Health Assessment

Tennessee Department of Health 2013 Review, 2014 PreviewFor the past several years, the state has been slowly but steadily moving the needle on the health status of Tennesseans. While still far from where the leadership of the Tennessee Department of Health would like to be, there is a conviction that programming and partnerships truly are making a real difference in real lives all across the state. David Reagan, MD, PhD, chief medical officer for the Tennessee Department of Health, recently spoke with Medical News to reflect on 2013 efforts and discuss focal points for the coming year.Compounded MedicationsThe fungal meningitis outbreak, identified in the fall of 2012, continued to play out in 2013 in a number of ways. In assessing response to the discovery of the tainted batches of the preservative-free steroid injections, Reagan noted, “It took eight days from the first report of a case to the Tennessee Department of Health to the national recall of the three lots of contaminated medication — methylprednisolone acetate — nationwide.” The quick reaction, he continued, “prevented, we estimate, 368 exposures … 368 patients in Tennessee who did not receive contaminated steroids. We believe it probably prevented 69 deaths.”Unfortunately, 750 individuals nationwide, including 150 in Tennessee with 16 deaths, were impacted before the lots were pulled from the New England Compounding Center. To try to prevent a future tragedy, Reagan said a number of steps have been taken on a state and federal level “to make sure Tennesseans receive the safest possible compounded medication.”On Nov. 27, 2013, President Obama signed into law the Drug Quality and Security Act, which more clearly defines the role of the U.S. Food & Drug Administration and state health officials in the oversight and regulation of compounding pharmacies. Reagan said the Tennessee Department of Health worked closely with Sen. Lamar Alexander (R-TN), one of the bill’s chief authors.In Tennessee, a number of changes were approved by the State Board of Pharmacy to improve the oversight and safety of state-licensed compounding facilities. However, a ruling by the attorney general called one of the measures into question. The cease-and-desist provision was deemed to be in conflict with Tennessee’s Administrative Procedures Act. More work will undoubtedly be done on both an administrative and legislative level in 2014 to reach a balance between access to needed medications and public safety. Prescription Drug AbuseAddressing the prescription drug abuse epidemic, a number of improvements to the Controlled Substance Monitoring Database (CSMD) and new requirements for prescribers were implemented last year.“Effective Jan. 1, 2013, all prescribers were required to register with the CSMD,” noted Reagan. He added that on April 1, prescribers were required to search the database prior to prescribing controlled substances to look for patient red flags. “What we’ve seen is a three-fold increase in searches since before the law was implemented, and there has been a 50 percent decrease in doctor shoppers from August 2012 to July 2013,” he said.In addition, Reagan said a number of steps have been taken to improve the technology for clinical users. “We’ve implemented two significant groups of improvements and a third group is being tested now to make an excellent experience for clinicians using the database,” he said. “The average search only takes a few seconds.”Making it simple to identify patients at high risk for addiction and abuse is critical, he continued. Reagan said the latest data showed 1,093 overdose deaths in 2012. “That’s more than the number of deaths from motor vehicle accidents and more than the number of homicides,” he said. “When you look at the breakdown, the great majority of those deaths are accidental overdoses that involved opioid analgesics.” Also of note in 2013, Tennessee forged collaborative database agreements with Virginia, South Carolina and Michigan. In 2014, the state will actively working on similar agreements with other states, particularly those contiguous to Tennessee.Pain Management GuidelinesIn a related matter, the Department of Health reached out to pain management specialists in Tennessee to convene an expert panel looking at the best methods to help patients while curbing medication addiction. “We’re working really hard on establishing chronic pain management guidelines in Tennessee,” Reagan noted. He said the guidelines are a compilation of innovative ideas and best practices from Tennessee and other states’ programming, as well as national pain society recommendations.Reagan added the practice guidelines should be ready this month. “These guidelines will be a significant help to practicing clinicians who are caring for patients requesting pain medicines in increasing numbers.”Newborn HealthNeonatal Abstinence Syndrome (NAS): In 2013, an emphasis was placed on identifying and curbing the number of babies suffering from NAS, which occurs when the mother is taking opioids while pregnant. “It’s very traumatic for the child,” Reagan stated, adding, “It’s something that should be rare because it is nearly completely preventable.”With the mindset that you must know the scope of the problem to effectively combat it, Reagan said, “We made neonatal abstinence syndrome a reportable condition in Tennessee in 2013, and I think we were the first state in the country to do so.”By early December, there were more than 800 documented cases of NAS in Tennessee. Recognizing there could be reporting bias with the change in requirements, he said the 2013 figure appeared to be a 25 percent increase over numbers gathered in 2011 through hospital discharge diagnoses data. Additional education, combined with the new pain management guidelines for caring for pregnant patients, will be a focus in 2014.Screenings: “We screened about 85,000 newborns in 2013 with a panel of 54 different screenings for genetically-based illnesses,” Reagan said. A law passed in 2012 and implemented in 2013, added bedside pulse oximetry to the panel to screen primarily for a treatable cardiac birth defect prior to an infant becoming symptomatic. “We’ve already had babies who have benefited from this, receiving critical medical care in a timely way,” he said.Reagan noted he anticipated adding another new screen to the panel in 2014.Eliminating Elective Early Deliveries: One of the Department of Health’s most effective partnerships has been focused on eliminating elective deliveries before 39 weeks. The collaboration between the state, March of Dimes, Tennessee Hospital Association and TIPQC ( HYPERLINK "http://tipqc.org/" Tennessee Initiative for Perinatal Quality Care) led to the support of every birthing hospital in Tennessee and included the educational initiative, ‘A Healthy Baby is Worth the Wait.’“The last month for which I have data is September 2013. There were only five early elective deliveries in the entire state,” Reagan said with clear excitement. “And that compares to 96 in May of 2012.”He said it was a joint effort with all of the hospitals and their staff members pulling together to create a culture change to “make sure babies born in Tennessee have the best opportunity not only to survive their first year of life but to enjoy the best health possible throughout their lives.”Safe Sleep: The ABCs of Safe Sleep campaign — Alone, on their Back, in a Crib — kicked off in 2012 and has continued to grow since then. Planned in 2014 are continued distribution of door hangers to remind babysitters of the rules, bus signs and billboards, and distribution of a new book on the subject. The latter, Reagan said, is in partnership with the Tennessee Hospital Association. The short, easy-to-read book was written by a Tennessee physician who lost a child to a sleep-related death. In 2011, the campaign resulted in at least 22 fewer sleep-related deaths in the state. Although not a huge number, Reagan was quick to point out it’s an entire kindergarten class.Breastfeeding: “Breastfeeding is quite simply, for at least the first six months, the best nutrition you can provide for your baby,” Reagan said. He noted it improves the immune function and is associated with better child health outcomes and decreased rates of obesity even into adulthood. “The benefits are so compelling,” he stated.In 2013, a breastfeeding hotline was piloted, and Reagan said the plan is to roll the toll-free number out statewide in 2014. Michael Warren, MD, who spearheads breastfeeding efforts for the Department of Health, also is working to make sure employers and companies serving the public understand how beneficial breastfeeding is. Leading by example, the new Department of Health offices include a mother’s room where employees and visitors can breastfeed in comfort.Infant Mortality: In combination, these programs along with other efforts — including a new partnership with First Lady Crissy Haslam that kicked off in the fall of 2013 to support new moms — have helped the state see a steady decrease in infant mortality rates over the past eight years.Reagan said, “Our infant mortality rate decreased to 7.2 per thousand live births, which is the lowest it’s ever been but is still above the national average … so there is still more work to be done.” Primary PreventionLast … but certainly not least … are efforts aimed at stopping problems before they start.“Primary prevention is the happiest kind of medicine,” said Reagan, adding it is also generally considered to be the most cost effective way to spend health dollars. He noted the Department of Health has increased its emphasis on collaborating with community partners to address needs. In addition to running its own programming, health officials across the state also worked on more than 250 community projects in 2013 addressing obesity, tobacco cessation, infant mortality, immunizations and substance abuse.Reagan added his office has been working with Governor Haslam’s Foundation for a Healthier Tennessee and expects to see more programming roll out around the topic of obesity in 2014. He also noted the food code was updated in 2013. “That’s really going to be helpful in the 25,000 food establishments we inspect across the state to protect the safety of the public better,” he concluded.