where she spent a number of years before joining Greenvale Pediatrics. From there, she was recruited to Birmingham Pediatrics and spent the last 22 years there. West has been a part of MGMA for 20 years and served on the board for eight years where she served in all positions, including President in 2014. She has also served on several other medical boards throughout her career.

(Left to right): Jennifer Perry, Immediate Past President; Debbie West; Jennifer Cork, President; Sherri Aaron, Vice President.

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