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  • December 15, 2016 8:32 AM | Sally Winkelman (Administrator)

    December 15, Wisconsin Health News

    Wisconsin ranks as the 20th healthiest state in the nation, up from last year when it was 24th, according to United Health Foundation's 2016 America's Health Ranking Annual Report. 

    Wisconsin was one of three states to increase their ranking by four places or more. It ranked behind Minnesota and Iowa, which came in 4th and 17th respectively. But the state received a higher score than Illinois and Michigan, ranked 26th and 34th respectively.

    Wisconsin had a high percentage of residents who have graduated from high school, which leads to better health outcomes, according to the report. It also had a lower uninsured rate and prevalence of diabetes compared to other states.

    But Wisconsin had the second highest amount of binge drinking in the nation and a high incidence rate of whooping cough. And the state has some of the lowest per capita public health funding in the nation.

    "Ranking the states in relativity to one another gives us an opportunity to look at where we can improve," said Dr. Rhonda Randall, chief medical officer of UnitedHealthcare Medicare and Retirement.

    In the past five years, drug deaths in Wisconsin have increased 23 percent from 11.4 to 14.0 deaths per 100,000. And in the last year, the number of children living in poverty has increased 13 percent from 16.2 percent to 18.3 percent.

    Disparities in health status by education have decreased. Randall noted in the past, Wisconsin has had a greater disparity between the percentage of adults with a high school education reporting good or excllent health compared to those without a degree.

    That disparity decreased 20 percent in the past year, from 32.2 percent to 25.8 percent.

    "What we're seeing are some very favorable trends and some trends that are concerning us," Randall said. "That kind of puts us at a crossroads with our health in the United States."

    She noted that nationwide the number of smokers has decreased and that the rate of uninsured Americans has hit the lowest level in history.

    On the other hand, the obesity rate has increased by 157 percent since the first report in the 1990. And the 2016 report shows death rates from heart disease increasing for the first time in the report's 27-year history.

    "One year is not enough to make a trend, but it's a very concerning change," she said. 

    See Wisconsin's profile.

  • December 14, 2016 12:37 PM | Sally Winkelman (Administrator)

    Building off record attendance at Doctor Day 2016, specialty societies and the Wisconsin Medical Society are expecting to draw another record attendance at the 2017 Doctor Day.  The event is scheduled in Madison on March 29.  Click here  for a list of participating organizations.

    This annual advocacy event is timed well for physicians to be able to meet with their legislators and/or staff members, and to have input on the budget and other important health care issues. Participants will hear from Medicaid Director Michael Heifetz of the Wisconsin Department of Health Services and others, then will take part in an issue briefing before heading to the Capitol. Lunch will be provided, and the day will conclude with a reception in downtown Madison. 

    Visit the Doctor Day website for more information and to register.

  • December 14, 2016 10:09 AM | Sally Winkelman (Administrator)

    December 14, Wisconsin Health  News

    The Group Insurance Board delayed a decision Tuesday on changes to the health plan for state employees, including whether to shift to a regional or self-insurance model. 

    Chair Michael Farrell said the board has directed Department of Employee Trust Funds staff and Segal Consulting to gather more information and data about the proposals. The board will reconvene in January.  

    "There is much complexity and volumes of information that relate to our consideration," he said. "We're not taking these decisions lightly." 

    During closed session Tuesday, members weighed seven scenarios offered by ETF staff, according to a memo.  

    One proposal could continue the current fully insured model with minimal changes. That model would have up to 16 different vendors participating.  

    Other scenarios under consideration would have between six and 11 participating vendors. Those proposals could be fully insured, self-insured or a hybrid. Some of them would divide the state into regions.  

    A seventh proposal, which is not recommended by ETF or Segal, would have one or two vendors under a self-insured model.  

    The board has been considering self-insurance off and on for five years according to the memo. It's also considering other changes like three-year contracts with health plans.  

    Phil Dougherty, spokesman for the Wisconsin Association of Health Plans, said his members "recognize that more can be done in the current competitive model to achieve the state's financial and quality goals." 

    "Moving to Segal's regionalization strategy would create the risk of reducing competition and choice, eliminating high quality healthcare networks and separating plan participants from their doctors and medical homes," Dougherty said in a statement. "The right answer for the state is to use the current competitive structure and Wisconsin health plans to build on what works." 

    Read a summary memo on the proposals and discussion.

  • December 14, 2016 8:54 AM | Sally Winkelman (Administrator)

    The Wisconsin Medical Society is offering “Wisconsin Medical Examining Board Opioid Prescribing Guidelines,” a two-hour webinar available on-demand. The course satisfies the new MEB mandate requiring physicians with a DEA number to complete two continuing medical education (CME) credits on its Opioid Prescribing Guidelines during the current CME cycle, as well as another two credits during the next cycle.

    Presented by Society member Michael McNett, MD, the webinar provides a comprehensive review of the guidelines. I completed it myself last week and thought it was not only outstanding, but a good reminder of the excellent work the Society does every day to meet its members’ needs. Click here to register or for more information.

  • December 12, 2016 12:54 PM | Sally Winkelman (Administrator)

    Major changes are likely in store for the country's healthcare system. Obamacare, Medicaid and Medicare could all be in for overhauls.

    How far will lawmakers go? Will people with pre-existing conditions get to keep their coverage? What about the 22 million Americans, and 200,000 Wisconsinites, who have gained health insurance? How would the industry react to a transition period? Are they ready to start over?  Learn more at a Wisconsin Health News Panel Event Jan. 12 at the Madison Club.  Panelists include: 

    • Eric Borgerding, CEO, Wisconsin Hospital Association 
    • Coreen Dicus-Johnson, CEO, Network Health Plan
    • Donna Friedsam, Health Policy Programs Director, University of Wisconsin Population Health Institute
    • Mike Wallace, CEO, Fort HealthCare
    Register now.
  • December 08, 2016 12:34 PM | Sally Winkelman (Administrator)

    Wisconsin Health News

    Rep. Joe Sanfelippo, R-New Berlin, will continue to chair the Assembly Committee on Health next session, according to a Wednesday statement.   Rep. Samantha Kerkman, R-Salem, will serve as vice chair of the committee.

    Assembly Speaker Robin Vos, R-Burlington, also reappointed Rep. Paul Tittl, R-Manitowoc, to serve as chair of the Assembly Committee on Mental Health. Rep. John Jagler, R-Watertown, will vice chair the committee.  Rep. Tom Weatherston, R - Caledonia, will chair the Assembly Committee on Aging and Long-Term Care. Rep. Warren Petryk, R-Eleva, will vice chair that committee.  Rep. Kevin Petersen, R-Waupaca, was tapped to chair the Assembly Committee on Insurance and Rep. Cindi Duchow, R-Delafield, was picked for vice chair.

    Vos also announced new committees for next session, including one focused on science and technology and one on regulatory licensing reform.

    See more committee leadership appointments.

  • December 01, 2016 4:50 PM | Sally Winkelman (Administrator)

    Wisconsin Health News

    Group Insurance Board members questioned the amount of savings the state receives under its current health insurance model and called for increased access to data as they discussed a possible move Wednesday to self-insurance. 

    Michael Heifetz, state Medicaid director, said the board needs better access to data to make sure they're providing the best care at the best price to employees who "have more skin in the game - a phrase I hate but gets used all the time - than they ever had before.” 

    "We need data to know if we are getting the best deal and to know if we are getting the best quality," he said. "For us not to have that control and to rely on the vendors puts us at a disadvantage." 

    The board selected Truven Health Analytics to serve as its data warehouse vendor at the meeting. But Heifetz noted that if the board doesn't have "any actual good data to shove into that data warehouse, it's not going to help us very much." 

    "Folks can analyze the self-insured vs. fully insured model, but if we don't have data, whatever decision we make is not well-founded," he said. "Politics at the national level have changed. Great. Maybe the Affordable Care Act goes away, maybe it doesn't. This board's mission hasn't changed and we still have to ensure high quality at a reasonable price for our members. And again, it takes data to do that."  

    He questioned the $283 million in cost reductions over the last nine years under the current model, described in a memo prepared by the Department of Employee Trust Funds. The reductions were determined by the difference between the preliminary and final bids by health plans.  

    "Without the right data, I don't know if those initial bids are great numbers or not, or if it's 'Let's see what the state will give us or not,'" said Heifetz, a former lobbyist for SSM Health Care of Wisconsin. "I've been on the other side of this to some degree and that number keeps being thrown at us as if it's sacrosanct and absolute. And I simply don't accept that premise."  

    He said it's "pretty self-serving" for someone to provide a number, then lower it and "tell us how much they saved," he said. "We don't know if we really saved that much."  

    Heifetz added that "a piece of me would love" to have the discussion on self-insurance held in open session, rather than the closed session the board held Wednesday afternoon.  

    "There are folks who will criticize us for being in closed session even though it's all proprietary things that they probably wouldn't want aired in the public arena," Heifetz said. "I have mixed emotions about going into closed session to discuss these things. I am a member of the public, I'm a taxpayer and I'm a member who gets benefits for my family through this process." 

    Phil Dougherty, senior executive officer for the Wisconsin Association of Health Plans, noted that health plans' rates for the State Group Health Program match the healthcare risk they cover. 

    "Driven by the market competition structure of the program, annual premium increases for the program over the past nine years averaged 3.7 percent, significantly below the national trend," he wrote in an email. 

    The state's decision to contract with Truven will provide data to ensure it gets competitive rates from health plans serving the program, he added.  

    J.P. Wieske, deputy insurance commissioner, noted that the average costs of the plans sold on the state's individual exchange are cheaper than those sold though the employers' exchange.  

    "Some of these carriers in Milwaukee and Dane County are carriers in the exchange as well," he said. "And the fact that their rates have been lower in the exchange than the employee plan is really surprising given the risks. I don't believe the population inside the exchange, especially with the problems that they have, especially with how (the Department of Health and Human Services) has administered it, the health of that individual market is probably worse than the state employee population, which is stable, large and consistent."  

    Herschel Day, a professor at the University of Wisconsin-Eau Claire, said that part of the problem could be that members are insulated from the carriers. He noted that they pay the same amount for plans in the highest tier regardless of how plans charge and called for more transparency.  

    "Folks can see what the actual premiums charged are, but given that there's no impact within Tier 1 for the member, I think in some sense we're insulating them from that difference," he said. "That could feed into the higher rates."

  • November 29, 2016 3:34 PM | Sally Winkelman (Administrator)

    Michael S. Pulia, MD, MSa; Robert Redwood, MD, MPHb; Brian Sharp, MDc

    a Emergency Medicine Antimicrobial Stewardship Program, BerbeeWalsh Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, 800 University Bay Drive, Suite 310, Madison, WI 53705, USA
    b Antibiotic Stewardship Committee, Divine Savior Healthcare, 2817 New Pinery Road, Portage, WI 53901, USA
    c The American Center, BerbeeWalsh Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, 800 University Bay Drive, Suite 310, Madison, WI 53705, USA

    Keywords

    Antimicrobial stewardship; Antibiotics; Sepsis; Clinical decision support; Biomarkers; Rapid pathogen identification assays; Quality measures; Emergency medicine

    Key points

    • Antimicrobial stewardship refers to efforts aimed at enhancing judicious prescribing of these unique therapeutic agents in health care settings.
    • Inappropriate use of antimicrobials represents a global threat to public health and a direct threat to individual patient safety.
    • Sepsis is a life-threatening, complex clinical syndrome without a gold standard diagnostic test and thus represents a unique clinical dilemma with regard to antimicrobial stewardship. 
    • Recent literature questioning the clinical impact of time to antimicrobials in sepsis before the onset of shock and improving the definition of sepsis may have a positive impact on antimicrobial stewardship.
    • Electronic health record clinical decision support, biomarkers, and rapid pathogen identification assays have tremendous potential to enhance antimicrobial stewardship in sepsis care and should be a focus of future research efforts.

    Introduction

    The term antimicrobial stewardship is often mistakenly considered to only include efforts to reduce or restrict use of these agents. A more comprehensive view includes a focus on the “4 Ds” of optimal antimicrobial therapy coined by Joseph and Rodvold1 in 2008: drug, dose, de-escalation, and duration. The focus here is on getting the right antimicrobial in the right dose to the right patient for the right amount of time. The opposite of optimal antimicrobial therapy is often referred to as inappropriate or overuse. These terms can refer to a range of practices, such as prescribing when no antimicrobial was indicated, prescribing an overly broad-spectrum agent, or prescribing an excessive length of therapy. In some instances, such as bronchitis, the right antimicrobial is no antimicrobial. In cases of septic shock, the right antimicrobial is broad-spectrum coverage of all likely pathogens. Both of these scenarios represent widely accepted approaches to antimicrobial stewardship. Unfortunately, when it comes to suspected sepsis in the emergency department (ED) setting, the ideal approach to the antimicrobial management is less clear. 
    The timely administration of antimicrobial agents with activity against the causative pathogen has been a cornerstone of sepsis management long before it was included in the original Surviving Sepsis consensus guidelines.2 Based on the literature linking time and appropriateness of antimicrobials to mortality in sepsis,3456 and 7 the ED implementation of this concept has been to rapidly cover all potential pathogens with broad-spectrum agents. De-escalation of therapy is left to occur days later after the patient has stabilized or when pathogen information is available.

    The problem with this approach stems from a lack of a true gold standard for diagnosing the complex syndrome that is sepsis and the corresponding inaccuracy of widely used diagnostic criteria. The Sepsis 2.0 definition of 2 systemic inflammatory response syndrome (SIRS) criteria plus suspected infection suffers from poor discriminant validity due to a lack of specificity for both infection and the occurrence of adverse outcomes.89 and 10 The combination of flawed diagnostic criteria with incredible time pressure to provide broad-spectrum antimicrobial therapy is troubling from the stewardship perspective, as it is not uncommon for patients with otherwise uncomplicated cases of common infections (eg, influenza, pneumonia, or pyelonephritis) to meet this widely used definition of sepsis.

    Emerging literature that questions the optimal timing and clinical impact of antimicrobial agents in sepsis before the onset of shock may relax some of the pressure on emergency providers and allow more judicious and targeted administration in response to clinical judgment and patient trajectory rather than rigid definitions.111213 and 14 Also, recently updated definitions of sepsis and septic shock appear to offer an improved ability to identify septic patients at risk for adverse outcomes and thus most likely in need of early broad-spectrum antimicrobials.9 and 15 As these definitions were developed with hospital mortality as the primary outcome variable,15 their value as broad screening tools for sepsis in the ED and impact on antimicrobial stewardship will require further study. Unfortunately, these promising developments for antimicrobial stewardship in sepsis exist in sharp contrast to the recently implemented Centers for Medicare and Medicaid Services (CMS) ED Sepsis Quality Measure, which codifies poor performing and outdated definitions of sepsis and links them to mandated use of a specific list of broad-spectrum agents.

    The discussion around more judicious use of antimicrobials in sepsis also must include data that suggest that up to 30% of patients diagnosed with sepsis in US EDs do not receive antibiotics before admission.16 There is clearly much work to be done in both defining what constitutes optimal antimicrobial use in sepsis and the development of implementation strategies that facilitate their appropriate administration. The aim of this article was to provide an overview of antimicrobial resistance, evidence-based antimicrobial stewardship interventions for the ED, and potential future directions with regard to antimicrobial use in sepsis care. Due to a paucity of interventional research aimed at improving antimicrobial use in sepsis, aside from enhancing time to administration, much of this information is gleaned from interventional ED stewardship research involving other types of infection. 

    Public health implications of antimicrobial overuse

    Antimicrobial resistance is a naturally occurring phenomenon in which antimicrobials exert selective pressure on pathogens that, in turn, develop defense mechanisms against that antimicrobial agent’s mode of attack.17 Overuse and misuse of antimicrobials has accelerated this natural process, resulting in multidrug-resistant organisms or “super bugs,” as well as a general trend toward antimicrobial resistance outpacing humankind’s ability to develop novel, effective antimicrobials.18

    Read Full Article.
  • November 23, 2016 10:44 AM | Sally Winkelman (Administrator)

    CMS Untethers Pain Quality Metrics from Reimbursement

    Until now, pain management questions on patient satisfaction surveys have been seen by some physicians as a barrier to moving toward optimal use of opioids in emergency care.  Many thanks to our member, Dr. Timothy Westlake, for working with Senator Ron Johnson (R-Wis) on legislation known as the Promoting Responsible Opioid Prescribing (PROP) Act, which prohibits those pain management questions on satisfaction surveys from being used to calculate Medicare reimbursement. 

    Due to the support seen for the PROP Act as well as feedback from the medical community during the comment period, the Department of Health and Human Services finalized a rule implementing provisions of the PROP Act to help curb the opioid epidemic.

    “I applaud the administration for implementing my bipartisan, commonsense solution to fight the opioid epidemic,” said Sen. Ron Johnson (R-Wis.), chairman of the Senate Homeland Security and Governmental Affairs Committee.  During the Committee’s field hearing in Pewaukee, Wisconsin, in April, Dr. Westlake, the Vice Chairman of the State of Wisconsin Medical Examining Board, testified that the PROP Act is “the single-most important piece of legislation reform that [policymakers] could do.”  

    “Physicians must be free to exercise their best judgment when prescribing the proper level of pain medication – that’s what patients and taxpayers expect,” said Johnson.

    Wisconsin, ACEP has developed Opioid Prescribing Guidelines specific to emergency medicine. Members are encouraged to download and post these guidelines, and also to attend the WACEP 2017 Spring Symposium on March 28 in Madison when up-to-date education and information on opioid prescribing will be presented. 

  • November 22, 2016 12:34 PM | Sally Winkelman (Administrator)

    Asymptomatic Bacteriuria: Are Emergency Physicians Part of the Problem or Part of the Solution?
    Bobby Redwood, MD, MPH

    A 72 year-old female presents from your local nursing home with altered mental status. She's comfortable and conversive with normal vital signs and no pain on exam, but thinks its 1956 and calls you and all your staff, "Ralphie". You're handed seven pages of medication administration records without any past medical history or history of present illness. You call for additional information, but they just had a shift change and no one at the facility is able to tell you what happened. After a head CT, chest Xray, EKG and rainbow labs, the only abnormal finding is a urinalysis with bacteria, pyuria, nitrites, and leukocyte esterase. Your nurse reports the urine was dark and foul smelling.

    Alright Ralphie, this is where the rubber hits the road...what do you do?

    If you are like me, you are probably tempted to do a quick fist pump because you found something to treat, order a gram of ceftriaxone, admit the patient to the medicine floor and get on with your shift. Depending on where you work, this method of management may earn you a talking to from the nursing home director or your infectious disease department. You may find yourself being shamed for practicing sloppy medicine and contributing to antibiotic resistance. Deep down, you have doubts that the bacteriuria caused the altered level of consciousness, but you were practicing in the real world, with little clinical background on the patient, and needed to make a game day decision...what's an emergency physician to do?

    Asymptomatic bacteriuria (also known as an asymptomatic urinary infection) is defined as an isolation of bacteria in an appropriately collected urine sample without signs or symptoms to a urinary infection (sorry folks, altered mental status is not a sign of a UTI). The prevalence of asymptomatic bacteriuria is between 5-7% in healthy adult women, but skyrockets to 10-50% in the nursing home population and nearly 100% in patients with chronic indwelling catheters. 

    There was a time when all asymptomatic bacteriuria was treated as though it were a clinical UTI. The practice started because pregnant women with asymptomatic bacteriuria frequently went on to develop pyelonephritis. When the asymptomatic bacteriuria was treated, no pyelonephritis ensued. Clinicians of that era hypothesized that asymptomatic bacteriuria was consistently harmful in all populations and thus warranted antimicrobial treatment. This turns out not to be true; outside of pregnancy and patients undergoing urologic procedures, treating asymptomatic bacteriuria gives your patient all the risks of antimicrobial therapy with none of the benefit. Adding insult to injury, the practice of treating asymptomatic bacteriuria contributes significantly to the public health threat of antimicrobial resistance (especially in nursing home populations). Ready for a shock? A 2014 report from the CDC estimates that 39% of antibiotics prescribed for "UTI" were not necessary. The data is there, but so is the dogma...so I ask you again...what's an emergency physician to do? 

    By arming ourselves with information, we can develop an approach to asymptomatic bacteriuria that is reasonable, defensible, and protects the public health without jeopardizing the health of the individual patient. Here are some common myths about UTIs and asymptomatic bacteriuria:

    • Smelly pee = UTI. Foul smelling urine or change in urine appearance does not correlate with infection. It is usually related to hydration status.
    • WBCs = UTI. Pyuria is inflammation within the genitourinary tract and is measured as WBCs in the urine. It is a common accompaniment of asymptomatic bacteriuria and should not influence decisions about antimicrobial therapy.
    • Leukocyte esterase and/or nitrites = UTI. Not so fast, leukocyte esterase suggests pyuria and nitrites suggest bacteria--either of these could be present in asymptomatic bacteriuria, so clinical context (i.e. symptoms) really matters.
    • Positive culture always means UTI. A good specimen has fewer than five epithelial cells per low-power field on urinalysis. A "positive" culture is meaningless if the sample was contaminated.
    • UTI is a common cause of altered mental status in the elderly. Actually it is an uncommon cause and this type of anchoring bias can work against us in terms of uncovering the true cause of our patient's altered mental status. Before you think UTI, think of more common (and also more subtle) etiologies like medication reactions, sundowning, dehydration or sensory impairment.

    Let's get back to our patient; she's altered, her urinalysis sure looks "positive", and she lives in a nursing home that is likely covered from floor to ceiling in a thin film of gram positive rods, so I ask you yet again...what's an emergency physician to do? 

    • First, check prior records to see if her urinalysis always appears "positive", you may discover a trend of asymptomatic bacteriuria. 
    • Second, recall that UTI is an actually an uncommon cause of delirium and the chances that your patient has occult bacteremia from a urinary source are low. 
    • Third, do not administer antibiotics and let your admitting physician know that you are consciously resisting the urge to treat the "UTI" in favor of uncovering the more likely alternate cause of her altered mental status.
    • Lastly, check your inbox to read emails of praise from your infectious disease and long term care colleagues--you, my friend, are a cautious physician and a noble steward of antibiotics!

    In summary, inappropriate treatment of asymptomatic bacteriuria is a big problem. Some of us are part of the problem, others are part of the solution. If 39% of the antibiotics prescribed for UTIs are unneccesary, we have some work to do in terms of educating our workforce and our patients about asymptomatic bacteriuria. If this is a topic that is relevant in your ED, think about sitting down with your inpatient team and hammering out a protocol to ensure a uniform approach towards asymptomatic bacteriuria. 

    Want to learn more? Check out this 2016 article on the topic by Wisconsin emergency physician Jeff Pothof!

    Bottom line: "Elderly patients with acute mental status changes accompanied by bacteriuria and pyuria, without clinical instability or other signs or symptoms of UTI, can reasonably be observed for resolution of confusion for 24–48 h without antibiotics, while searching for other causes of confusion" [J Emerg Med. 2016;51(1):25-30].