E-News

Please send items of interest for the E-News -- and any other feedback -- to E-News editor Dave Cundiff, MD, MPH. Thanks!

AAPHP's Preventive Services ToolKit (PSTK) project gave its inaugural workshop at the American College of Preventive Medicine (ACPM) and American College of Medical Quality (ACMQ) meeting near Reno, Nevada on Wednesday, February 22, 2006. "Preventive Services ToolKit" is the new name for the CDC-funded "AA060 Grant" project.

About 35 Preventive Medicine physicians attended the PSTK presentation, which was delivered by PSTK's Principal Investigator Joel L. Nitzkin, MD, MPH, DPA; AAPHP Member Robert G. Harmon, MD, MPH; and AAPHP Secretary Dave Cundiff, MD, MPH.

The speakers and contents appeared to get high marks. An informal survey showed that participants in this audience judged "Power Structure Analysis (PSA)" and "Community Oriented Primary Care (COPC)" to be the most useful of the six modules.

Most participants requested follow-up contact by E-mail, and several physicians asked to be considered for on-site follow-up. Further presentations are being scheduled for this one-day or two-day workshop, or for selected portions. Please contact Dr. Nitzkin at jln@jln-md.com for details.

Course materials may be examined on the Web at http://www.aaphp.org/pstk/index.htm. This material can be reprinted, with attribution, for educational presentations that are to be presented free of charge. AAPHP's advance permission is required for other uses.

Please let us know how you use these materials, so we can have a better idea of the PSTK project's nationwide impact.

AAPHP thanks Dr. Nitzkin and the other presenters. We also appreciate the contributions of the other PSTK Curriculum Development Committee members: Kim Buttery, MD, MPH; Hugh S. Fulmer, MD, MPH; and Jonathan B. Weisbuch, MD, MPH.

3) AAPHP Member Studies Impact of Flu Vaccine Shortage:

At the 2006 ACPM meeting in Reno, AAPHP member Charles Schade, MD, MPH presented research about the impact of influenza vaccine shortages on vaccine use in West Virginia. This study used billing data collected over time, as well as survey data from 2000-2001. In most years, approximately 60% of vaccines given to Medicare recipients in West Virginia are reflected in the fee-for-service (FFS) billing data.

From 1994 to 1999, the influenza rate among West Virginia FFS Medicare recipients rose steadily from 36% to 42%. During the vaccine delays of 2000-2001, the influenza vaccination rate of Medicare recipients over age 65 declined back to 36%. Physicians vaccinating more than 25 Medicare recipients per year were studied further. “Continuity rates” — the percentage of each vaccinator’s prior-year vaccine recipients who were vaccinated by the same billing practitioner the next year — dropped from 60% to 34%.

Among previously high-volume vaccinating practitioners whose continuity rates were poor in 2000, twenty percent said they would reduce or eliminate influenza vaccination in subsequent years. Apparently that's exactly what they did. It took three years for vaccination rates to return to 42%, while continuity rates recovered only to 55% — NOT to the pre-2000 rate of 60%.

The influenza vaccine shortage of 2004-2005 had a much more severe impact than the delays of 2000-2001. Vaccination rates for FFS recipients (from claims data) dropped from 42% to 27%. Continuity rates plummeted to four percent (4%). This represents a shortfall of 50,000 vaccine doses. Some may have received vaccine from non-billing providers, but the majority of these 50,000 patients probably received no influenza vaccine at all.

The authors speculate that it may take several years to return to prior vaccination rates after a major disruption to the vaccine system. If so, the impact of a severe vaccine shortage may be felt several years after the shortage itself has ended.

More information can be obtained from Dr. Schade and colleagues at cschade@wvmi.org.

4) Diabetes Mellitus - Improve Care, Lose Money:

Every clinician sees diabetic patients who get standard diabetes care and who drift through it, or struggle unsuccessfully with it. Some of these patients seem, at least on the surface, to be unmotivated. Others seem to try, but don't meet goals for glucose control, weight loss, lipids, or exercise. We often imagine we could address the problems more effectively with earlier intervention, with more intensive education, and with more intensive use of non-physician education and counseling staff. We suspect we could prevent infections and amputations if we had more effective partnerships between patients and health care institutions.

That's been tried. It works. It prevents complications. It saves money for the nation. But according to a recent news article, it loses money for the healthcare institutions that sponsor it -- and it would probably lose money for any private insurance company daring enough to promote it.

On 2006-01-11, the New York Times printed an analysis of this problem by Ian Urbina, headlined "In the Treatment of Diabetes, Success Often Does Not Pay". Mr. Urbina describes four innovative and effective programs in New York City. Three have already closed. The fourth continues only because of continuing support from a wealthy benefactor.

Hospitals' willingness to pay for better care appears linked to financial concerns. Communication and education services that prevent diabetes complications cannot be viable unless they either attract ongoing support from very large donors, or attract additional patients for the hospital's profitable inpatient services. Dr. Diana K. Berger, director of New York City's diabetes prevention program, notes that per-hour reimbursement rates for diabetes education are often less than 0.1% of the per-hour rate for bariatric surgery. In that case, she asks, "where do you think [the hospital's] priorities will be?"

Insurors' willingness to pay for diabetes care appears to be related to the imminence of potential harm, and to the likelihood of litigation and bad publicity. Dialysis, amputation, and other rescue measures are usually reimbursed generously and without complaint. But patients often have difficulty obtaining test strips; educational sessions are rationed and poorly reimbursed; and prevention measures are usually poorly organized and underfunded.

Insurors could save money by promoting more effective models of care, but most don't -- at least in New York. Insurors perceive a long delay between the improvement of care and the lowering of long-term health care costs. In a competitive market, no health plan wishes -- or can afford -- to attract a higher proportion of diabetics than its competitors.

Governmental healthcare agencies -- Medicare, Medicaid, and their contractors -- are a potential solution, as they could theoretically take a long-term view of the social benefits of care. However, Mr. Urbina's article portrays these agencies as following current private-insurance policies, at least in New York, rather than leading the healthcare system to embrace an enhanced model of complication-preventing care.

Mr. Urbina's article is available in ad-supported format directly at http://www.nytimes.com/2006/01/11/nyregion/nyregionspecial5/11diabetes.html?ex=1140930000&en=92510185cd67a86a&ei=5070, or through the New York Times Diabetes gateway at http://topics.nytimes.com/top/news/health/diseasesconditionsandhealthtopics/diabetes/. E-News readers who need a PDF format may request the article as a 7-megabyte PDF file "EconomicsOfDMCare20060111.pdf" individually from the E-News editor.

5) Endorsed Candidate Wins Election as ACPM Regent:

AAPHP Trustee Arthur P. Liang, MD, MPH served for two terms as Public Health Regent for the American College of Preventive Medicine (ACPM). AAPHP is grateful for Dr. Liang's dedicated service to our specialty.

AAPHP Trustee Sindy M. Paul, MD, MPH requested and received endorsement from the AAPHP Board of Trustees for election to the Public Health Regent position vacated by Dr. Liang. Dr. Paul's candidacy was featured on Page 3 of the December 2005 AAPHP Bulletin (http://www.aaphp.org/Bulletins/bulletin05dec.pdf).

At last month's Preventive Medicine meeting in Reno, ACPM announced Dr. Paul's election as Public Health Regent. She will take office along with several other members and friends of AAPHP: Marcel E. Salive, MD, MPH as Mid-Atlantic Regent; Daniel S. Blumenthal, MD, MPH as General Preventive Medicine Regent; Lorraine Yeung, MD, MPH as Young Physician Regent; and Bart Harvey, MD, PhD, MEd as International Regent.

AAPHP congratulates the new ACPM Regents. Thank you for your service!

6) Notes Washed Up in a Bottle:

Since our last E-News, AAPHP's member and correspondent Don MacCorquodale, MD, MSPH has posted three issues of "Notes Washed Up in a Bottle":

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The 2005-12-20 "Notes" at http://www.aaphp.org/bottle/2005/dec20.htm presents some highlights from the federal publication "Health, United States, 2005". Trends show INCREASES in life expectancy at birth (now 77.6 years), and in the percentage of Americans who are older than 75. Between 2001 and 2003, the proportion living in poverty increased from 11.7% to 12.5%. Overweight, obesity, and diabetes rates continue to increase.

Trends show a DECREASE in overall teen birth rates. Adult smoking continues to decline. The early-1990's increase in teen smoking peaked around 1997 and have been declining since then. Tuberculosis rates declined in 2003 for the eleventh consecutive year.

DISPARITIES persist, many of them severe, due to education, income, and ethnicity. The mortality gap between black and white Americans is narrowing, but is still 5.2 years.

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Dr. MacCorquodale's 2006-01-15 "Notes" at http://www.aaphp.org/bottle/2006/jan15.htm corrects a racial classification error from the discussion in the 2005-12-20 issue.

The 2006-01-15 issue then summarizes findings from the "National Survey of Family Growth" conducted in 2002 by the National Center for Health Statistics (NCHS). Sexual behavior, sexually transmitted infections, and unintended pregnancy vary among different educational, social, ethnic, and economic groups -- without many recent surprises.

There may be some surprises, though, in a recent analysis of maternal deaths by race/ethnicity in the Annals of Epidemiology. After controlling for medical risk status, it appears that African-American and Hispanic women with high-risk pregnancy-related diagnoses in Illinois may be EIGHT TO TEN TIMES more likely to die than European-American women with the same diagnoses. (While the point estimates were high, the confidence intervals were wide.)

Finally, a single study in the Archives of Internal Medicine looks at prostate-specific antigen (PSA) screening among VA patients. The authors compared the PSA screening rates among men who died of any cause after being diagnosed with prostate cancer, with the screening rates among controls still living with or without a prostate cancer diagnosis. With or without race adjustment, or when limiting analysis to deaths caused by prostate cancer, the authors found no apparent survival benefit from PSA screening.

[E-News editor's note: If there's selection bias in the PSA study, it would more likely be in the total-mortality case/death group, since screened men who die of unrelated causes are more likely to have received a pre-mortem diagnosis of prostate cancer than are unscreened men who die of unrelated causes. Unless lethal prostate cancers go undetected before death, though, that bias wouldn't affect the case-control analysis of deaths caused by prostate cancer. A confounding variable -- such as African-American ethnicity, which raises prostate cancer lethality and could lower PSA screening rates -- might cancel out a true benefit of screening. Dr. MacCorquodale hopes for more studies of this subject. So do I. DRC]

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The 2006-01-30 "Notes" at http://www.aaphp.org/bottle/2006/jan30.html discuss the effect of gargling, with water or with povidone-iodine, on upper respiratory tract infections. Water wins, but not by much. Comparison of water gargling with "usual gargling habits" barely achieves statistical significance. Povidone-iodine is in the middle, with a confidence interval that overlaps both of the other two groups.

African-American and Native Hawaiian smokers in California and Hawaii report fewer cigarettes smoked per day than other smokers -- but among participants who smoked no more than 30 cigarettes a day, African Americans and Native Hawaiians had significantly greater risks of lung cancer than did other groups.

Finally, a recent study in the American Journal of Epidemiology suggests that amyotrophic lateral sclerosis (ALS) may be elevated in certain technical and professional occupations. The replicability and significance of this finding is unclear.

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AAPHP's complete collection of Dr. MacCorquodale's "Notes Washed Up in a Bottle" series is indexed at http://www.aaphp.org/bottle/allnotes.htm.

7) AAPHP Correspondence Delayed This Winter:

Due to staff turnover at our contractor's offices, correspondence addressed to AAPHP's national office was not processed for at least a five-week period this winter. The contractor has begun corrective action, but has not yet supplied an inventory of the correspondence that was received during this period.

If you sent correspondence via E-mail, voicemail, postal mail or fax that didn't receive a response (check below under "Member Update" for acknowledgements of membership applications), please notify AAPHP's Secretary at cundiff@reachone.com. We'll do our best to catch up quickly!

8) Job Market Initiative (JMI) and Featured Job:

ACPM/AAPHP Job Market Initiative (JMI) volunteer Robert Gilchick, MD, MPH prepared and circulated a volunteer recruitment flyer for the JMI at the Preventive Medicine meeting in Reno. The flyer was aimed at ACPM Young Physicians and said, in part:

"The more jobs abstracted, the more comprehensive and valuable the JMI is for everyone in the specialty. The more preventive medicine docs who find appropriate employment opportunities, the more the different sectors of the health care market see the value of preventive medicine docs in a variety of health care roles, and the more jobs there are for us in the future. Makes sense, right?"

Three Young Physicians expressed interest in volunteering as new abstractors. We hope more volunteers will join the four physicians who currently search job listings for jobs of interest to Preventive Medicine physicians. To volunteer, or to explore the idea of volunteering, please contact AAPHP's JMI chairman Joel L. Nitzkin, MD, MPH, DPA at jln@jln-md.com.

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Featured Job:

"Physician Specialist, MD, Quality Assurance":

Our "Featured Job" for this E-News issue is one of the few Public Health jobs that requires applicants to be Board Certified in Public Health and General Preventive Medicine.

Public Health Physician Jeffrey D. Gunzenhauser, MD, MPH is recruiting a "Physician Specialist, MD, Quality Assurance" for the Los Angeles County Health Department. If you're qualified, consider sending a CV and application!

The full listing appears as a "Full Page ad" on the AAPHP & ACPM Job Market Initiative Website. Click directly on http://www.aaphp.org/Jobs/2006/mar/Callamd_phqa030406.html for details.

9) AAPHP Member Update:

Thanks to new and renewing AAPHP members John D. Agwunobi, MD, MBA, MPH; Monica Alborg; Mary A. Anderson, MD, MPH, MS, MA; Timothy P. Barth, MD; David D. Blaney, MD, MPH; Lynn R. Blavin, MD; Katina Bonaparte, MD, MPH; Wendy E. Braund, MD, MSEd; Kathy K. Byrd, MD; Amada D. Castel, MD, MPH; Thomas R. Coleman, MD, MS; Curtis E. Cummings, MD, MPH; Kim Curi, MD, MPH; Christian Paul Erickson, MD; Steven Gelber; William Greaves, MD, MSPH; Carolyn H. Grosvenor, MD; Stephen A. Haering, MD; Robert G. Harmon, MD, MPH; Samreen Hasan; Supriya Janakiraman, MD; Marcella P. Jones, DO, MPH; C. William Keck, MD, MPH; David Lakey, MD; Sara E. Luckhaupt, MD, MPH; Perrianne Lurie, MD, MPH; Wayne Z. McBride, DO, MPH; David Menschik, MD, MPH; Susan Mims, MD, MPH; Mehdi Nabipour, MD; Jolene Nakao; Joel L. Nitzkin, MD, MPH, DPA; Benjamin Oaikhena, DDS; Erica G. Olson, MD; Melissa Overman, DO, CHES; Esther Paek, MD, MBA, MPH; Jay D. Parkinson, MD; Hung G. Pham, MD; Claudia Pollet, MD, MPH; Padmini D. Ranasinghe, MD; Peter G. Rumm, MD, MPH; Linette Scott, MD, MPH; Charurut Somboonwit, MD; Kenneth Soyemi, MD, MPH; Shamsuddoha Babar Syed, MD, DPH; Peter T. Troell, MD; Edmund R. Weise, MD; Christina Weng; and Rachel K. Wierzba, MD, MPH.

Our contractor promises that the 2006 renewal forms for 2005 members will be sent by postal mail within the next few weeks.

AAPHP membership applications are on the Web at http://www.aaphp.org/Membership/memb_form_2-17-06.pdf. These membership forms are sent to AAPHP's current contractor in Washington, DC. For tracking purposes, please consider E-mailing the AAPHP Secretary when sending any correspondence to the national office.

Thanks, members!

Dave Cundiff, MD, MPH (cundiff@reachone.com)
AAPHP Secretary and E-News Editor

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This message is an electronic update from the American Association of Public Health Physicians (AAPHP) to public health physicians.
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