Chester County Medicine Winter 2022

YO U R CO M M U N I T Y R E S O U R C E F O R W H AT ’ S H A P P E N I N G I N H E A LT H C A R E

WINTER 2022

CHESTER COUNTY

P u b l i s h e d

b y

P e n n s y l v a n i a ’s

F i r s t

M e d i c a l

S o c i e t y

The Art of Chester County

Presents gregory blue

Addressing the Closure of Brandywine & Jennersville Hospitals

A Voice from the Community PAGE 8

Accessing Drug and Alcohol Services in Chester County PAGE 19

31 S T A N N U A L

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DAVID SANBORN & FRIENDS

JAKE SHIMABUKURO

SPECIAL EFX ALL-STARS JOHN NÉMETH BÉLA FLECK: MY BLUEGRASS HEART

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Contents OFFICERS 2022

56

WINTER 2022

Pet Therapy

President

Bruce A. Colley, DO President-Elect David E. Bobman, MD Vice President Mahmoud K. Effat, MD Treasurer Winslow W. Murdoch, MD Past President Mian A. Jan, MD, FACC Board Members Brian K. Abaluck, MD Norman M. Callahan, DO Heidar K. Jahromi, MD John P. Maher, MD Manjula J. Naik, MD Richard O. Oyelewu, MD David A. McKeighan Executive Director Chester County Medical Society 1050 Airport Road PO Box 5344 West Chester, PA 19380-5344 Website – www.chestercms.org Email – chestercountymedsoc@gmail.com Telephone - (610) 357-8531

In Every Issue 4 President’s Message 16 The Art of Chester County

20 No Surprises Act Effective January 1, 2022 — Issues for Telemedicine Providers

Features 11 The Global Threat of Antimicrobial Resistance

24 Diabetes Mellitus — A Silent Killer

14 Worst Drug Epidemic in US History

27 SGLT2 Inhibitors in Diabetic Kidney Disease: The Time to Act is Now

15 Chester County Accidental Overdose Deaths — Data is from OverdoseFreePa

Chester County Medicine is a publication of the Chester County Medical Society (CCMS). The Chester County Medical Society’s mission has evolved to represent and serve all physicians of Chester County and their patients in order to preserve the doctor-patient relationship, maintain safe and quality care, advance the practice of medicine and enhance the role of medicine and health care within the community, Chester County and Pennsylvania.

The opinions expressed in these pages are those of the individual authors and not necessarily those of the Chester County Medical Society. The ad material is for the information and consideration of the reader. It does not necessarily represent an endorsement or recommendation by the Chester County Medical Society.

8

Addressing the Closure of Brandywine & Jennersville Hospitals — A Voice from the Community

28 Nothing about them without them! International Adolescent Health Week: 18 Substance Use Disorders During the For and by adolescents Pandemic; Getting Help in Chester 30 The 2022 Elections County Including the Race for 20 Accessing Drug and Alcohol Services US Senate from in Chester County Pennsylvania Letters to the Editor: If you would like to respond to an item you read in Chester County Medicine, or suggest additional content, please submit a message to chescomedsoc@comcast.net with “Letter to the Editor” as the subject. Your message will be read and considered by the editor, and may appear in a future issue of the magazine.

Cover: Winter Sentinel, Stroud Preserve | 42" X 46" | Oil on Linen | 2019 by Gregory Blue.

Read more in The Art of Chester County on page 16.

PUBLISHER: Hoffmann Publishing Group, Inc. 2669 Shillington Rd, Box #438, Reading, PA 19608 www.Hoffpubs.com

For Advertising Information & Opportunities Contact: Tracy Hoffmann 610.685.0914 x201 tracy@hoffpubs.com

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PR E S I DE NT’S M E SSAG E

Winter 2022

BY BRUCE A. COLLEY, DO PRESIDENT OF CHESTER COUNTY MEDICAL SOCIETY

I

returned to my home about midnight on January 31, 2022. I was driving back after a visit to the Brandywine Hospital ER. It was a time of day and a trip I had made, to my best estimate, 200 hundred times in the twenty-seven years I admitted my patients to Brandywine Hospital.

Fortunately, I was not there for personal reasons or to care for one of my patients.

Unfortunately, I was there with at least 250 others who were doctors, hospital staff, former patients, or friends of Brandywine Hospital to watch the hospital’s doors lock for the final time.

Brandywine Hospital is now closed. After over one hundred years of serving the community, gone. My drive to the hospital on this recent cold winter night soon flooded my memories of those clinical adventures I experienced there. Though I had not admitted anyone for the past five years, those jaunts I made for 25 years tripped my memory and emotions. “Really?!” “My patient presents in the wee hours of the morning and needs admission now?” “Are you kidding me?” “I am cold, and boy, I’m tired.”

D r. B r u c e A . C o l l e y

To contact Dr. Colley send email to: bacolley828@gmail.com

For those at the hospital who worked these hours and the physicians on call you certainly know where I am coming from. Then as I would pull into the emergency room parking lot, inevitably I would feel a rush of energy and a certain exaggerated wakefulness. Yes, there was an element of apprehension and even a bit of fear. Will I be able to figure out what is causing my patient’s distress, and will I remember what to do? Then walking into the ER a sense of calm and an immediate focus on the task at hand. There was an energy there, the staff all called out a hello and hearty welcome (“Cheers” comes to mind) – yes, I know the night shift at hospitals are a bit of a lonely bunch, but they are a team, and they absorbed me into the team. Frankly, there was and is this esprit de corps on all the shifts and on all the floors at Brandywine and Chester County Hospital to this day. There was, however, a special, family-team spirit among the staff and physicians at Brandywine Hospital. Maybe nostalgia, but I do not think so.

I returned home after a brief blessing by the long-time hospital Chaplin, a few songs, intense emotion among all in attendance, and a beautiful poem written by one of the ER technicians, Heather L. Myers, who had only worked at Brandywine Hospital for one year.

Please note her poem at the end of this message. Too much pathos one may think, but I find it a beautiful and honest summation of the people and spirit of Brandywine Hospital.

Thank you for sharing your poem, Heather, bless you. After her reading, all those still with I.D. badges turned them in, throwing them into a box. All the faces of those who animated the hospital, like a deep badge grave. The doors were locked, and all left in deafening silence.

Thousands of Chester Countians’ lives have been saved and health restored at Brandywine. Now gone, the hospital, the ER, the wound clinic, the skilled radiologists, behavioral health, pathologist, clinical laboratory, heart station and catheterization unit, diabetic educators, social work, physical therapy and on. A living place of healing, may you be a smoldering Phoenix and soon rise again. The citizens of Chester County await and deserve your rebirth.

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To Brandywine Hospital

HEATHER L. MYERS • 1/31/22

Coatesville Hospital, founded in 1902, once sat on Strode

I know this hospital didn’t have a great reputation

Now known as Brandywine Hospital, or Reeceville, is 120 years old

There’s some hate from personal experience or a bad situation

Coming across the bypass, whether from family vacation or driving alone

Yet, we employees still came here and hit the hallways with a stride Most of us with dignity and a great sense of pride

“Brandywine Hospital – Next Exit,” a sure sign you were home.

Once, always people moving down the halls; possibly looking for labs or xray

And now the busy halls, with their hustle & bustle have all quieted down Down to a lack of movement comparable to that of a ghost town.

Sometimes a perfect stranger would stop and actually show the way

And they covered her eyes with shades of plastic

There’s so much personal history within these walls

With some of us still in here and it felt quite drastic.

I’m sure we’ve each had a procedure done; whether big or small

So, as we say goodbye, please continue to hope, to wish and to pray

I was born at the old one back in 1978

That someone reputable and respectful will come in and save the day.

And I had my first son here. 8/21/1993 was the date.

Please, please don’t let them take Brandywine Hospital away.

Yes, there used to be a pediatric unit and even an OB/GYN Some of you may be too young to remember. It was way back when.

PATIENT BROCHURES Available through PA MEDI Contact the CCMS Staff to order brochures for your waiting room.

Help your patients find proper, local resources to help them with Medicare enrollment.

Call the CCMS Office (610) 357-8531 or email chescomedsoc@comcast.net.

WINTER 2022 | CHESTER COUNT Y Medicine 5

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Pet Therapy

BY KEVIN A. MCKEIGHAN

S

ince March of 2020, we as a state and as a country have been living in unprecedented times presented by the global pandemic. With the start of another new year, we remain in the shadow of the Coronavirus and its many variants as schools contemplate in-person vs virtual learning and hospitals are being pushed to capacity again this winter.

Over the last two years Americans have grown used to stay-athome orders, contact tracing, mask wearing, and countless other proper safety procedures when dealing with an airborne virus.

These measures are taken to ensure the best chance of protection against COVID-19, but these restrictions are also contributing to the deteriorating mental state of many adults and adolescents across the country. Before COVID-19, we as a country had an issue regarding mental health, which has only been amplified by the events of the last two years.

Pet therapy is a unique way for people to combat a variety of health issues that are both physically and mentally exhausting.

The idea is that dogs are full of unconditional love and many people are positively impacted by the presence and compassion of a friendly dog. There are different levels of certification that a potential therapy dog and their owner must acquire before they are permitted to offer their services.

Some services offered under the broad umbrella of pet therapy are animal assisted therapy that focuses on a patient’s overall therapy program. The welcomed inclusion of a furry friend and some animal assisted activities are intended to create a more comfortable environment for people in stressful situations. This sometimes includes helping children at vaccination appointments, sitting bedside with chemotherapy patients, or visiting the residents of a nursing home. Individual visits, public events and school visits are just a few more ways people can interact with therapy pets as the industry continues to grow.

A study published in the International Journal of Older People Nursing focused on Alzheimer’s patients’ interaction with a therapy dog and how it affected their ability to recall memories (Swal, et al, 2015). Five patients were recorded ten times each while they answered the researcher’s questions in the presence of a therapy dog. The dog’s presence seemed to reduce fear and anxiety in the patients by creating a more equal dynamic between the patient and the authors of this study (Swal, 2015).

People with Alzheimer’s are often inundated with fear and anxiety regarding what they can and cannot remember. The therapy dog’s calming nature, at least for the duration of the visit, was a factor in making the patients more aware of their surrounding and more capable of recalling memories (Swal, 2015). These findings are further backed by research done by the Mayo Clinic that indicates therapy pets can have similar effects on patients with dementia (2020). Furthermore, the Mayo Clinic also suggests therapy pets can be helpful in reducing fear and anxiety in children’s dental procedures (2020).

In addition to the findings of the Mayo Clinic, a study published in the Child and Adolescent Social Work Journal found that the inclusion of a therapy pet can significantly reduce anticipatory anxiety and/or situational fear in adolescents (Vincent, Heima, 2020). This study focused on children ages eight to twelve who exhibit varying levels of fear and anxiety when they require dental work. The controlled environment of a dentist’s office, or any other medical practice for that matter, affords the researchers in this case to easily observe the nature of the patients’ visits both with and without the intervention of the therapy pet (Vincent, Heima, 2020). In fact, their findings were so well received that the researchers encourage dentists and medical professionals alike to consider the possibility of including therapy pets in their practices as a non-pharmaceutical remedy for children with situational fear and anticipatory anxiety (Vincent, Heima, 2020).

The effectiveness of therapy pets in providing comfort and enjoyment for patients of all ages is properly documented. From children with situational fear, cancer patients, patients with dementia or those dealing with mental health issues, pet therapy can act as a catalyst for better accepting treatment and care.

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Introducing John and Ingrid Meet John DeSantis and his beloved Rough Collie, Ingrid from West Chester. John and Ingrid offer their service to people throughout the Philadelphia area. Several years ago, Mr. DeSantis adopted the then two-year-old dog and almost immediately knew how special she is. “She is truly a special dog,” DeSantis said, adding, “she’s incredibly calm and warm which I think has an effect on the people she is with.” Ingrid earned certifications from the American Kennel Club which then led to pet therapy training, designed to teach candidate animals and their handlers everything they need to know to be ultimately certified for service.

Ingrid has been dubbed “Chester County’s Most Famous Dog” in local newspaper articles and recently on Channel 6 Action News

When Ingrid is not on duty, she may not seem much different from most other dogs, besides her beautifully manicured coat which alone gives her the center of attention.

She is playful, loves to run, fetch, and can be found constantly following John around the house when they are home together.

When on duty, she is remarkably intuitive, very affectionate and just genuinely enjoys being around people.

John and Ingrid frequently volunteer their time around Chester County at schools (K-12) and West Chester University, as well as visits with first responders and retirement communities. Ingrid is also the star of the show at local food drives, sponsored by Pica’s and ShopRite, where she has a newfound talent for collecting non-perishables.

Mr. DeSantis elaborated on how much they enjoy working with children and how Ingrid can have an almost instantaneous effect on their overall mood. Think about the situational fear and anxiety that kids associate with a dentist appointment or getting a shot in their arm. Now think about walking into that same appointment and being greeted by a big fluffy companion like Ingrid, who is there to be petted and to smile back at you.

John and Ingrid’s schedule has gotten busier as venues began opening back up over the past year, and they are excited to continue offering their service to anyone who wants them. You can show your support and can get in touch with John through their Facebook page, Ingrid Collie.

Kevin McKeighan is a 2021 graduate of West Chester University with an interest in public relations & communications and a passion for animals.

Footnotes: Vincent, A., Heima, M., & Farkas, K. J. (2020). Therapy dog support in Pediatric Dentistry: A social welfare intervention for reducing anticipatory anxiety and situational fear in children. Child and Adolescent Social Work Journal, 37(6), 615. https://doi.org.10.1007/s/10560-020-00701-4 Swall, Ebbeskog, B., Lundh Hagelin, C., & Fagerberg, I. (2015).

Can therapy dogs evoke awareness of one’s past and present life in persons with Alzheimer’s disease? International Journal of Older People Nursing, 10(2), 84–93. https://doi.org/10.1111/opn.12053

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Addressing the Closure of Brandywine & Jennersville Hospitals

A Voice from the Community

BY EVAN TULL

T

he closure of Brandywine Hospital continues the dissection of the health care resources in our county. To remove a lifeline from a community that has depended on it is to take away a painter’s canvas, remove a guitar’s strings, take away a piano’s keys, or take out a car’s engine, and expect the same results.

The immediate impact that this closure has had lays just as close as Freedom Village or the two schools located across the street. On a normal day people from these locations could require emergency medical treatment on a regular basis. The time difference it will take to receive medical treatment will reduce survival rates drastically. That is, if the hospital staff can see the patients as soon as they are transported there.

There are other elder care facilities and schools that depend on Brandywine Hospital. To say we need a lifeline thrown is not an understatement. As somebody who has dealt with mental health issues, I can personally understand the impact of not having resources available. For many people to lose the security of having a behavioral hospital right down the street could mean the difference between thinking there is hope or thinking there is not.

Something as simple as taking the ability to walk to get help, and instead, have to get in a car to receive it while being in the middle of an irrational moment. That is, of course, if a car is at your disposal.

With the closing of Brandywine Hospital and Jennersville Hospital, only thirty days apart from each other, our response system has been thrown into turmoil. Creating longer wait times as our ambulances and our first responders are forced to travel further. These further distances will take resources away from our community. By taking these resources away from our community we will then need others. Creating even longer response times the further into the system it goes. This means that at some point, it

will not affect just our community, it will start affecting the communities around us and the counties around us.

These two hospitals are critical to the life support of Chester County. As we see violence spread through the media, and mental illness being a contributing factor, our communities cannot afford to lose psychiatric wards, local health resources, all-in-one health care spaces.

Brandywine Hospital was always accessible by taking public transportation.

These hospitals have been serving this area for many years and serve collectively 150,000 to 200,000 people. Our VA Hospital right down the street will incur immediate effects as well. In simple terms, to take a hospital away from a community that has depended on it for so many years is extremely damaging.

It is like taking the foundation away from our community.

Foundations are important for people to have a good day. As I referenced earlier, it is like taking away a canvas from a painter and asking them to create a painting. Taking away a sturdy foundation, having the knowledge of a hospital nearby, can shake up a person’s day.

Mental health and physical health are important to building a good blueprint for a good support system. Risks such as snowplowing your driveway, sledding down a hill, getting into an automobile accident, all become greater taking these hospitals away. What we can do as a community in times like this though, is to come together and let our voices be heard. In a world with such controversy going on all around us, with multiple causes, listening is important. Steps such as starting a petition, writing your representatives letters, speaking with your neighbors, are extremely important.

The solutions to situations like taking a hospital away from the community that depends on it, lay within its community.

“To be part of a group. To be part of a cause. To be part of a difference, not only feels amazing, but helps to get things done.”

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Evan’s billboard is located on Route 202 just outside West Chester The resources we have at our fingertips have really made being heard easier. Honestly the internet can be a strong tool for your campaign. Nowadays, it is growing more important, to understand that you are not alone. That coming together starts an understanding that your voice is important and should be heard.

Most importantly, should you choose to get involved, remember to not promote violence. Again, mental health is a front burner topic.

business plan. Come together and be strong. Instead of working against each other, work together on common grounds. Most importantly, when situations such as our hospital closure arise around you, remember you can be heard. You are not alone. You do not have to feel stuck. Be patient, be heard, be positive. Most importantly be involved!

The first step is to develop a plan. Look at the situation going on within your community. Think of how these situations, such as our hospital closing, will impact your life. How will these impact your neighbor’s life? How will this impact your friend’s life? How will this impact your community’s life? Adding your voice is key to hearing new ideas. Putting up flyers in town to get the community involved is one good way to be involved. Speaking to your local media is another resource that is available to you.

Editor’s Note: the Chester County Medical Society has been receiving calls and emails from patients in southern and western Chester County …. 84-year-old retired Coatesville resident John P. reported that he’d read about the medical society’s efforts in the local newspaper and he wanted to thank us and see how he could help.

Everyone in our community and surrounding areas should be able to offer different ways to help the cause. Resources as easily accessible as change.org allow the public to assist as well.

Coming together, understanding, and seeing things universally will help us find our solutions sooner. As we grow, our charity is focused on bringing community together and giving people from the community a place to go. Like creating a virtual town hall, it will be a web source, for solutions, with up-to-date news on the situations we are involved in. Envisioning and applying community involvement to find productive solutions.

Finding solutions is as simple as looking out for one another and standing up as our local resources get stripped away from us during a health crisis. The numbers that are important in this situation are the number of lives that will be impacted. The number of avoidable situations that are created by a failed hospital

Other Community members have coordinated and circulated petitions with thousands of signatures and sent to elected officials urging them to keep the hospitals open.

Nearly every elected official throughout Chester County has said how they are doing everything they can in support of keeping the hospitals open. State Representative Dan Williams held a virtual Town Hall in January and noted that the hospital closings not only impact heath care options but also have a devastating impact on the local economy.

The Alliance for Equity in Coatesville (formerly known as the Brandywine Health Foundation) announced that it has formed a task force to develop strategies for coping with the loss of the medical centers.

Several individuals have donated funds to help support our legal fees. There are many ways to get involved in efforts to preserve access to care!

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CONSIDER MEMBERSHIP in The Chester County Medical Society Join Us! Established in 1828, the Chester County Medical Society, founded by Dr. William Darlington, M.D., is thought to be the oldest county medical society in the State. The Medical Society is involved in all aspects of healthcare policy, practice, and education and serves to advance the health of the community and to protect and expand the healthcare resources available to its citizens.

T​ he Chester County Medical Society works collaboratively with the Pennsylvania Medical Society, but our focus is on our local community.

The Society’s role in Chester County is to support, protect, and advocate for our physicians and our patients. We look forward to growing an important healthcare service for our community that will benefit us all, and we look forward to hearing from you.

Member Benefits

Chester County Medicine, the official publication of the Chester County Medical Society for many decades. CCMS members receive a subscription to our quarterly magazine for their own reading and we encourage physicians to share the magazine with patients in their waiting rooms. CCMS members are also encouraged to contribute articles for publication and to purchase advertising to help promote their practices! Chester County Medicine features a popular ongoing series focusing on the art and artists of Chester County. The current and archived editions are available for readers on the society’s website: www.chestercms.org.

Advocacy – the CCMS is an active supporter on many important local and regional task forces, work groups and coalitions such as the Chester County Immunization Coalition; the Regional Overdose Prevention Task Force; the Chester County Suicide Prevention Task Force; the Pennsylvania Coalition for Civil Justice Reform and more.

The Clam Bake – our annual legislative dinner program is an opportunity for the physicians of Chester County to meet and enjoy a casual evening of great food and conversation with elected officials. The event also features the presentation of two scholarships to West Chester University pre-med students.

PracticeBeat – an outstanding member benefit offering practices a chance to enhance their on-line presence, improve patient satisfaction and ensure practice communications and scheduling requests are IPAA compliant. PracticeBeat offers CCMS members a significant discount off their monthly base fee. Data-based insight is also provided relative to the competitive landscape in your specialty and geographic area.

Leadership opportunities available – the CCMS leadership is eager to continue representing our membership and opportunities are available to serve for medical students, residents and fellows, early career physicians and our “full active” members Practice management assistance – contact CCMS staff with questions about a wide array on “business” matters pertaining to your practice. Our experienced staff at the local and state level offer outstanding assistance. Participate in our in-person and virtual programs to help guide your practice on issues such as reimbursement, credentialing, recruiting and many more important aspects of running a practice.

To learn more, join or renew, visit https://www.pamedsoc.org/about-pamed/Membership

CHESTER COUNTY COMMUNITY FOUNDATION Let your legacy make a difference, now & forever Our eternal thanks to these major philanthropists who knew where there's a will, there's a way.

Penelope "Penny" Perkins Wilson

Eva Low Verplanck, Ph.D.

1923-2021

1924-2021

Aaron J. Martin, Ph.D.

Ronald "Ronn" E. Fletcher

1928-2021

1947-2020

28 W. Market St., West Chester, PA 19382 | 610.696.8211 | chescocf.org 10 CHESTER COUNT Y Medicine | WINTER 2022

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The Global Threat of Antimicrobial Resistance

BY JOHN P. MAHER, MD, MPH

T

his past December the U.S. Centers for Disease Control and Prevention (CDC) announced that it had awarded $22 million to nearly 30 organizations around the world to combat the global threat of antimicrobial resistance (AMR) and other health threats. The funding goes for the establishment of two new networks: (a) The Global Action in Healthcare Network (GAIHN), and (b) The Global Antimicrobial Resistance Laboratory and Response Network.

Given the ongoing current obsession with the SARS-2 virus and COVID-19 disease, it is perhaps understandable why the mass media did not afford this event much coverage. However, there are certain aspects to the news which have significant import and implications for all healthcare providers and especially practicing physicians. According to the ProMED-AMR network website, “another pandemic, smoldering for decades, and perhaps worsened by the onslaught of COVID-19, is the illnesses caused by AMR pathogens.” Further, the World Health Organization (WHO) has declared that AMR is one of the top 10 global health threats facing humanity. And, in addition, an important new study has been published in the British journal, The Lancet (1/19/22).

C. Murray, et soc, having entered data from a systematic literature review, hospital systems, surveillance systems, and other sources, in a predictive statistical modeling approach, have estimated a global incidence of 4.95 million deaths associated with bacterial AMR occurred in just the one year, 2019 (Info also found in ProMEDAMR Mail for 1/22/22).

Paralleling the CDC’s efforts to improve global laboratory effectiveness, the WHO has made a strong effort to develop a Global AMR and Use Surveillance System (GLASS) by enrolling labs in more countries and areas to try to improve availability, representativeness and quality of their data. However, as of September 2021, GLASS was not yet at the point where it can provide such quality integrated data across all those countries because (among other factors) of differences in lab capacity and clinical testing practices.

In 2013 the CDC published its first report on antibiotic resistance (AR), sounding the alarm about the danger of antibiotic resistance, and noting that each year in the U.S., at least 2 million people get an antibiotic-resistant infection and some 23,000 of them die of it. By now, these figures have increased to 2.8 million per year, with some 35,000 deaths among them. If deaths due to C. difficile were to be added to that the U.S. totals would rise to more than 3 million infections and 48,000 related deaths.

More recently, the WHO has joined in the fray making it clear that AMR is not simply a local issue nor a problem solely of bacterial resistance to antibiotics. Rather, they say, “AMR is a complex problem that requires a united multi-sectorial approach.”

They advocate “the One Health approach which brings together multiple sectors and stakeholders engaged in human, terrestrial and aquatic animal and plant health, food and feed production, and the environment, to communicate and work together in the design and implementation of programs, policies, legislation and resources to attain better public health programs.”

There is good reason to think this way, because the issues are global, affecting all nations in every quarter of the globe.

Moreover, it is now apparent that there is a difference between the concepts of “antibiotic resistance” (or AbxR) and “antimicrobial resistance” (or AMR), and distinguishing between the two is significant. AbxR refers specifically to bacterial resistance to antibiotics, whereas AMR describes/includes “the opposition of any microbe to the drugs which scientists created to kill them.”

Thus, the category of antimicrobials includes not only antibiotics, but antivirals, antifungals, and antiparasitics — broadly, then, any medications used to prevent &/or treat infections in humans, animals or plants. AMR occurs whenever bacteria, viruses, fungi or parasites change over time and no longer respond to medications, making them harder to treat and increasing the risk of disease spread, severe illness and death. AMR can occur naturally over time, usually through genetic changes. It is also true that AMR organisms can be found in people, animals, food, plants and the environment (water, soil, and air).

One of the newer approaches (ISID-Pro-MED Report 6/5/2020) to increasing surveillance has been recently set up by the International Society for Infectious Diseases (ISID) and the webbased ProMED program. It aims to collect new information using digital disease detection methods and non-traditional sources which will be vetted, analyzed, and commented upon by a global team of AMR subject specialists. Reports will then be disseminated in real time to an international audience in the effort to enhance global AMR surveillance In 2019, the CDC published its report, Antibiotic Resistance Threats in the United States -2019, which includes the latest national death and infection rates for 18 AbxR bacteria and fungi, which are listed in 3 categories: urgent, serious, and concerning [See Table I]. It also includes a Watch List with 3 additional threats which have not (yet) spread widely in the U.S. but might become more common without continued aggressive action. continued on next page >

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CDC photos of antibiotic reistant bacteria

Table I: The CDC’s List of 18 AbxR Threats in the U.S. Urgent:

Carbapenem-resistant Acinetobacter, Candida auris, Clostridioides difficile, Carbapenem-resistant Enterobacterales, D-r* Neisseris gonorrheae

Serious:

D-r Campylobacter, D-r Candida, ESBL-producing Enterobacterales, Vancomycin-resistant Enterococci (VRE), MDR**- Pseudomonas aeruginosa, D-r non-typhoidal Salmonella, D-r Salmonella typhi, D-r Shigella, MRSA staph aureus, D-r Streptococcus pneumoniae, D-R Tuberculosis

Concerning: Erythromycin-resistant Group A Streptococcus, Clindamycin-resistant Group B Streptococcus Watch List:

Azole-resistant Aspergillus fumigatus, D-r Mycoplasma genitalium, D-r Bordatella pertussis

____________________________________________________________________________________ * D-r = Drug-resistant Source: CDC 2019 Report, op cit

** MDR = multi-drug-resistant

Especially alarming is the rapid global spread of multi- and pan-resistant bacteria (“superbugs”) which no longer respond to existing medications such as antibiotics. The CDC hopes their 2019 report will serve: (1.) as a reference for information on AbxR; (2.) to provide the latest U.S. AbxR burden estimates for human health; and (3.) to highlight emerging areas of concern and additional actions needed.

The main drivers of AMR, according to a 2021 WHO report, are shown in Table II.

Table II. Main Drivers of AMR Overuse & Misuse of antimicrobial agents Lack of access to clean water & hygiene for both humans and animals Poor infection and disease control practices in both healthcare facilities and farms Poor access to quality and affordable medicines, vaccines and diagnostics Lack of awareness and knowledge Lack of enforcement and legislation

Source: 11/17/21 WHO Report on AMR

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Other sources would add to these “drivers” such factors as the easy over-the-counter availability of certain antimicrobials in various countries where local residents can buy O-T-C antibiotics, antimalarials, etc., and the mail order or web-based versions of similar drugs. International travel, easy border crossings, etc., add to the problem. Even governmental laxity, such as allowing infected individuals into the country without adequate screening and treatment (under the pretext that those people are told to report to their local health department clinics), not only makes identifying and treating them very difficult, but also very costly to local governments. As an aside, years back, when this author was active in Public Health in this county, our TB clinic handled numerous patients from at least 13 different nations including some of those “3rd world nations” known to be sources of drug-resistant organisms such as STDs, M. tuberculosis, and some tropical diseases seldom if ever seen by local physicians.

Adding to the growing sense of urgency, the WHO reports what may seem to be obvious to clinicians, namely that antibiotics are becoming increasingly ineffective, and that new antibiotics are urgently needed. However, they also report that “the clinical pipeline is dry!” While 32 antibiotic drugs were in clinical development in 2019, only 6 were “innovative” (new) — meaning that the rest were merely “tweaked” variants of already existing drugs. Meanwhile, the costs of AMR to national economies and to healthcare systems is significant, affecting the productivity of both patients and caregivers through prolonged hospital stays and the need for more intensive and expensive care.

In the global effort to respond to the global issue of AMR, several plans of action have been initiated. The WHO has a Global Action Plan (GAP) which was promulgated in 2015 during their 2015 World Health Assembly, while the CDC website (www.cdc. gov/antibacterial-resistance) provides links to their 2019 outline of CDC strategies that work in healthcare and in community settings.

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www.Hoffpubs.com

Dr. Maher is a retired physician, a former Director of the County Health Department, and long time member of the CCMS Board of Directors. In drafting this article, he has made free use of all the related information on the websites mentioned as well as certain ID journals and long personal experience.

WINTER 2022 | CHESTER COUNT Y Medicine 13

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BY MATT BAKER

W

hile all the media attention is focused on the Covid Pandemic we also are engaged in the Opioid/Drug Epidemic.

Since 1999, there have been over 1 million deaths in the US due to overdoses. According to new data released by the CDC there were an estimated 100,306 overdose deaths last year in the U.S. during the period ending April 2021, or about 175 drug overdose deaths per day. These deaths are more than World War 1, World War 2, Korean War and Vietnam War combined.

In 2020, in Pennsylvania per the Pennsylvania Department of Health, there were 5,063 overdose deaths. This number of deaths exceeds those caused by car accidents and guns combined.

Nationwide: • Opioid misuse has been a major U.S. health threat for more than two decades, largely affecting rural areas and white populations. However, a recent shift in the drugs involved, from prescription opioids to illegally manufactured drugs such as fentanyl, has resulted in an expansion of the epidemic in urban areas and among racial and ethnic groups.

• From 1999 to 2013, increasing death rates from drug abuse, primarily for those 45 to 54 years of age, contributed to the first decline in life expectancy for white non-Hispanic Americans in decades. There was a modest national decline in overdose mortality from prescription opioids from 2017 to 2019, but the COVID-19 pandemic has upended many of these advances.

• According to provisional data from the CDC’s National Center for Health Statistics, there were an estimated 100,306 drug overdose deaths in the United States during the 12-month period ending in April 2021, an increase of 28.5% from the 78,056 deaths during the same period the year before.

14 CHESTER COUNT Y Medicine | WINTER 2022

• Also, according to the CDC, overdose deaths from synthetic opioids (primarily fentanyl) and psychostimulants such as methamphetamine also increased in the 12-month period ending in April 2021. Cocaine deaths also increased, as did deaths from natural and semi-synthetic opioids (such as prescription pain medication).

• According to the Commonwealth Fund, total overdose deaths spiked to record levels in March 2020 after the pandemic hit. Monthly deaths grew by about 50% between February and May to more than 9,000. Prior to 2020, U.S. monthly overdose deaths had never risen above 6,300.

• Opioid-related deaths drove these increases, specifically synthetic opioids overdose deaths increased in almost every state during the first eight months of 2020. Opioids accounted for around 75 percent of all overdose deaths during the early months of the pandemic; around 80% of those included synthetic opioids.

• Several reasons attributed to the increase in death during the pandemic: o Disruptions to the drug market, leading people who use drugs to purchase them from new and unfamiliar sources; o Reduction in the ability to obtain naloxone; o Indviduals using the substances alone, so the opportunity to utilize naloxone may have been lower by a bystander; o Fear of going to the ED, especially early in the pandemic; and o Barriers to accessing treatment for substance use disorders.

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Pennsylvania: • According to the PA Department of Health, the prescription opioid and heroin overdose epidemic is the worst public health crisis in Pennsylvania in almost a generation. There were 5,063 accidental and undetermined overdose deaths in 2020 compared to 4,458 in 2019 – nearly a 14% increase.

• Pennsylvania has been among the states hardest hit by the opioid epidemic. It had one of the highest rates of death due to drug overdose in 2018, with 65%, a total of 2,866 fatalities, involving opioids.

• There were also sharp increases in certain racial and age groups in the state. The rate of overdose deaths among Black residents increased by 63% in 2020 compared to 2018 – the largest of any racial group.

The rate of overdose deaths for white residents increased by 5% from 2018 to 2020 and 31% for all additional races. Men also showed a higher rate of drug overdose deaths compared to women.

• People in the 35 to 44 age group had the highest rate of overdose deaths. There were considerable increases in the youngest (0-14) and oldest (65+) age groups as well.

Conclusion: We are unfortunately witnessing the unprecedented and deadly convergence of the opioid/drug epidemic and the COVID-19 Pandemic.

Our federal, state, and local leaders as well as our heroic but strained healthcare workers are to be commended for their hard work, dedication and commitment to addressing these very trying and difficult challenges.

Much more work still needs to be done in order to address the concurrent growing opioid/ drug epidemic and Covid pandemic, however; I am grateful and want to thank our elected leaders, medical personnel, law enforcement, and faith-based organizations for their steadfast resolve in displaying Herculean efforts in the daily struggle to help and heal others.

Matt Baker is a former senior level federal official who served as Region 3 Director of the U.S. Department of Health & Human Services. Mr. Baker also served previously as a 13 term member of the Pa. House of Representatives and was Chairman of the Health Committee.

Chester County Accidental Overdose Deaths ** Data is from OverdoseFreePa • There were 718 accidental overdose deaths in Chester County from 2015 – 2021 • In 2020 there were 107 accidental overdose deaths compared to 97 in 2019. This was the first increase in accidental deaths following a decrease in three consecutive years, from a high of 144 in 2017. (Preliminary data available for 2021 is 86 deaths) • Fentanyl, heroin and cocaine were the most frequently identified substances in decedents for 2015-2021.

On an annual basis the most frequent substances identified varied some, although fentanyl was in the top three for all years, as exemplified below: 2015 – Heroin, Alcohol and Fentanyl 2016 – Fentanyl, Heroin, Alprazolam 2017 – Fentanyl, Heroin, Cocaine 2018 – Fentanyl, Heroin, Cocaine 2019 – Fentanyl, Cocaine, Heroin 2020 – Fentanyl, Methamphetamine and Cocaine (2021 – Fentanyl, Cocaine, Ethanol) • The largest percentage of decedents have consistently been white (84%), males (74%) from 2015 – 2021. (White males represented 70% of the deaths in 2021) • People in the 25-44 age group had the highest rate of overdose deaths. ** Data for 2021 is still preliminary Note: If you or someone you know is struggling with a substance use disorder, please see the article on pages 18 - 19 “Getting Help in Chester County.”

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w w w.c h e s t e r c m s .o r g

The Art of

Chester County

Gregory Blue

BY BRUCE A. COLLEY, DO

W

est Chester, the epicenter of the Brandywine Valley art community, is where I ventured early this winter and met Gregory Blue at his studio. A beautiful, converted garage with the studio on the top floor. It was flooded with natural light coming through windows that girdled the ceiling walls. The studio was filled with his current projects all in separate phases of completion. We spent several hours discussing Gregory’s motivations and approach to art. I was amazed to find that many of his large works begin with three to five preliminary studies.

Gregory grew up in south central Pennsylvania in a small town surrounded by the lush farmlands of Pennsylvania’s western most Piedmont near Gettysburg. An area much like Chester County, Cumberland County lends itself to hiking and that’s what Gregory did.

As a young boy he wandered the woods and farmlands that surrounded his hometown and continues to meander across Chester County today.

Observing the sunlight spilling over the landscape creating patterns of shadow and light fascinated him.By college, and now an art major, Gregory recognized his intense interest in analyzing light, shadows, and March 6, Snow, Stroud Series 10" X 10" | Oil on Panel | 2021

Stroud Woods, Autumn

Summer Evening Front, Stroud Series

16" X 20" | Oil on Canvas | 2018

40" X 46" | Oil on Linen | 2019

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Morning Light, Stroud Preserve 9" X 12" | Oil on Panel | 2018

color. As a child, Gregory remembers spending hours looking at art in The World Book Encyclopedia– (for those that remember encyclopedias), and he especially liked a painting by Renoir, the Bal du moulin de la Galette. He still vividly remembers trying to understand why the man in the center of the image was wearing a spotted coat. As a young man, he was fortunate to stand in front of the original, and he was changed. In that moment he felt as if he could “walk right into the painting,” and he knew those were the kind of pictures he wanted to paint. He went on to art school to learn about light, shadows, and color and continues to pursue each of those throughout his landscape paintings.

“My goal as an Impressionist is to create a back and forth, or a dialogue, between myself and the viewer.”

Gregory’s current project is a series inspired by the nearby Stroud Preserve. A property of Natural Lands, located just west of West Chester, Gregory has spent countless hours there trying to

November 3, Stroud Series 10" X 10" | Oil on Panel | 2021

capture the Preserve in all seasons and times of day. To give back to Natural Lands for serving as such an elegant muse, a portion of all prints and paintings sold from the Stroud Series, will support the work of Natural Lands in protecting and maintaining the beautiful open spaces in our county. A visit to the Stroud Preserve will make you appreciate his talents even more.

“It is something I do as a sixth sense. Since childhood I hike, draw, and analyze light.”

Evening Light, March, Stroud Series 34" X 40" | Oil on Linen | 2020

August 24, Greens, Stroud Series 10"X 10" | Oil on Panel | 2021 WINTER 2022 | CHESTER COUNT Y Medicine 17

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Substance Use Disorders During the Pandemic; Getting Help in Chester County

BY CHESTER COUNTY DEPARTMENT OF DRUG AND ALCOHOL SERVICES

O

ver the past two years, Chester County, just like the rest of the world, has faced ongoing challenges presented by the COVID-19 pandemic. There is no question that these challenges have created or increased feelings of anxiety, uncertainty, stress, and loneliness for everyone.

In addition to navigating the pandemic and accompanying challenges, Chester County, much like the rest of the country, continues to address another public health crisis, substance use disorder (SUD); most recently accentuated by the opioid epidemic. While opioids have greatly contributed to the SUD crisis, it is important to recognize the crisis involves all substances, including alcohol.

When we consider how people deal with increased feelings of anxiety, stress, uncertainty and loneliness, not all coping mechanisms are healthy, such as using substances, and could result in substance use disorder. Over the course of the pandemic, we have seen increased rates of alcohol consumption, among other substances, and subsequent related problems.

In addition to those who developed a substance use disorder from challenges associated with the pandemic, there are individuals who had a substance use problem before the pandemic and will continue to have those problems unless treatment services are accessed.

In some ways, those problems may be worse due to sudden, reduced access to a substance of choice, and additional stress, isolation, loneliness.

For those in recovery from a SUD, the pandemic presented a significant challenge with a change in the way recovery supports were available – with many no longer available in person or limited in capacity. The recovery community thrives from connection and relationships, which has been challenged during the pandemic. However, our community is resilient and adapted with alternative formats such as virtual recovery supports.

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As our communities continue to navigate the current pandemic, the impact of substance use disorders may be felt even greater, not just by the individual who is using a substance, but their family as well. If you or a loved one are struggling with substances, help is available regardless of insurance. Treatment and support services, which include 12 step meetings and other supports, have, and will continue through the pandemic.

Accessing the drug and alcohol services will be dependent upon individual insurance coverage.

If the individual has insurance, including Medicaid, please call the number listed on the back of your insurance card to get information on how to access drug and alcohol services.

If the individual does not have insurance, funding is available through Chester County. To access drug and alcohol funding through the county, please call one of the following agencies which is closest to you, for help: • Gaudenzia Coatesville (Coatesville) - 610-383-9600 • Mirmont Outpatient (Exton) - 484-565-1130

• Creative Health Services (Pottstown) - 610-933-1223 • Gaudenzia West Chester (West Chester) - 610-429-1414 Chester County offers a free information and referral line which residents can call 1-866-286-3767 Monday through Friday, 9:00am-5:00pm for assistance accessing drug and alcohol treatment or general information.

Additionally, the PA Department of Drug and Alcohol Programs offers a 24/7 Get Help Now line which residents can call 1-800-662-HELP (4357) provides accessing services assistance.

For more information on drug and alcohol information and services, please visit the Chester County Department of Drug and Alcohol Services website.

• Holcomb Behavioral Health Systems (Kennett Square) 610-388-9225

Accessing Drug and Alcohol Services in Chester County Experiencing life threatening Situation such as a medical or psychiatric emergency?

If ambulance is needed call 911.

If ambulance is not needed, go to nearest Emergency Department.

Once admitted to the Emergency Department, patient will be stabilized.

Outpatient Assessment Providers* Gaudenzia (West Chester ): 610-429-1414 Holcomb (Kennett Square): 610-388-9225 Creative Health Services (Pottstown): 610-933-1223 Gaudenzia (Coatesville ): 610-383-9600 Mirmont Outpatient (Exton): 484-565-1130

If detox is needed, hospital staff will attempt to set-up a transfer to a contracted residential drug and alcohol program.

If detox is not needed, patient will be advised to contact a contracted drug and alcohol program for an assessment.

Not experiencing a life threatening situation, but looking to access treatment?

REGARDLESS OF INSURANCE TREATMENT IS AVAILABLE.

If patient has insurance (private, CCBH or Medicaid)...

Patient should contact the number on the back of their insurance card for behavioral health treatment services. Insurance will advise next steps.

If patient does not have insurance...

Patient should contact the nearest Outpatient Assessment Provider * to schedule an assessment.

Other Resources Information and Referral Line

For questions regarding drug and alcohol services or funding, please call this toll-free Information and Referral Line: 1-866-286-3767 PA DDAP Get Help Now Assistance in finding a treatment provider or funding for substance use disorder treatment 24/7.

Hotline: 1-800-662-HELP (4357) Refer Web Community Resource Directory online application for the Chester County Department of Human Services. http://www.referweb.net/chesco/

www.Chesco.org/DrugandAlcohol

WINTER 2022 | CHESTER COUNT Y Medicine 19

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NO SURPRISES ACT EFFECTIVE JANUARY 1, 2022 Issues for Telemedicine Providers

O

BY GEORGE W. BODENGER, ESQUIRE

n December 27, 2020, the No Surprises Act was signed into law as part of the Consolidated Appropriations Act, 2021.

In July and October 2021, respectively, the Department of Health and Human Services, the Department of Labor, the Department of the Treasury and the Office of Personnel Management (collectively, the “Departments”) issued two (2) interim final rules implementing core aspects of this legislation, including: (1) prohibiting nonparticipating providers from balance billing individuals who receive services in participating facilities unless prior notice and consent is provided and obtained (referred to as Part I)1; and (2) requiring providers and facilities to provide good faith estimates (“GFE”) to uninsured (or self-pay) individuals of expected charges prior to their scheduled services (referred to as Part II, and together with Part I and the statute, the “NSA”).2 Effective as of January 1, 2022, to the extent that an out-ofnetwork telemedicine provider furnishes services to a patient at an in-network facility, the disclosure notice requirements and balance billing prohibitions under Part I apply. Additionally, to the extent that a telemedicine provider furnishes services to an uninsured (or self-pay) patient, the transparency requirements under Part II, including the requirement to provide a good faith estimate “GFE”), may apply. Notably, the NSA provides for significant penalties, including imposition of civil monetary penalties of up to $10,000 per violation. Additional information regarding a telemedicine provider’s compliance obligations under the NSA are described in the following paragraphs.

Disclosure Notice The NSA requires providers and facilities to make publicly available, post on their website, and give to patients a one (1) page notice describing balance billing requirements and prohibitions created by NSA (the “Disclosure Notice”).3 The Disclosure Notice has three (3) essential elements: 1 Requirements Related to Surprise Billing; Part I, 86 Fed. Reg. 36872 (July 13, 2021).

2 Requirements Related to Surprise Billing; Part II, 86 Fed. Reg. 55980 (Oct. 7, 2021).

3 45 C.F.R. 149.430.

• A statement explaining the provider’s and facility’s obligations under the NSA; • A statement explaining any state law requirements regarding how much an individual may be charged for receiving services from nonparticipating providers and facilities; and • Contact information for state and federal agencies that an individual may use if they believe a provider or facility has violated a requirement described in the notice.

The Disclosure Notice must be given to an individual no later than the date and time the provider or facility requests payment from the individual, including requests for copayment made at the time of a visit to the provider or facility, and may be provided either in-person, via mail, or electronically, as selected by the individual. HHS has issued a model Disclosure Notice that providers and facilities may use, which HHS considers an indication of good faith compliance.

Providers offering services in connection with a “visit” to a healthcare facility must provide the Disclosure Notice to patients.

Telemedicine providers face unique challenges in complying with this requirement. Specifically, a telemedicine provider may not know that it is providing services to a patient related to a facility “visit,” which can extend to certain services rendered before or after the actual stay at the facility, such as post-operative services. Additionally, by definition, telemedicine providers are not physically present on-site to provide notices to patients.

As such, telemedicine providers have two (2) options to comply with the Disclosure Notice requirement: • HHS allows a facility to provide the Disclosure Notice on behalf of a provider pursuant to a written agreement. In these instances, the Disclosure Notice must include information regarding the balance billing requirements and prohibitions applicable to both the facility and the provider. HHS has expressly stated that it will permit a single disclosure even in situations where the providers and facilities bill separately for items and services. continued on next page >

WINTER 2022 | CHESTER COUNT Y Medicine 21

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No Surprises Act Effective January 1, 2022 - Issues for Telemedicine Providers continued from page 21

It may be beneficial for a telemedicine provider to enter into a written agreement with all facilities in which it provides services to enable the facilities to provide the Disclosure Notice on its behalf.

• A telemedicine provider can prepare its own Disclosure Notices tailored to each state in which it provides services to facilities.

However, even in this case, telemedicine providers may still need to coordinate with the facilities in which it provides services to assist in providing the Disclosure Notices to its patients on its behalf, or in seeking the patient’s consent to receive the Disclosure Notice from the telemedicine provider electronically.

Notice and Consent While the NSA prohibits balance billing a patient (i.e., billing the patient for the difference between what his/her insurance will pay to an out-of-network provider and the provider’s charges) in certain instances, the NSA provides an exception to balance billing protections for non-emergency services. Specifically, these protections may be waived if the patient is provided with sufficient notice and consents to paying for out-of-network costs (“Notice and Consent”).4 If the Notice and Consent are insufficient—or if the patient revokes consent—the protections remain in place and the nonparticipating provider cannot balance bill for those services. Notably, the Notice and Consent exception does not extend to certain ancillary services.5 The standard Notice and Consent must be in writing and given physically separate from and not attached or incorporated into any other documents. Additionally, a representative of the provider or facility must be physically present or available by phone to answer any questions and explain the documents and estimates to the individual. The Notice and Consent must state: • That the provider is an out-of-network for the individual’s health plan or coverage; • A good faith estimate of the amount that the nonparticipating provider may charge the beneficiary for the items and services involved, including any item or service that is reasonably expected to be furnished by the nonparticipating provider with such items or services;

provider is optional and that the beneficiary may instead seek care from an available participating provider.

If an individual schedules an item or service at least 72 hours before the date that the items and services are to be furnished, the Notice and Consent must be provided to the individual at least 72 hours before the scheduled date. If the individual makes an appointment within 72 hours of the date the items and services are to be furnished, the Notice and Consent must be provided to the individual, or the individual’s authorized representative, on the day the appointment is scheduled. If an individual is provided the Notice and Consent on the day the items or services are to be furnished, the documents must be provided no later than three (3) hours prior to furnishing the relevant items or services.

As with the Disclosure Notice, it may be difficult for a telemedicine provider to provide the Notice and Consent to patients without coordinating with the facilities in which the patients receive the services.

Good Faith Estimate Requirements Finally, the NSA requires the healthcare provider or facility that receives the initial request for a GFE from an uninsured (or self-pay) individual and is responsible for scheduling the primary item or service (called the “convening” provider) to furnish GFEs to uninsured (or self-pay) individuals at their request and at the time of scheduling an item or service. GFEs must be provided to individuals within the timeframes set forth in the regulations based on when the patient encounter is scheduled and/or when the request for the estimate is made.6 Providers are also required to provide a notice outlining an uninsured (or self-pay) individual’s right to receive a GFE. A GFE has several information requirements, including but not limited to the following: • a description of the primary item or service in clear, understandable language (and if applicable, the date the primary item or service is scheduled); • an itemized list of items or services reasonably expected to be provided alongside the primary item or service by the convening provider, convening facility, co-providers, or co-facilities; and

• That neither the good faith estimate nor the individual’s consent to waive the protections afforded by the NSA constitute a contract;

• applicable diagnosis codes, expected service codes, and expected charges associated with each listed item or service.

• That prior authorization or other care management limitations may be required before receiving such items or services at the facility; and

Convening providers or facilities must also contact all “co-providers and co-facilities,” which are other providers or facilities anticipated to provide services to the patient alongside the primary item or service.

Convening providers and facilities must request co-providers and

• That consent to receive items and services from a nonparticipating

22 CHESTER COUNT Y Medicine | WINTER 2022

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co-facilities to submit all information relevant to the GFE no later than one (1) business day after an appointment is scheduled or a request is made. However, the general requirement to incorporate information from co-providers and co-facilities is subject to enforcement discretion through December 31, 2022.

of a GFE, or may be a convening provider themselves to the extent an uninsured (or self-pay) individual schedules an appointment with the telemedicine provider at least three (3) business days in advance.

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least three (3) business days in advance or the patient requests a GFE case, as described above, is to contract in advance with all facilities The PA Alliance of Professional Associations (PAPA) isitaffiliated with directly from the telemedicine provider.

In these instances, may the telemedicine provider typically provides services to assist in leading appa apparel, furniturefulfilling retailers, bethousands easier for a of telemedicine providerelectronics, to provide jewelry, the GFEand by email the telemedicine provider’s obligations, such as providing attractions and museums, overnight and destination travel, and 57,000 or local, other regional electronicand means, as the regulations permit a convening Disclosure Notices and obtaining a signed Notice and Consent in national restaurants and service providers. Use of this provider to electronically transmit GFE if the patient requests to balance bill. card affords attractive savings,the discounts or cash back on everyorder shopping, thisdining method delivery. andoftravel purchase, and it supports local community initiatives.

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4 45 CFR 149.420(c).

5 Id. 6 45 C.F.R. § 149.610.

WINTER 2022 | CHESTER COUNT Y Medicine 23

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DIABETES MELLITUS

A Silent Killer

BY MIAN A. JAN, M.D., F.A.C.C., F.S.C.A.I., AND AHMED SHAMSI

Introduction Diabetes mellitus (DM) is a chronic metabolic disease characterized by elevated blood glucose levels (hyperglycemia).

DM may result from defects in insulin secretion, resistance to insulin action, or both. Approximately 537 million adults (2079 years) had diabetes in 2021 according to the International Diabetes Federation (IDF), with a projected rise to 643 million adults by 2031. Progression of diabetes mellitus results in tissue and blood vessel damage leading to severe complications including retinopathy, neuropathy, and nephropathy as well as cardiovascular complications. Diabetes mellitus is a silent killer, with approximately 7.3 million U.S. adults who met laboratory criteria for diabetes not being aware of or reporting having diabetes.

Etiology In the pancreas, there are two major classes of hormoneproducing cells: the insulin-secreting beta cells, and the glucagonsecreting alpha cells. Insulin induces muscle and liver cells to take up glucose, decreasing blood glucose concentration, whereas glucagon serves to increase the concentration of blood glucose.

Without the balance of insulin and glucagon, glucose levels will reach improper concentrations. In the case of diabetes mellitus, insulin is either absent, or there is receptor level resistance to the effects of insulin, leading to hyperglycemia.

The vast majority of diabetes cases fall into two broad categories by etiology: type 1 diabetes, and type 2 diabetes.

Type 1 Diabetes Mellitus (T1DM) Type 1 diabetes mellitus (T1DM) accounts for 5-10% of those with diabetes. T1DM is characterized by the destruction of beta cells in the pancreas, resulting in absent or extremely low insulin production. Markers of the destruction of beta cells include antibodies against islet cells, insulin, glutamic acid decarboxylase-65 (GAD-65), and tyrosine phosphatases IA-2 and IA-2ß. At least one of these autoantibodies is present in 85-90% of individuals when fasting hyperglycemia is initially detected.

This form of diabetes most commonly occurs in children and adolescents and is associated with genetic predisposition and environmental factors such as viruses or toxins.

24 CHESTER COUNT Y Medicine | WINTER 2022

Type 2 Diabetes Mellitus (T2DM) Type 2 diabetes mellitus (T2DM) is far more frequent than T1DM, accounting for 90% to 95% of those with diabetes.

T2DM is characterized by a diminished response to insulin by muscle, fat, and liver cells, which is termed insulin resistance.

Insulin resistance is initially countered by an increased production of insulin by the pancreas to maintain normal blood glucose levels. Over time, however, insulin production decreases and type 2 diabetes mellitus is diagnosed. T2DM is often undiagnosed for many years due to the gradual development of hyperglycemia, and early symptoms that are not severe enough to be recognized by patients.

The risk of developing T2DM increases with age, obesity, and physical inactivity, and is associated with a strong genetic predisposition.

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Epidemiology Diabetes mellitus is a global epidemic with 1 in 10 adults affected worldwide. T1DM may be diagnosed at any age, however, it peaks at 5-7 years of age and again at 10-14 years of age. Unlike most autoimmune diseases, which disproportionately affect women, type 1 diabetes affects both males and females equally. The incidence and prevalence of T1DM is increasing in the world, with data from international epidemiological studies indicating a rate of increase of 2-5%.

Type 2 diabetes mellitus continues to increase with the increasing rates of obesity and sedentary lifestyles. The onset of T2DM is most common in persons older than 45 years, although obesity in adolescents has led to an increase in T2DM in younger groups. Globally, an estimated 462 million individuals are affected

by T2DM. A high incidence of microvascular complications is found in individuals with T2DM with half of patients presenting such complications. Cardiovascular disease, including coronary heart disease, cerebrovascular disease, and peripheral vascular disease, typically develops 14.6 years earlier in patients with T2DM, and with a greater severity, than individuals without DM. Type 2 diabetes mellitus varies among ethnic groups with Asians, African Americans, and Latinos having a higher prevalence than whites in the United States.

Pathophysiology T1DM is characterized by the autoimmune destruction of pancreatic beta cells by activated macrophages, CD4+ T cells and CD8+ T cells which infiltrate the islets. Islet cell antibodies are present in 85% of patients with a majority of these patients also having anti-insulin antibodies. These islet cell antibodies are usually directed against glutamic acid decarboxylase (GAD) in pancreatic beta cells. The destruction of beta cells in the pancreas leads to absent or extremely low insulin production, resulting in the metabolic derangements characterized by T1DM. The destruction of beta cells is coupled with the abnormal function of alpha cells which secrete excess glucagon, exacerbating the metabolic defects of insulin deficiency.

to decreased insulin production or increased insulin resistance, glucose homeostasis cannot be maintained, and T2DM is diagnosed. The majority of obese individuals have insulin resistance, a consequence of adipose tissue release of excess free fatty acids (FFAs), reactive oxygen species (ROS), and proinflammatory cytokines.

History and Physical DM is often presented asymptomatically, underscoring the dangerous nature of this metabolic disease. When symptoms do develop, patients commonly present increased urination, increased thirst, and weight loss. Patients with prolonged hyperglycemia may experience blurred vision and numbness in the hands and feet. Type 1 and type 2 diabetes can be distinguished based on the patient’s clinical history and examination. The majority of patients with T2DM are overweight/obese and present signs of insulin resistance including patches of dark, velvety skin known as acanthosis nigricans. Patients must be tested for retinopathy, neuropathy, and pulses should be examined to check for peripheral arterial disease.

Evaluation Tests utilized to diagnose DM include Fasting Plasma Glucose (FPG), Two-Hour Oral Glucose Tolerance Test (OGTT), and Glycated Hemoglobin (Hb) A1C. An FPG tests glucose levels after an eight hour fast and is usually done in the morning. An OGTT checks glucose levels before and two hours after an ingestion of 75 gm of glucose. Hb A1C measures blood glucose level over the previous 2 to 3 months. According to the American Diabetes Association, diabetes is diagnosed at a fasting blood sugar of greater than or equal to 126 mg/dl, a 2-hour blood sugar greater than or equal to 200 mg/dl, and an A1C of greater than or equal to 6.5%.

Treatment/Management

T2DM is characterized by two pathological defects: insulinresistance and associated beta cell dysfunction. Initially, insulin resistance is compensated as beta cells undergo a transformation capable of increasing insulin supply. Over time, however, due

T1DM is primarily treated through insulin administration, either through injections or insulin pumps. The majority of T2DM patients are overweight/obese, and so initial treatments center around a healthy diet and caloric restriction as well as regular exercise and monitoring of glucose. Prescribed diabetic medications may be utilized with metformin being the first line of treatment. The use of metformin may be followed by other therapies that target insulin secretion or insulin sensitivity including sulfonylureas, dipeptidyl peptidase IV inhibitors continued on next page >

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Diabetes Mellitus continued from page 25 (DPP-4), Glucagon-like-peptide-1 (GLP-1) receptor agonists, meglitinides, alpha-glucosidase inhibitors, thiazolidinediones, selective amylinomimetics, and sodium-glucose transporter-2 (SGLT-2) inhibitors. Bariatric surgery may normalize glucose levels in morbidly obese patients but is only recommended for individuals who are unresponsive to other treatments.

Microvascular screenings should be performed regularly including retinal exams to test for diabetic retinopathy and neurologic examination to identify patients with neuropathy.

Diabetic peripheral neuropathic pain may be treated with FDA approved medications pregabalin and duloxetine and with anticonvulsant and antidepressant drugs. Urine albumin excretion should be undertaken at least twice a year.

Regular blood pressure screening for diabetics is also recommended. The goal blood pressure should be less than 130/85. Treatment for hypertensive diabetics includes ACE inhibitors, angiotensin II receptor blockers (ARBs), beta-blockers, and/or calcium channel blockers. Lipid monitoring should also be performed with a goal LDL-C less than 100mg/dl if there is no atherosclerotic cardiovascular disease (ASCVD). If ASCVD is present, LDL-C should remain below 70mg/dl. Statins are primarily utilized to lower cholesterol and are linked to lower risk of heart disease and stroke.

Differential Diagnoses Certain diseases and conditions may present similar clinical features and symptoms to diabetes mellitus. An education of these conditions is pertinent to make an accurate diagnosis. These conditions include: • Glucocorticoid-induced hyperglycemia • Hormonal syndromes including cushing syndrome, pheochromocytoma, acromegaly, glucagonoma • Conditions damaging the pancreas, including pancreatitis, pancreatic cancer, cystic fibrosis, hemochromatosis • Thyroid disorders

Prognosis As of 2020, diabetes mellitus is the 8th leading cause of death in the United States. Patients with diabetes are twice as likely to experience heart disease or a stroke than individuals not affected with DM. Diabetic neuropathy affects approximately 50% of patients, and vision-threatening retinal complications will develop over time in 50% of T1DM patients and 30% of T2DM patients.

Treatment with drugs for hyperglycemia, managing blood pressure, and lowering LDL cholesterol are key in preventing vascular complications and slowing disease progression to reduce morbidity and mortality.

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Complications Several complications may occur in uncontrolled diabetes mellitus including microvascular and macrovascular conditions. DM is a leading cause of heart disease, blindness, kidney disease, nerve damage, and amputations in the lower limbs. Microvascular complications include nephropathy, neuropathy, and retinopathy, and affect approximately half the patients with T2DM. Macrovascular complications of T2DM include coronary artery disease, arrythmias, cerebrovascular disease, and peripheral artery disease.

Deterrence and Patient Education Patients should be educated on glycemic control and lifelong lifestyle changes to reduce complications associated with diabetes mellitus. Diet and exercise must be stressed as well as quitting smoking and minimizing alcohol consumption. Checking of blood glucose daily, regular estimation of glycated hemoglobin and LDL levels, and taking medications as prescribed are important steps for patients wanting to take responsibility of managing their diabetes.

Summary “I may have diabetes but diabetes does not have me.”

Elise Quarrington I think this quote should be the basis of management of DM. A step by step approach starting with a correct diagnosis followed by diet and exercise program. If these modalities are unsuccessful then add drugs as described in the body of the article.

A team approach between general practitioners and specialists is the best way of dealing with this very complex and devastating pathology.

This article was written

by Mian A. Jan, M.D., Chairman, Department of Medicine Penn Medicine Chester County Hospital, and Ahmed Shamsi, an intern at West Chester Cardiology.

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SGLT2 INHIBITORS IN DIABETIC KIDNEY DISEASE:

THE TIME TO ACT IS NOW

BY MICHAEL LATTANZIO, DO, FASN

D

iabetes mellitus is a major cause of diabetic kidney disease (DKD) and end stage kidney disease (ESKD) in the United States. About one-third of patients with diabetes mellitus will ultimately develop DKD and individuals with DKD are at substantial higher risk of cardiovascular disease and death.

Renin-angiotensin system (RAS) blockade with ACE inhibitors and ARBs will reduce the risk of DKD by approximately 20% (1).

Despite this clear benefit, RAS blockade in DKD remains highly underutilized. Moreover, although DKD is associated with a tremendous cost and healthcare burden, scientific advancement in the field has gone largely unmet.

Sodium glucose cotransporter-2 inhibitors (SLGT-2i) have emerged as a powerful treatment option in DKD and has the potential to immediately revolutionize kidney care. Multiple randomized controlled trials analyzing the impact of SGLT-2i on DKD outcomes have recently emerged (2,3,4). These studies involved patients with DKD who were already receiving maximally tolerated doses of RAS blockade, which would be considered the standard of care treatment for DKD. These studies consistently and convincingly demonstrated a substantial reduction in renal outcomes of approximately 30%. SGLT-2 inhibitors are the first drugs for the treatment of DKD that have demonstrated a reduction in all-cause mortality suggesting that the cardiovascular and kidney protection afforded from SGLT2i occur in parallel.

The ability of SGLT2i to improve kidney outcomes in individuals with DKD has been an eagerly awaited breakthrough in kidney care community.

With any medical intervention, the benefits of such therapies need to be weighed against potential adverse events. With regards to SGLT2 inhibition, these risks include: increased risk of UTI, mycotic genital infections, ketoacidosis, and volume depletion.

Additionally, a rise in creatinine (drop in glomerular filtration rateGFR) is expected with the initiation of SGLT2i. The drop in GFR is a reversible, hemodynamic effect and does not represent intrinsic decline in kidney function. The decline in GFR occurs shortly after SGLT2i initiation and is followed by sustained preservation of kidney function over time. Conversely, individuals with DKD that are not treated with SGLT2i will experience a gradual decline in kidney function over time.

The advent of SGLT2i for the treatment of diabetic kidney disease has the potential to transform the future landscape of kidney care. Importantly, the avoidance of ESKD among individuals with progressive DKD is now a realistic and achievable outcome. Now, as a medical community, we must work collaboratively to deploy broad-scale implementation strategies among our patients with type 2 diabetes. A concerted effort for early detection of DKD and prompt identification of candidates for SGLT2i therapy is paramount. If you are part of a medical community caring for individuals with diabetes mellitus, the time to act is now.

References 1) Brenner BM, Cooper ME, de Zeeuw D, Keane WF, Mitch WE, Parving HH, Remuzzi G, Snapinn SM, Zhang Z, Shahinfar S; RENAAL Study Investigators. Effects of losartan on renal and cardiovascular outcomes in patients with type 2 diabetes and nephropathy. N Engl J Med. 2001 Sep 20;345(12):861-9. doi: 10.1056/NEJMoa011161. PMID: 11565518.

2) Perkovic V, Jardine MJ, Neal B, Bompoint S, Heerspink HJL, Charytan DM, Edwards R, Agarwal R, Bakris G, Bull S, Cannon CP, Capuano G, Chu PL, de Zeeuw D, Greene T, Levin A, Pollock C, Wheeler DC, Yavin Y, Zhang H, Zinman B, Meininger G, Brenner BM, Mahaffey KW; CREDENCE Trial Investigators. Canagliflozin and Renal Outcomes in Type 2 Diabetes and Nephropathy. N Engl J Med. 2019 Jun 13;380(24):22952306. doi: 10.1056/NEJMoa1811744. Epub 2019 Apr 14. PMID: 30990260.

3) Heerspink HJL, Stefánsson BV, Correa-Rotter R, Chertow GM, Greene T, Hou FF, Mann JFE, McMurray JJV, Lindberg M, Rossing P, Sjöström CD, Toto RD, Langkilde AM, Wheeler DC; DAPA-CKD Trial Committees and Investigators. Dapagliflozin in Patients with Chronic Kidney Disease. N Engl J Med. 2020 Oct 8;383(15):1436-1446. doi: 10.1056/NEJMoa2024816.

Epub 2020 Sep 24. PMID: 32970396.

4) Wanner C, Inzucchi SE, Lachin JM, Fitchett D, von Eynatten M, Mattheus M, Johansen OE, Woerle HJ, Broedl UC, Zinman B; EMPAREG OUTCOME Investigators. Empagliflozin and Progression of Kidney Disease in Type 2 Diabetes. N Engl J Med. 2016 Jul 28;375(4):323-34. doi: 10.1056/NEJMoa1515920. Epub 2016 Jun 14. PMID: 27299675.

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NOTHING ABOUT THEM WITHOUT THEM! INTERNATIONAL ADOLESCENT HEALTH WEEK: FOR AND BY ADOLESCENTS

By Laura A. Offutt MD, FACP

“I believe that teenagers require different health education than other age groups, and I want people to understand what issues, unique to our generation, teenagers are dealing with socially, mentally, and physically.” Lauren, 16, Souderton Area High School.

March brings spring and International Adolescent Health Week (IAHW). This month, communities all over the world will be participating in this annual health campaign consisting of dynamic participatory events to inspire adolescents and their communities to advocate for a successful transition into adulthood. Initiated as “Pennsylvania Teen Health Week” in 2016, and observed globally since 2018, IAHW engages adolescents through health-related activities and education, but also importantly, is shaped by local and international youth leaders.

“I think that teen health should be a bigger priority in our health system.” Christopher, 16, Plymouth Whitemarsh High School Each year, Penn Adolescent and Young Adult Medicine (PAYAM) in Radnor, has spearheaded IAHW community activities in the Delaware Valley along with local youth volunteers and honoring Philadelphia metropolitan area students as Teen Health Champions. This year, PAYAM is working with a group of teens from a dozen local school to imagine and plan this year’s PAYAM IAHW event. The new Teen Advisory Council (TAC) was created to encourage youth involvement as adolescent health advocates and to serve as liaisons with area youth. This group of teens advises PAYAM and advocates for their peers through a

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variety of projects. They have shared what they consider features of an “ideal adolescent medicine practice” which PAYAM is using to self-assess and incorporate; they are creating a peer-to-peer Teen Health PSA about a topic of their choosing; and they are community IAHW peer advocates through their special IAHW teen health event.

“I joined the Penn Adolescent and Young Adult Medicine Teen Advisory Council because it’s important to have good representation when it comes to making decisions about teen health, and I want to keep informing people about taking the mental and physical steps towards being healthy.” Madisen, 16, Downingtown East High School This year, due to the ongoing Covid pandemic, the advisors were charged with imagining a physically distant or virtual event.

After some energetic brainstorming for adolescent health events that would be engaging and fun for young people, the TAC narrowed their ideas to four final propsals: a healthy cooking / nutrition class, a meditation and yoga class (perhaps with a goat!), an event featuring a celebrity speaking about their mental health experience, and an orienteering hunt with health related activity stations. Determined by a vote, it was settled that the TAC would host a virtual cooking class for teens. PAYAM has partnered with the Vetri Community Partnership, who will lead a hands-on workshop with a focus on recipes that are nutritious, economical, and make teens feel good inside and out. Teens will learn simple culinary techniques, discuss nutrition and wellness, and learn how to navigate convenience foods, and to celebrate

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the communal power of food. TAC members have designed their own promotional materials and are engaging school faculty, administration, and school clubs to encourage young people to attend this event.

Harnessing the power and ubiquity of social media, the TAC has decided to do an IAHW Social Media Takeover of Real Talk with Dr. Offutt, an interactive teen health platform. Via Instagram, the teens will share a Day in The Life of teen eating (the good, the bad and the ugly) as well as easy nutrition tips.

Some of the teen advisors have successfully championed IAHW to their school administrators and have arranged an entire week of different school activities and lime green spirit wear to highlight the importance of adolescent health.

“It is important to me to help create an awareness and give personal insight on how best to support and improve teenagers’ health experiences to best benefit their lives.” Eve, 14, The Baldwin School Penn Adolescent and Young Adult Medicine (PAYAM) is a unique medical practice that focuses solely on the needs of young people ages 12 to 29. This specialized practice provides consultative and primary care in a comprehensive manner with a full understanding of the physical and psychological changes associated with transition to adulthood. PAYAM has represented the Philadelphia region in International Adolescent Health Week activities since its inception.

“Transition,” the theme for International Adolescent Health Week 2022, was selected by another group of young people representing 30 countries around the world in their roles as IAHW Youth Ambassadors. These young people wanted to reflect adolescence as the time on life’s journey between childhood to adulthood, as well as this time of transition throughout the world – from a pre-Covid world into a pandemic world, from online or disrupted education to in-person education, from older and more homogenous world leadership to younger and more diverse representation.

“To me, “transition” means a process of challenging change, a term closely related to the stage of adolescence because it implies a period of physical, social and emotional changes. This period is an interim between total dependence on the family during childhood and independence in adult life. It is especially challenging, not only because of the intrinsic changes of the adolescent person, but also because we are in one of the most uncertain phases of history about the future: health crisis, climate crisis, social crisis (inequalities), triggers to quality and affordable education, among others.” Ruby, 22, Peru.

Adolescent health issues that predated Covid-19 remain important, even during an ongoing global pandemic. Therefore, organizations are invited to observe IAHW by highlighting any adolescent health issues relevant in their communities, from encouraging healthy behaviors and habits to advocating for youthfocused policy addressing healthy and safe communities, socioeconomic determinants of health, and adolescents’ rights.

During IAHW, from March 20-26, Philadelphia will illuminate several prominent buildings lime green for the 5th year in a row.

For more information about the PAYAM / Vetri Community Partnership Teen Cooking workshop, please contact IAHWPenn@gmail.com For more information about Penn Adolescent and Young Adult Medicine, please visit: pennmedicine.org/ for-patients-and-visitors/find-a-program-or-service/ primary-care/adolescent-and-young-adult-medicine For more information about International Adolescent Health Week, please visit: Internationaladolescenthealthweek.org Twitter: @IAHW2022 Instagram: @adolescent_health_week Facebook: @internationaladolescenthealthweek #IAHW2022 Laura A. Offutt, MD, FACP Founder and Director, International Adolescent Health Week Medical Director, Penn Adolescent and Young Adult Medicine Teen Advisory Council Host, Real Talk with Dr. Offutt

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The 2022 Elections Including the Race for US Senate from Pennsylvania

By Larry L. Light

I

n the end, there will be no dearth of words to accurately describe the primary and general election campaigns this year to elect a new US Senator from Pennsylvania. There are so many adjectives that might attach to the event, words like historic, extraordinary, expensive, momentous, contentious, competitive, unprecedented, battleground and turbulent….and it seems like they may all apply.

The reason is that the Senate seat currently held by Patrick Toomey (R) is “open” because after serving two terms Sen. Toomey announced that he would not seek re-election. His successor will be chosen in the November 8, 2022 general election. Given the time it took to verify vote totals for Pennsylvania in the 2020 Presidential election, the vote count might not be completed for several days after the polls close.

The ballots prepared for the Commonwealth’s 8.5 million registered voters in November will be full of interesting, highly charged and competitive races. In addition to the open Senate seat, we will be electing a new Governor (Gov. Wolf is term limited), 18 Members of Congress in newly reapportioned districts, 25 State Senators in districts with new boundaries and 203 State Representatives on a map that will surely be changed significantly and likely face court challenges. The primary election, scheduled for May 17th, may even be delayed as those challenges are resolved. The elections held immediately after reapportionment are unique. Some incumbents from the same party will be forced to face off in the primary and in a few elections incumbents from different parties will contest the same seat in the subsequent general election. The process of drawing new legislative district lines with the goal of creating compact and contiguous districts will guarantee an interesting election cycle.

Most assuredly though, the crown jewel of 2022 election contests in Pennsylvania will be the open Senate seat. There are two politically strategic reasons. First, Pennsylvania is viewed as a competitive swing state when it comes to statewide campaigns, having produced winning margins for Trump (2016) and then Biden (2020). With Senators Casey (D) and Toomey in office the Senate seats have been politically split between the two parties since 2006. The question is whether the Biden victory has primed the pump enough to keep the Keystone state blue.

Second, control of the US Senate hangs in the balance. One third of the 100 Senate seats are filled every other year. With the current even split between the parties only providing a Democratic

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majority in the person of presiding officer Kamala Harris, the Vice President, the stakes for the 34 Senate races spread across the country in 2022 are extremely high. But none are higher than the race in Pennsylvania. Most political analysts agree that each party has four Senate seats in the category of highly competitive.

At total of 26 Senate seats are considered safe and not likely to change party. Both national parties have declared Pennsylvania a key battleground in determining control of the Senate. But first, the Democratic and Republican candidates for the general election must win their own party primary election on May 17th.

Among the milieu of multiple primary candidates in both parties (each party has at least five), money spent on early television commercial buys, primary candidate debates, self funded candidates, candidates with tenuous claims to residency in the state, desperate campaigns from both parties to claim the open seat and a primary that could be delayed if the state or federal reapportionment plans are not finalized in time, it is already clear that the word physician will become a regular feature in campaign verbiage for both parties.

It’s not completely unknown to have a physician from Pennsylvania serve in the US Congress. Benjamin Rush signed the Declaration of Independence and was then elected to the Second Continental Congress.

Over the years several other physicians were elected, but always to seats in the House of Representatives. Physicians from other states have served with distinction in the Senate, most recently and probably most notably Bill Frist, MD (R-TN). Frist served two terms in the chamber and was the Senate Majority Leader for four years. Four physicians, all Republicans, are currently US Senators.

But there has never been a physician, a woman or an African American elected to the US Senate from Pennsylvania.

With physicians among the crowded primary fields of both parties, this high-profile Senate election in Pennsylvania could be the tipping point in so many ways. What are the chances?

Well, among the declared candidates two months before the filing deadline there were three physicians running as primary election candidates. Valerie Arkoosh, MD, Montgomery County Commissioner Chair, was the only individual in either party who ticks both the physician and female candidate boxes before she announced her withdrawal from the Democratic primary on February 4th.

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In any election, capturing the attention and interest of both voters and potential supports is the core goal of every campaign because candidates need contributors and funds to spread their message on the issues and the campaign needs a pathway to translate that engagement to votes on election day.

The issues in the primaries will be as broad in scope as the ranks of candidates themselves. And they will be issues of significance for any interested citizen. Given what is at stake, primary election candidates will have no problem exploiting the differences between their position and the other candidates from their own party, even if that will weaken the winning candidate in the general election. It becomes one step at a time, win the party primary first.

The core issues for the Senate campaigns are relatively clear cut. Maintaining or restricting fracking, how to address climate control, attacking or defending Roe v. Wade, dealing with the problems of immigration, election reform that will either make it easier or more “secure” for citizens to vote, relations with China and support for the 2nd Amendment versus restrictions aimed at curbing gun violence are all at the top of everyone’s issues list.

For female candidates Kathy Barnett (R) and Carla Sands (R) reforms to expand the role of women in the workplace is also a top tier issue. And for physician candidates Kevin Baumlin, MD, (D) and Mehmet Oz, MD, (R) the fight to bring the Covid virus under control will certainly be highlighted.

In addition to Dr. Baumlin, from southeastern PA, Democrats will have Lt. Governor John Fetterman and Congressman Conor Lamb, both from western PA, in the primary field along with Philadelphia State Representative Malcolm Kenyatta.

The Republican contenders include two women, Carla Sands, a former ambassador, and Kathy Barnette, a conservative commentator, along with attorney George Bochetto, Dr. Oz, former Lt. Governor candidate Jeff Bartos and David McCormick, a hedge fund CEO. The opportunity to win an open US Senate race is a rare occurrence in politics. The list of quality candidates from both parties, the sustained evidence that the candidates are spending aggressively from their campaign or personal funds and the comprehensive media coverage are all strong indications of how critical the election of a US Senator will be both in Pennsylvania and the nation. And the primary election this spring is just the start.

Larry Light retired from PAMED as the Senior Vice President for Physician and Political Advocacy.

But the overarching issues are partisan control of the Senate and the filibuster. And that guarantees that this Pennsylvania election will have national implications.

It’s possible that the grind of a winter-spring primary election season may change the dynamics for candidates in both parties.

Like Dr. Arkoosh, perhaps other candidates will withdraw from the race. Or more candidates may emerge before the filing deadline. Candidates’ petitions will be circulated for signatures between February 15th and March 8th. While no candidate is likely to have difficulty in reaching the minimum requirement of 2,000 signatures from fellow party members (voters can only sign one petition for a Senate candidate from their party), this is also the time period where campaign messaging, polling results and fund raising fall under more intense analysis. In fact, in this primary season close scrutiny will fall on not only how much money is raised, but how much money is supplied by the candidates from personal resources and how much money is received from out of state sources.

PATIENT BROCHURES Available through PA MEDI

An astonishing aspect of this primary campaign is the energy and resources that several candidates have already invested in aggressively attacking the higher profile candidates from the “other” party.

Contact the CCMS Staff to order

Several candidates have made significant television commercial ad buys in the effort to improve their polling numbers. PACs are already contributing money to the candidates who will accept it and non-affiliated groups are running negative television ads to discredit otherwise viable candidates. In a very real sense, all of the descriptive words cited earlier will most certainly apply.

local resources to help them

brochures for your waiting room.

Help your patients find proper, with Medicare enrollment.

Call the CCMS Office (610) 357-8531 or email chescomedsoc@comcast.net.

WINTER 2022 | CHESTER COUNT Y Medicine 31

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