Dylan Stephenson, Author at Southern Medical Association

All posts by Dylan Stephenson

Thinking about attending the 2019 Southern Regional Assembly?

Here is a list of activities you and your family cane enjoy together in the city of Birmingham, The Magic City.

Birmingham Civil Rights Museum 

Richly detailed exhibits in the Civil Rights Institute reveal slices of black and white life in Alabama from the late 1800s to the present. A series of galleries tells the stories of daily life for African-Americans in the state and the nation and how dramatically different it was from the lives white people of that era took for granted.

Vulcan Park and Museum

Young and old. Modern and classic. It’s a fusion that makes Birmingham truly magical. At Vulcan Park and Museum, we’re a perfect blend of past and present, representing the spirit of our city. With breathtaking views of the city and a modern, yet timeless space for hosting, Vulcan Park and Museum holds distinction as a premier venue in Birmingham.

McWane Science Center

Four floors of hands-on exhibits and an IMAX Dome Theatre are all part of the fun of learning at McWane Science Center. Celebrating science and discovery, the exhibits include everything from dinosaurs to space travel. Play tunes with your feet on the Giant Piano, and learn about gravity with a daring ride on the High Cycle. Pet the sharks and stingrays in the Shark & Ray Touch Tank, and check out the Zoetrope for visual illusions of motion from still pictures.

Alabama Theater

Built in 1927, the Alabama Theatre is one of the nation’s last operating movie palaces, featuring first-run and revival films, concerts and other special events. It is one of the grand architectural accomplishments saved from the wrecking-ball fate of many others of that era. The “Mighty Wurlitzer” organ still rises from the orchestra pit and is often played to accompany silent films.

This is just some of the many attractions that Birmingham has to offer.  Check out the links below for more options.

We hope you join us in the Magic City!

All images provided by CVB Birmingham and Bham Now

The Southern Medical Journal is the official, peer-reviewed journal of the Southern Medical Association. It has a multidisciplinary and inter-professional focus that covers a broad range of topics relevant to physicians and other healthcare specialists, including medicine; surgery; women’s and children’s health; mental health; emergency and disaster medicine; public health and environmental medicine; bioethics and medical education; and quality health care, patient safety, and best practices.

Southern Medical Journal Vol. 112 • No. 06 • June 2019

Bioethics & Medical Education
Everyday Leadership: A Combined Resident and Faculty Workshop
Sherine Salib, MD, MRCP, FACP, and Victoria Valencia, MPH

OPEN: Practical Considerations for the Academic Physician Moving to a New State
Jeremy B. Richards, MD, MA, and Susan R. Wilcox, MD

CME Article: Workplace Violence: Experiences of Internal Medicine Trainees at an Academic Medical Center
Becky Lowry, MD, Leigh M. Eck, MD, Erica E. Howe, MD, JoHanna Peterson, MD, and Cheryl A. Gibson, PhD

Dealing With Surrogate Conflict: A Student’s Perspective
Derek Su, MD, and David A. Fleming, MD, MA

Commentary on “Dealing with Surrogate Conflict: A Student’s Perspective”
G. Richard Holt, MD, MSE, MPH, MABE, DBioethics

Predictors of Empathic Compassion: Do Spirituality, Religion, and Calling Matter?
Caroline L. Thomas, MD, Mariana Cuceu, MD, Hyo Jung Tak, PhD, Marija Nikolic, MD, Sakshi Jain, MD, Theodore Christou, MD, and John D. Yoon, MD

Women’s & Children’s Health
Increasing Prevalence of Chronic Hepatitis C Virus Infection in a Southern Academic Obstetrical Clinic
Gweneth B. Lazenby, MD, Cody Orr, BA, Constance Guille, MD, and Eric G. Meissner, MD, PhD

Quality Care & Patient Safety
Availability of Hospital Resources and Specialty Services for Stroke Care in North Carolina
Mehul D. Patel, PhD, Gilson Honvoh, MSPH, Antonio R. Fernandez, PhD, Rhonda Cadena, MD, Emma R. Kelly, BSPH, Philip McDaniel, MA, and Jane H. Brice, MD, MPH

Holiday Discharges Are Associated with Higher 30-Day General Internal Medicine Hospital Readmissions at an Academic Medical Center
Ajay Dharod, MD, Brian J. Wells, MD, PhD, Kristin Lenoir, MPH, Wesley G. Willeford, MD, Michael W. Milks, MD, and Hal H. Atkinson, MD, MS

Mental Health
Canine-Assisted Therapy in Hospitalized Patients Awaiting Heart Transplantation
David Snipelisky, MD, Jessica Smidt, BS, Shawn Gallup, RN, Jane Myrick, RN, Brent Bauer, MD, and M. Caroline Burton, MD

Medicine & Medical Specialties
Summary of Selected Healthcare Encounters among a Selection of Patients with Myotonic Muscular Dystrophy
Kevin J. Bennett, PhD, Joshua R. Mann, MD, MPH, and Lijing Ouyang, PhD

Emergency Medicine & Disaster Preparedness
On “Healthcare Professionals and In-Flight Medical Emergencies: Resources, Responsibilities, Goals, and Legalities as a Good Samaritan”
Jim Q. Ho, BA, and Ware G. Kuschner, MD

Authors’ Response
Pascal Joseph de Caprariis, MD Brooklyn, and Angela de Caprariis-Salerno, RPh, MS

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We hope you will enjoy this program. View the program articles.

Alzheimer’s disease and most other dementias are not fatal diseases. Patients often survive many years after the diagnosis is made. During this time their mental functions deteriorate and their personality often changes. This is distressing and unnerving to caregivers and loved ones who often are at a loss: they simply do not know how to handle their loved one anymore.

Caregivers have to be constantly vigilant, twenty-four hours a day, seven days a week, fifty-two weeks a year. They become apprehensive, restless, sleep deprived, mentally and physically exhausted. Their loved ones with dementia appear to be so unpredictable and their behavior aberrant so much out of line with the person they knew, respected and loved before dementia set in.

Caregivers often state that they do not know when a catastrophic reaction will unexpectedly erupt. They find themselves sucked in, trapped, unable to change course and unable to avoid the catastrophic outcome. They feel powerless and sometimes guilty.

It is our contention that many of these aberrant and unpredictable behaviors are in fact predictable and often can be anticipated and defused.

In this series of cases, based on real patients, we explore how some “aberrant behaviors” develop and may have a catastrophic ending. The first part of each case study is a description of the scenario showing how the catastrophic situation arose, escalated and reached its climax. It is followed by a step by step examination of what went wrong in the caregiver/patient interaction and how that catastrophic outcome could have been avoided, averted or defused. Each case study concludes with a brief rationalization of the aberrant behavior in patients suffering from this particular type and stage of dementia and includes tangible advice to caregivers in order to avoid that particular behavior from developing, escalating and erupting.

We hope that clinicians and health care professionals will find this material useful advice to caregivers who might seek their help with similar problems.

Finally, as a result of the collaboration between Gerontology and Geriatric Medicine and the Southern Medical Association, interested clinicians may wish to test their knowledge and earn CME credits by answering a few multiple-choice questions1

1This accredited continuing medical education Journal-based CME series has been developed in cooperation with the Southern Medical Association, a regional, multi-specialty membership organization accredited by the ACCME (with a mission:  To improve quality of patient care through multidisciplinary, interprofessional education”), physicians from the Departments of Gerontology and Psychiatry at East Tennessee State University, the Gerontology and Geriatric Medicine, an on-line peer-reviewed open access medical journal, and SAGE Publications.


Too Many Choices Confuse Patients with Dementia
Click here to read the article Click here to access the CME

Patients with Dementia are Easy Victims to Predators
Click here to read the article Click here to access the CME

Hallucinations Are Real to Patients with Dementia
Click here to read the article Click here to access the CME

Patients with Dementia Are Easily Distracted
Click here to read the article Click here to access the CME

Repetitive Questioning Exasperates Caregivers
Click here to read the article Click here to access the CME

Repetitive Questioning II
Click here to read the article Click here to access the CME

Impulsive, Disinhibited Behavior—Dining in a Restaurant
Click here to read the article Click here to access the CME

Driving and Patients with Dementia
Click here to read the article Click here to access the CME

Agnosia Interferes with Daily Hygiene in Patients with Dementia
Click here to read the article Click here to access the CME

Insomnia and Mild Cognitive Impairment
Click here to read the article Click here to access the CME

Visual Hallucinations and Paranoid Delusions
Click here to read the article Click here to access the CME

Fronto-temporal Dementia, Diabetes Mellitus & Excessive Eating
Click here to read the article Click here to access the CME

Diseases from mosquito and tick bites occur in every state and territory.

Recent outbreaks of Zika, chikungunya, and West Nile viruses and the steady increase in Lyme disease cases point to the need for state and local agencies to have comprehensive vector-borne disease prevention and control programs.

The pace of emergence of new or obscure vectorborne pathogens through introduction or belated recognition appears to be increasing. Since 2004, these have included two previously unknown, life-threatening tickborne RNA viruses, Heartland (5) and Bourbon (6), both reported from the U.S. Midwest. A tickborne relapsing fever agent, Borrelia miyamotoi, first described in Japan, has been found widely distributed in the United States (7) and another bacterial spirochete, Borrelia mayonii (8) was discovered in the upper U.S. Midwest. Two tickborne spotted fever RickettsiaeR. parkeri (9) and Rickettsia species 364D (10), and a tickborne Ehrlichia (E. muris eauclairensis) (11) were discovered to be pathogenic to humans. The mosquitoborne viruses chikungunya and Zika were introduced to Puerto Rico in 2014 and 2015, respectively.

In the face of increasing incidence and threat from novel pathogens, the burden on local and state public health departments has increased. Critical to effectively preventing or responding to disease outbreaks is sensitive disease and vector surveillance, backed by well-organized, well-prepared, and sustained vector control operations. Good surveillance and reporting depend on rapid, accurate diagnostic confirmation; more sensitive and specific tests that can be used locally are needed.

The Federal government is taking steps including: funding states, territories, industry, university, and international groups to detect and respond to infections from mosquitoes, ticks, and fleas and report cases to the CDC; conducting and developing diagnostic tests, vaccines, and treatments; educating the public about protecting themselves; supporting 5 regional centers of excellence to address emerging diseases from mosquitos and ticks; and, convening a tick-borne disease working group to improve federal coordination.

On May 8, 2019, the Department of Health and Human Services (“HHS”) announced a final rule that will require direct-to-consumer television advertisements to include the list price for prescription pharmaceuticals that are covered by Medicare or Medicaid. The rule, which was promulgated through the Center for Medicare & Medicaid Services (“CMS”), requires the “the Wholesale Acquisition Cost” (i.e., the list price) of the drug to be included in the advertisement if the price is $35 or more for a one-month supply, or for the usual course of therapy.

“Patients have the right to know the prices of healthcare services, and CMS is serious about empowering patients with this information across-the-board,” said CMS Administrator Seema Verma.

This new CMS rule requires that advertisements for certain prescription drugs or biological products on television (including broadcast, cable, streaming and satellite) contain a “textual statement” indicating the Wholesale Acquisition Cost (referred to as “WAC” or the “list price”) for a “typical 30-day regimen or for a typical course of treatment, whichever is most appropriate, as determined on the first day of the quarter during which the advertisement is being aired or otherwise broadcast.” The statement is as follows: “The list price for a [30-day supply of] [typical course of treatment with] [name of prescription drug or biological product] is [insert list price]. If you have health insurance that covers drugs, your cost may be different.” It is important to note that the rule only applies to television advertisements, but not advertisements through other platforms, such as YouTube or Facebook.

Click here for a fact sheet about the final rule.

CDC’s Guideline for Prescribing Opioids for Chronic Pain is intended to improve communication between providers and patients about the risks and benefits of opioid therapy for chronic pain, improve the safety and effectiveness of pain treatment, and reduce the risks associated with long-term opioid therapy, including opioid use disorder and overdose. The Guideline is not intended for patients who are in active cancer treatment, palliative care, or end-of-life care.

Determining When to Initiate or Continue Opioids for Chronic Pain

  • Opioids are not first-line therapy

Non-pharmacologic therapy and non-opioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with non-pharmacologic therapy and non-opioid pharmacologic therapy, as appropriate.

  • Establish goals for pain and function

Before starting opioid therapy for chronic pain, clinicians should establish treatment goals with all patients, including realistic goals for pain and function, and should consider how opioid therapy will be discontinued if benefits do not outweigh risks. Clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety. 

  • Discuss risks and benefits

Before starting and periodically during opioid therapy, clinicians should discuss with patients known risks and realistic benefits of opioid therapy and patient and clinician responsibilities for managing therapy.

Opioid Selection, dosage, Duration, Follow-Up, and Discontinuation

  • When starting opioid therapy for chronic pain, clinicians should prescribe immediate-release opioids instead of extended-release/long-acting (ER/LA) opioids
  • When opioids are started, clinicians should prescribe the lowest effective dosage. Clinicians should use caution when prescribing opioids at any dosage, should carefully reassess evidence of individual benefits and risks when considering increasing dosage to ≥50 morphine milligram equivalents (MME)/day, and should avoid increasing dosage to ≥90 MME/day or carefully justify a decision to titrate dosage to ≥90 MME/day
  • Long-term opioid use often begins with treatment of acute pain. When opioids are used for acute pain, clinicians should prescribe the lowest effective dose of immediate-release opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. Three days or less will often be sufficient; more than seven days will rarely be needed
  • Clinicians should evaluate benefits and harms with patients within 1 to 4 weeks of starting opioid therapy for chronic pain or of dose escalation. Clinicians should evaluate benefits and harms of continued therapy with patients every 3 months or more frequently. If benefits do not outweigh harms of continued opioid therapy, clinicians should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids

Assessing Risk and Addressing Harms of Opioid Use

  • Before starting and periodically during continuation of opioid therapy, clinicians should evaluate risk factors for opioid-related harms. Clinicians should incorporate into the management plan strategies to mitigate risk, including considering offering naloxone when factors that increase risk for opioid overdose, such as history of overdose, history of substance use disorder, higher opioid dosages (≥50 MME/day), or concurrent benzodiazepine use, are present
  • Clinicians should review the patient’s history of controlled substance prescriptions using state prescription drug monitoring program (PDMP) data to determine whether the patient is receiving opioid dosages or dangerous combinations that put him or her at high risk for overdose. Clinicians should review PDMP data when starting opioid therapy for chronic pain and periodically during opioid therapy for chronic pain, ranging from every prescription to every 3 months
  • When prescribing opioids for chronic pain, clinicians should use urine drug testing before starting opioid therapy and consider urine drug testing at least annually to assess for prescribed medications as well as other controlled prescription drugs and illicit drugs
  • Clinicians should avoid prescribing opioid pain medication and benzodiazepines concurrently whenever possible
  • Clinicians should offer or arrange evidence-based treatment (usually medication-assisted treatment with buprenorphine or methadone in combination with behavioral therapies) for patients with opioid use disorder.

According to the 2018 Physical Activity Guidelines for Americans, nearly 80% of adults are not meeting the recommended activity level. Women across all age groups are less likely to be physically active than men. The app, which was developed exclusively for the study and is not commercially available, had three main functions, including a pre-programed interactive daily message or video that reinforced what was learned during a beginning counseling session, and a daily activity diary to record progress. The app automatically increased the participants’ activity goals by 20 percent each week to 10,000 steps daily. To improve adherence, participants received an automated message if the app had not been used for three consecutive days. Read more.

The trial involved 210 physically inactive women, ages 25 and 65. They were equally divided into three groups--a control that had no intervention but used a tracking device for the nine months of the trial; a “regular” group that got counseling and used the tracker and the app for three months, then used only the tracker for the remaining six months; and a “plus” group that got counseling and used the tracker and the app for the entire nine months. Unlike most other studies, the researchers measured women’s activity every 60 seconds, every day for nine months, instead of relying on self-reported activity or intermittent activity measured by the tracker.

During the first three months, the tracker showed that, compared to the control group, the women in the regular and plus groups logged about 2,000 steps more per day, equivalent to approximately 1 mile or 20 minutes of walking. They also increased their moderate to vigorous physical activity by 18 minutes a day.

In the following six-month maintenance period, however, the regular and plus groups logged about 1,400 steps more than the control group and got in eight more minutes of moderate to vigorous physical activity. Researchers said these findings show that the women were able to sustain an impressive level of activity above their starting point. However, continued use of the app by the plus group did not add any extra benefit to help maintain this increased activity, compared to the regular group, which had stopped using the app after the first three months.

“Sustaining any behavior change is difficult in general, and in particular, sustaining the increased physical activity that resulted after the intervention,” Fukuoka said. “Still, it is encouraging to see that 97.6% of women in our trial completed a nine-month visit and kept up part of their increased activity.”

The researchers’ next goal is to refine maintenance strategies that can help maintain those increased levels of activity over a longer period.

These outbreaks are a reminder to always wash hands thoroughly with soap and water right after touching chickens, ducklings, and anything in their environment.

Owning backyard chickens and other poultry can be a great experience. However, people have gotten sick with Salmonella from handling poultry or items in the area where they live and roam. Even handling baby birds displayed at stores or exhibits can spread Salmonella infections to people.

Take steps to reduce changes of getting Salmonella:

  • Always wash your hands
  • Don’t let backyard poultry inside the house
  • Wear a pair of shoes designated for taking care of poultry and keep them outside
  • Children under 5, adults older than 65, or anyone with a weakened immune system should not handle poultry

Symptoms of Salmonella infection include:

  • Diarrhea
  • Vomiting
  • Fever
  • Abdominal cramps

CDC’s Salmonella website has more information about the infections and signs of a severe infection.

Poultry can also can carry avian influenza (flu) viruses. Take steps to protect yourself.

The United States is facing an opioid use disorder epidemic with opioid overdoses killing 47,000 people in the U.S. in 2017. The past three decades have witnessed a significant increase in the prescribing of opioids for pain, based on the belief that patients were being undertreated for their pain, coupled with a widespread misunderstanding of the addictive properties of opioids. This increase in prescribing of opioids also saw a parallel increase in addiction and overdose. In an effort to address this ongoing epidemic of opioid misuse, policy and regulatory changes have been enacted that have served to limit the availability of prescription opioids for pain management.

Overlooked amid the intense focus on efforts to end the opioid use disorder epidemic is the perspective of clinicians who are experiencing a significant amount of daily tension as opioid regulations and restrictions have limited their ability to treat the pain of their patients facing serious illness. Increased public and clinician scrutiny of opioid use has resulted in patients with serious illness facing stigma and other challenges when filling prescriptions for their pain medications or obtaining the prescription in the first place. Thus clinicians, patients, and their families are caught between the responses to the opioid use disorder epidemic and the need to manage pain related to serious illness.

The National Academies of Sciences, Engineering, and Medicine sponsored a workshop on November 29, 2018, to examine these unintended consequences of the responses to the opioid use disorder epidemic for patients, families, communities, and clinicians, and to consider potential policy opportunities to address them. This publication summarizes the presentations and discussions from the workshop.

Get the publication from The National Academies of Science, Engineering and Medicine .

A pregnancy can be one of the most joyous times for a family; the excitement of choosing a name, picking out colors for the nursery, selecting furniture. However, for many families this joy is short lived. According to the CDC, about 700 women die each year from complications of pregnancy with 60% of pregnancy related deaths preventable.

A pregnancy-related death can happen during pregnancy, at delivery, and even up to a year afterward (postpartum).

For 2011-2015:

  • About 1/3 of deaths (31%) happened during pregnancy;
  • About 1/3 (36%) happened at delivery or in the week after; and
  • About 1/3 (33%) happened 1 week to 1 year postpartum

Heart disease and stroke caused more than 1 in 3 deaths (34%). Other leading causes of death included infections and severe bleeding.

Every death reflects a web of missed opportunities. Factors playing a part include:

  • Access to care
  • Missed or delayed diagnoses
  • Not recognizing warning signs

Most deaths are preventable, no matter when they occur.

Join Drs. Nancy Phillip and Donald DiPette as they discuss Hypertension in Pregnancy and Diabetes in Pregnancy at the Focus on Women’s Health Conference.

Read more here.

U.S. Surgeon General releases new video "The Doctor Is In"

U.S. Surgeon General Jerome M. Adams, M.D., M.P.H., released a new video, “The Doctor Is In,” on the topic of vaccinations. As the Nation’s doctor, VADM Adams wants to share the message that vaccines are safe and effective ways to protect your children, your family, your neighbors, and yourself.

This is particularly timely, given that CDC announced yesterday that from January 1 to May 3, 2019, 764 individual cases of measles have been confirmed in 23 states. This is an increase of 60 cases from the previous week. This is the greatest number of cases reported in the U.S. since 1994 and since measles was declared eliminated in 2000.

In the video, Dr. Adams responds to frequently asked questions about vaccination.

Watch the video.


SMA's Focus on Women's Health Conference is the go-to meeting for any healthcare professional seeking a quality CME opportunity. This four-day conference with an abbreviated daily schedule is perfect for primary care physicians, nurses, as well as those in specialty practice.

Join us in beautiful Kiawah Island, South Carolina to gain updated knowledge on topics such as: Issues in Pregnancy, Eating Disorders, Substance Use Disorders in Women, Alternate Therapy for Obesity, Diabetes, and Thyroid Disease, Contraception Controversies, Behavioral Change for the Office-based Physician, Physician Burnout, and more!



Women's & Children's Health


These podcasts address all aspects of care of the female patient across her lifespan, including obstetrics and gynecology, mental health, and internal medicine. It also explores the special and unique care of children and adolescents, including the maternal-fetal period of life, ethical issues in pediatric medical and surgical care, and growth and development in children.

The Southern Medical Journal is the official, peer-reviewed journal of the Southern Medical Association. It has a multidisciplinary and inter-professional focus that covers a broad range of topics relevant to physicians and other healthcare specialists, including medicine; surgery; women’s and children’s health; mental health; emergency and disaster medicine; public health and environmental medicine; bioethics and medical education; and quality health care, patient safety, and best practices.

Southern Medical Journal Vol. 112 • No. 05 • May 2019

Mental Health
Sickle Cell Disease, More Than Just Pain: The Mediating Role of Psychological Symptoms
Mona A. Robbins, PhD, Lakeya S. McGill, MA, Breanna M. Holloway, BA, and Shawn M. Bediako, PhD

Bioethics & Medical Education
A National Evaluation of Scholarly Activity Requirement in Osteopathic EM Residency Programs: Survey of EM Program Directors
Alexander Kirkpatrick, DO, Tom Doran, DO, David Mullins, DO, David Gnugnoli, DO, and John Ashurst, DO, MSc

Saying Goodbye
Robert Goldszer, MD

On “Team-Based Learning Activities for First-Year Medical Students: Perception of the Learners”
Hanieh Enayati and Jai Mathur

Emergency Medicine & Disaster Preparedness
CME Article: Patients on Involuntary Hold Status in the Emergency Department
Archana Roy, MD, Christian Lachner, MD, Adrian Dumitrascu, MD, Nancy L. Dawson, MD, Tyler F. Vadeboncoeur, MD, Michael J. Maniaci, MD, Ian C. Lamoureux, MD, Patricia C. Lewis, ARNP, Teresa A. Rummans, MD, and M. Caroline Burton, MD

Women’s & Children’s Health
OPEN: Incidence of Pediatric Cervical Spine Injuries in Iraq and Afghanistan
Xandria Gutierrez, BA, Michael April, MD, DPhil, Joseph Maddry, MD, Guyon Hill, MD, Tyson Becker, MD, and Steven Schauer, DO, MS

Commentary on “Incidence of Pediatric Cervical Spine Injuries in Iraq and Afghanistan”
LTC Wendy J. Wilcoxson, DO, USAF, MC

Propofol Versus Dexmedetomidine for Procedural Sedation in a Pediatric Population
Nicole M. Schacherer, MD, Tamara Armstrong, MD, Amy M. Perkins, MS, Michael P. Poirier, MD, and James M. Schmidt, MD 

Medicine & Medical Specialties
Otolaryngology: Breadth, Depth, Challenge, and Choice
Robert T. Sataloff, MD, DMA, Mary J. Hawkshaw, BSN, RN, and Brian J. McKinnon, MD, MPH

Commentary on “Otolaryngology: Breadth, Depth, Challenge, and Choice”
Mark Boston, MD

Fetal Hemoglobin Modulators May Be Associated With Symptomology of Football Players with Sickle Cell Trait
Carroll Flansburg, MA, MPH, Christina M. Balentine, BS, Ryan W. Grieger, MS, Justin Lund, MA, Michelle Ciambella, BS, Deandre White, BS, Eric Coris, MD, Eduardo Gonzalez, MD, Anne C. Stone, PhD, and Lorena Madrigal, PhD

Use of Cardiac Troponin Testing in the Outpatient Setting
Steven J. Ross, MD, Nikhil H. Shah, MD, Steve A. Noutong Njapo, MD, Daniel J. Cordiner, MD, and David E. Winchester, MD, MS

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HHS To Deliver Value-Based Transformation in Primary Care
The CMS Primary Cares Initiative to Empower Patients and Providers to Drive Better Value and Results

Today, U.S. Department of Health and Human Services (HHS) Secretary Alex Azar and Centers for Medicare & Medicaid Services (CMS) Administrator Seema Verma are announcing the CMS Primary Cares Initiative, a new set of payment models that will transform primary care to deliver better value for patients throughout the healthcare system. Building on the lessons learned from and experiences of the previous models, the CMS Primary Cares Initiative will reduce administrative burdens and empower primary care providers to spend more time caring for patients while reducing overall health care costs. The models were developed by the Innovation Center under the leadership of Adam Boehler and are part of Secretary Azar’s value-based transformation initiative.

“For years, policymakers have talked about building an American healthcare system that focuses on primary care, pays for value, and places the patient at the center. These new models represent the biggest step ever taken toward that vision,” said HHS Secretary Alex Azar. “Building on the experience of previous models and ideas of past administrations, these models will test out paying for health and outcomes rather than procedures on a much larger scale than ever before. These models can serve as an inflection point for value-based transformation of our healthcare system, and American patients and providers will be the first ones to benefit.”

Empirical evidence shows that strengthening primary care is associated with higher quality, better outcomes, and lower costs within and across major population subgroups. Despite this evidence, primary care spending accounts for a small portion of total cost of care, and is even lower for patients with complex, chronic conditions. Primary care clinicians serve on the front lines of the healthcare delivery system, furnishing services across a wide range of specialties, from family medicine to behavioral health to gerontology. For many patients, the primary care clinician is the first point of contact with the healthcare delivery system. CMS’s experience with innovative models, programs and demonstrations to date have shown that when incentives for primary care clinicians are aligned to reward the provision of high value care, the quality and cost effectiveness of patient care improves.

“As we seek to unleash innovation in our health care system, we recognize that the road to value must have as many lanes as possible,” said CMS Administrator Seema Verma. “Our Primary Cares Initiative is designed to give clinicians different options that advance our goal to deliver better care at a lower cost while allowing clinicians to focus on what they do best: treating patients.”

Administered through the CMS Innovation Center, the CMS Primary Cares Initiative will provide primary care practices and other providers with five new payment model options under two paths:

Primary Care First and Direct Contracting.

The five payment model options are:

  1. Primary Care First (PCF)
  2. Primary Care First – High Need Populations
  3. Direct Contracting – Global
  4. Direct Contracting – Professional
  5. Direct Contracting – Geographic

The Primary Care First (PCF) payment model options will test whether financial risk and performance based payments that reward primary care practitioners and other clinicians for easily understood, actionable outcomes will reduce total Medicare expenditures, preserve or enhance quality of care, and improve patient health outcomes. PCF will provide payment to practices through a simplified total monthly payment that allows clinicians to focus on caring for patients rather than their revenue cycle. PCF also includes a payment model option that provides higher payments to practices that specialize in care for high need patients, including those with complex, chronic needs and seriously ill populations (SIP).

Both models under PCF incentivize providers to reduce hospital utilization and total cost of care by potentially significantly rewarding them through performance-based payment adjustments based on their performance.  These models seek to improve quality of care, specifically patients’ experiences of care and key outcome-based clinical quality measures, which may include controlling high blood pressure, managing diabetes mellitus, and screening for colorectal cancer. PCF will be tested for five years and is scheduled to begin in January 2020. A second application round is also planned for participants starting in January 2021.

Like the PCF payment model options, the Direct Contracting (DC) payment model options are also focused on transforming primary care, allowing health care providers to take greater control of managing the costs of care for an aligned population of Medicare fee-for-service (FFS) beneficiaries. While the PCF models are focused on individual primary care practice sites, the DC payment model options aim to engage a wider variety of organizations that have experience taking on financial risk and serving larger patient populations, such as Accountable Care Organizations (ACOs), Medicare Advantage (MA) plans, and Medicaid managed care organizations (MCOs).  The DC payment model options are designed to create a competitive delivery system environment where organizations offering greater efficiencies and better quality of care will be financially rewarded. The payment model options include a focus on care for patients with complex, chronic needs and SIPs, as well as a voluntary alignment option that allows beneficiaries to align with the health care provider of their choosing.

Depending on the DC payment model option in which an organization is participating, the model participant will receive a fixed monthly payment that can range from a portion of anticipated primary care costs to the total cost of care. Participants in the global payment model option will ultimately bear full financial risk, while those in the professional payment model option will share risk with CMS. This will provide prospective model participants a range of financial risk arrangements from which to choose while providing a more predictable revenue stream and reducing health care provider burden commensurate with level of financial risk.

In addition, CMS is seeking public comment on one DC payment model option with an expected performance period launch in January 2021. The Geographic Population-Based option is designed to offer innovative organizations the opportunity to assume responsibility for the total cost of care and health needs of a population in a defined target region. Driving accountability to a local level empowers communities to devise strategies best designed to meet their health care needs. Given the novelty of this option, we are seeking public comment through a new Request for Information.

Together, CMS anticipates these five payment model options administered under the Primary Cares Initiative could:

  • Provide better alignment for over 25 percent of all Medicare FFS beneficiaries – nearly 11 million Medicare beneficiaries would potentially be included (a collective 5 million beneficiaries in the DC payment model options and a collective 6.4 million in PCF payment model options);
  • Offer new participation and payment options and opportunities for an estimated one in four (25 percent) primary care practitioners as well as other health care providers; and
  • Create new coordinated care opportunities for a large portion of the 11-12 million beneficiaries dually eligible for Medicare and Medicaid, specifically those in Medicaid managed care and Medicare FFS.

All five payment model options focus on supporting care for patients who have chronic conditions and serious illnesses. Through the PCF payment model options, high need patients with serious illness who do not have a primary care practitioner or care coordination and indicate an interest in receiving care from a practice participating in the model will be assigned to a model participant. Participating practices that choose to care for SIP patients will be required to provide care to clinically stabilize the patient. All payment model options include enhancements to encourage participation of providers who are focused on care for these populations.

CMS based the design of these payment model options on considerable stakeholder input. The models draw from Physician-Focused Payment Model Technical Advisory Committee (PTAC) review of proposals, including, but not limited, to The Advanced Primary Care Model from the American Academy of Family Physicians, An Innovative Model for Primary Care Office Payment from Jean Antonucci, MD, The Patient and Caregiver Support for Serious Illness Model from the American Academy of Hospice and Palliative Medicine, and The Advanced Care Model from the Coalition to Transform Advanced Care. All payment model options are responsive to stakeholder feedback that we received from advanced primary care practices expressing interest in accepting increased financial risk in exchange for greater flexibility and fewer requirements.

For a fact sheet on the CMS Primary Care First payment model options, please visit https://www.cms.gov/newsroom/fact-sheets/primary-care-first-foster-independence-reward-outcomes. More information on CMS Primary Care payment model options is at: https://innovation.cms.gov/initiatives/primary-care-first-model-options/.

For a fact sheet on the Direct Contracting payment model options, please visit https://www.cms.gov/newsroom/fact-sheets/direct-contracting. More information on the Direct Contracting model options is at: https://innovation.cms.gov/initiatives/direct-contracting-model-options/.

To view a fact sheet on the CMS Primary Cares Initiative, please visit: https://innovation.cms.gov/Files/x/primary-cares-initiative-onepager.pdf.

To review the Direct Contracting—Geographic Request for Information, please visit: https://innovation.cms.gov/Files/x/dc-geographicpbp-rfi.pdf.

CMS is also releasing the first annual evaluation report for the Comprehensive Primary Care Plus (CPC+) Model, which details the implementation experience and impact on beneficiary outcomes over the first year for practices that started participating in the CPC+ model in January 2017. To view the findings-at-a-glance, please visit: https://innovation.cms.gov/Files/reports/cpcplus-fg-firstannrpt.pdf. To see the report, please visit: https://downloads.cms.gov/files/cmmi/cpcplus-first-ann-rpt.pdf.

Navigating Insulin-Based Therapy for Type 2 Diabetes

Downloadable Slide Set Now Available

In this online webinar and slide set, Dr. Veronica Piziak discusses the application of new studies on NPH, regular insulin, switching, and other approaches to avoid hypoglycemia, control hyperglycemia, and reduce CV risk.

Join Dr. Piziak at the upcoming Focus on Women's Health Conference, July 15-18 in Kiawah Island, South Carolina where she will be discussing similar topics.

The Southern Medical Journal is the official, peer-reviewed journal of the Southern Medical Association. It has a multidisciplinary and inter-professional focus that covers a broad range of topics relevant to physicians and other healthcare specialists, including medicine; surgery; women’s and children’s health; mental health; emergency and disaster medicine; public health and environmental medicine; bioethics and medical education; and quality health care, patient safety, and best practices.

Southern Medical Journal Vol. 112 • No. 04 • April 2019

Mental Health
Evaluating the Burnout-Thriving Index in a Multidisciplinary Cohort at a Large Academic Medical Center
Rebecca Gates, BS, David Musick, PhD, Mark Greenawald, MD, Kimberly Carter, PhD, RN, Richard Bogue, PhD, and Lauren Penwell-Waines, PhD

Medicine & Medical Specialties
Outcomes in an Interdisciplinary Diabetes Clinic in Rural Primary Care
Dana E. King, MD, MS, Ashley B. Petrone, PhD, Frederick M. Alcantara, MD, Megan M. Elavsky, PharmD, Michelle O. Prestoza, MD, Judy Siebart, MS, RD, and Greg Castelli, PharmD

Is Endurance Exercise Safe? The Myth of Pheidippides
Christine Rutlen, BA, and David L. Rutlen, MD

Commentary on “Is Endurance Exercise Safe? The Myth of Pheidippides”
G. Richard Holt, MD, MSE, MPH, MABE, DBioethics

Mycobacterium fortuitum Meningitis: Approach to Lumboperitoneal Shunt Infection
Jack Zakrzewski, BS, Kimberly Hu, BS, Brandon L. Neisewander, BA, Darian R. Esfahani, MD, MPH, Abhiraj D. Bhimani, BS, Harsh P. Shah, MD, Dafer W. Haddadin, MD, and Ankit I. Mehta, MD

OPEN: Inconsistencies in Colonic Tattooing Practice: Differences in Reported and Actual Practices at a Tertiary Medical Center
Joshua P. Spaete, MD, Jiayin Zheng, PhD, Shein-Chung Chow, PhD, Rebecca A. Burbridge, MD, and Katherine S. Garman, MD

A Brief Review of the Pharmacology of Hyperkalemia: Causes and Treatment
James M. Wooten, PharmD, Fernanda E. Kupferman, MD, and Juan C. Kupferman, MD, MPH

Quality Care & Patient Safety
Objectively Measured Physical Activity and All-Cause Mortality Among Cancer Survivors: National Prospective Cohort Study
Paul D. Loprinzi, PhD, and Allison Nooe, BS

Native Joint Septic Arthritis: Comparison of Outcomes with Medical and Surgical Management
Kaoru Harada, MD, Ian McConnell, MD, Eric C. DeRycke, MPH, Jürgen L. Holleck, MD, and Shaili Gupta, MD

CME Article: Comparison of Factors Identified by Patients and Physicians Associated with Hospital Readmission (COMPARE2)
Eric Dietrich, PharmD, BCPS, Kyle Davis, PharmD, BCPS, Lisa Chacko, MD, MPH, Kiarash P. Rahmanian, MPH, Lauren Bielick, BSN, RN, David Quillen, MD, David Feller, MD, Maribeth Porter, MD, MS, John Malaty, MD, and Peter J. Carek, MD, MS

Public Health & Environmental Medicine
Know the New HIV Testing Guidelines?
Pradeepthi Badugu, MD, and Steven Lippmann, MD

Bioethics & Medical Education
On “Importance of Interdisciplinary Medical Education: A Frontline Perspective”
Regwaan Choudhury, Third Year MBBS Student, and Jai Mathur, Fifth Year MBBS Student

SMA Services, Inc.

Sponsored by SMA Services, Inc.

Donna L. Breen, MD

I am an Otolaryngologist practicing general ENT and allergy for the past 30 years in Marksville, Louisiana after finishing my residency at Tulane Medical Center in 1988. I graduated from University of Alabama Medical School cum laude in 1983. Also, I completed a fellowship in Otolaryngic Allergy in 1992. I am proud to serve the needs of a semirural small town community and take care of adults and children with ear, nose, and throat problems who would have to travel many miles for their care.

Practicing in a small community was very new to me when I first came here. I grew up in New Orleans, Louisiana and was educated in the public and parochial schools there. Living in a smaller community remained a challenge for me in adjustment, but I have come to realize that this environment is perfect for me. I get to know my patients and their families, and their extended families, and relatives, which engages me in their lives, both as a medical doctor, friend and mentor. It is truly the best of both worlds and I have come to treasure my practice as a small town doctor in this community.

I joined the SMA in 1984, while I was a resident and I have been a member ever since. I enjoyed the collegiality as well as the learning experience. It is a big organization with a small town atmosphere in that we are emboldened to learn from the experts in a spirit of congeniality and relaxed learning experience. It is an organization where everyone has equal time, every question has equal value, and everyone has the right to understand the concepts that are being presented. No question or thirst for knowledge is too little and everyone is included in the quest for medical knowledge and skills in the healing arts.

Donna L. Breen, M.D.

The Centers for Medicare & Medicaid Services has issued a new report that offers a look at how physicians fared the first year of its Quality Payment Program (QPP).

According to CMS, the goal of releasing the data in the report is to highlight successes and pain points that can inform QPP participation in the future.

The QPP includes two possible tracks for doctors, the Merit-based Incentive Payment System (MIPS) and the Advanced Alternative Payment Model. In 2017, more than 1 million doctors enrolled in MIPS, about 95% of those eligible, while more than 99,000 qualified for APM, which is a higher risk-bearing, according to the report.

The participation numbers outperform CMS’ projections and goals for the program’s first year. According to the report, the agency was aiming for 90% participation in MIPS and for about 70,000 physicians to enter the more advanced models.

According to the findings, clinicians in rural practices participated in MIPS at a rate of 94%, which was effectively equal to the overall average and a remarkable accomplishment.

“We look forward to continuing to listen and identify ways to improve the Quality Payment Program to help drive value, reduce burden, and improve outcomes for our beneficiaries,” CMS wrote.

In a study funded by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) it was found that taking a vitamin D supplement does not prevent type 2 diabetes in adults at high risk. D2d(link is external) is the largest study to directly examine if daily vitamin D supplementation helps keep people at high risk for type 2 diabetes from developing the disease.

The study included adults aged 30 or older and assigned participants randomly to either take 4,000 International Units (IU) of the D3 (cholecalciferol) form of vitamin D or a placebo pill daily. All study participants had their vitamin D levels measured at the start of the study. At that time, about 80% of participants had vitamin D levels considered sufficient by U.S. nutritional standards.

A diverse group of participants with a range of physical characteristics, including sex, age, and body mass index, as well as racial and ethnic diversity were enrolled in the D2d study. This representation helps ensure that the study findings could be widely applicable to people at high risk for developing type 2 diabetes.

“In addition to the study’s size, one of its major strengths is the diversity of its participants, which enabled us to examine the effect of vitamin D across a large variety of people,” said lead author Anastassios G. Pittas, M.D., principal investigator from Tufts Medical Center, Boston.

At the end of the study, 293 out of 1211 participants (24.2%) in the vitamin D group developed diabetes compared to 323 out of 1212 (26.7%) in the placebo group – a difference that did not reach statistical significance. The study was designed to detect a risk reduction of 25% or more.

Dr. Veronica Piziak will be speaking on the topic of Diabetes at the upcoming Focus on Women’s Health Conference, July 15-18 in Kiawah Island, South Carolina. Visit sma.org/womens-health for additional information.

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