North Carolina Health News
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Autism Insurance Bill Likely to Die in Session’s Final Days

A bill that would allow children with autism to get health insurance coverage for treatment that passed the House over a year ago looks like it won’t make it across the finish line in the current General Assembly session.

The bill
, which would require treatment called applied behavioral analysis to be covered by insurers, was passed by the House of Representatives in May of last year.

Advocates looking to convince lawmakers to pass the autism insurance measure roamed the halls of the General Assembly to speak to legislators early in July.

Advocates looking to convince lawmakers to pass the autism insurance measure roamed the halls of the General Assembly to speak to legislators early in July. Photo credit: Rose Hoban

Applied behavioral analysis has been shown by research to be one of the most effective treatments in helping children with the disorder to be “mainstreamed” into schools and society.

ABA is covered in more than 35 states, including South Carolina, but North Carolina lags behind.

According to the Centers for Disease Control and Prevention, one in 68 children are diagnosed with autism spectrum disorder, and it’s almost five times more common in boys than girls.

After pushing unsuccessfully both last year and this for Senate movement, House lawmakers rolled the provision into SB 493, a 46-page regulatory reform bill that was referenced to committee after passing the second and third reading in the House.

Advocates had hoped the autism insurance provision would be included in the final budget; but with the release of last night’s document, their hopes were dashed.

“We’re very saddened by that, to be honest with you,” said Jennifer Mahan, vice president for governmental affairs for the Autism Society of North Carolina.

“The services that have demonstrated efficacy are behaviorally based,” said Susan Hyman, a researcher from the University of Rochester in a video interview published today on MedPage Today. She said one recent study demonstrated that “naturalistic” services, such as ABA, which takes place in the home and would have been covered by the bill, are the most effective at helping children with autism.

“We know from new data that’s been published that children who have optimal outcome are diagnosed earlier … and have earlier access to evidence-based behavioral service,” Hyman said.

Mahan said the lack of action has been “incredibly disappointing” for families who have kids who would benefit from getting the coverage.

“It’s looking like it’s not going to happen. I don’t say it won’t happen until everything’s over and the gavel falls,” Mahan said. “But it’s not looking good right now.”

Health Care Budget Briefs: Epi Pens, Tanning Beds, Raise the Age

By Jasmin Singh, Hyun Namkoong, Rose Hoban

As lawmakers worked behind closed doors this week to put the finishing touches on this year’s budget revision, health care advocates and lobbyists were walking the halls, holding conversations with key lawmakers where they could. They were hoping to induce movement on a number of bills that have been parked in obscure legislative committees, some for more than a year.

The final budget bill includes some of the measures of concern to health care lobbyists, but some came away disappointed.

School epinephrine pens

A bill passed by the House last year would have provided for schools to supply epinephrine auto-injector devices in every school.

EpiPen on a thigh

EpiPens are designed to administer a dose of epinephrine into a thigh through clothing, if necessary. Image Greg Friese, flickr creative commons.

The devices allow for quick treatment of severe allergic responses, whether it be to a peanut or the venom of a bee sting. The most serious kind of reaction is called anaphylaxis, a rapid onset of hives, throat swelling and low blood pressure. Untreated, anaphylaxis can quickly proceed to death.

The bill has been waiting for action by the Senate since last year.

The budget released late last night includes a provision to have schools obtain epinephrine injection devices and train several staff members in how to use them in case of an emergency. An earlier version of the budget introduced by the House included the same provision.

The original bill was one of many sponsored by Rep. Jim Fulghum (R-Raleigh), a physician who died earlier this month from complications due to cancer.

Youth skin cancer prevention

Another bill co-sponsored by Fulghum last year and passed by the House would restrict teens under 18 years old from using tanning beds – a measure legislators were convinced would reduce the number of premature cases of skin cancer.

tanning bed, Image courtesy flickr creative commons, Evil Erin

Tanning bed. Image courtesy flickr creative commons, Evil Erin

Initially, the bill faced stiff resistance from the tanning bed industry, but the industry has since withdrawn opposition to the bill.

This bill is a response to the growing number of skin cancer cases in the country’s youth. The Centers for Disease Control and Prevention reports that in 2012, 61,061 people in the United States were diagnosed with melanomas of the skin – 35,248 men and 25,813 women. The research also shows that young people who begin tanning before the age of 35 have a 59 percent higher risk of melanoma, the deadliest form of skin cancer.

Nonetheless, the measure has been languishing for more than a year, and it looks less likely that tanning bed regulation will become law at the end of this legislative session.

Initially, the bill was standalone, but after a year of inaction by the Senate, House budget writers wrote the provision into their version of the budget. That bill stalled, and House lawmakers then rolled the tanning bed bill into a larger regulatory reform bill, SB 493.

In a recent version of the budget, the statutory language banning teen use of tanning beds was included; but in the final version released late Wednesday evening, the language was gone.

“It’s a sad irony that we received the news about the North Carolina tanning bed bill the same week as the U.S. Surgeon General issued a national call to action on skin cancer,” wrote Brent Mizelle, head of the N.C. Dermatology Association, in a statement Thursday morning.

Raise the age

Historic legislation that would allow 16- and 17-year-olds to be charged as minors rather than adults in the criminal justice system passed the House in May after failing multiple times in the past decade.

handcuffsNorth Carolina and New York are the only states in the country that automatically try 16- and 17-year-olds as adults in the criminal justice system.

But almost two months after overwhelmingly passing muster in the House, the bill continues to languish in the Senate. Advocates and lawmakers in favor of the bill argue that North Carolina juveniles are unfairly subjected to the negative economic impact of a criminal record.

They also point to findings from the National Prison Rape Elimination Commission that show that 16- and 17-year-olds placed in adult prisons have the highest risk for sexual abuse, more than any other group of incarcerated people.

Advocates worried privately that the troubles resolving the budget would result in the bill remaining stuck in the House. But they said they were determined to return to Raleigh next year to keep pushing for the measure.

UPDATED: Child Fatality Task Force in the Crosshairs – Again

An amendment to the technical corrections bill sponsored by Rep. Grier Martin (D-Raleigh) that eliminates the language repealing the Child Fatality Task Force was adopted in the North Carolina House Friday morning.

Rep. Paul Stam (R-Apex) supported the amendment, which he said “arose like Aphrodite from the sea foam of the Aegean.”

Stam’s seatmate Rep. Charles Jeter (R-Huntersville) also said he couldn’t understand why anyone would want to eliminate the task force.

“I saw in the newspaper the other day something about child welfare in North Carolina and how poorly we rank,” Jeter said. “I can’t imagine that repealing this is the right thing to do.”

The amendment passed 87-4.

By Rose Hoban

Karen McLeod spent the late afternoon Thursday knocking on doors at the General Assembly.

McLeod, who is the co-chair of the legislative Child Fatality Task Force, was looking for Republican lawmakers to help keep the panel from being eliminated as written into the annual “technical corrections” bill.

That bill, which had its debut Thursday morning, is usually reserved for changing grammatical errors deep in statutes or repealing obsolete local laws. But lawmakers often insert small “poison pill” pieces of legislation into the bill: For example, last year’s technical corrections bill changed the structure and completely changed the board of the North Carolina Institute of Medicine, making all of the members political appointees.

This year’s bill repeals the statute establishing the Child Fatality Task Force, sunsetting the body in July 2015.

graph showing 20 year decrease in child death rates

Graph shows a 20-year decrease in child death rates over the life of the Child Fatality Task Force. Data courtesy NC Child Fatality Task Force

The body has been in existence since 1991.

“It’s a 55-page bill,” said Rep. Paul Stam (R-Apex), when McLeod asked him to help her save the body. “You can’t fault me for missing a line.”

The task force’s elimination was contained in an innocuous line in the bill that reads: “SECTION 22.(a)  G.S. 7B‑1401(4), 7B‑1402, 7B‑1403, and 7B‑1412 are repealed,” and striking through references to the task force in other lines of the statute.

Stam has been a member of the CFTF for the past two years, and he gave McLeod a nod.

The bill will be heard on the House floor Friday morning.

Unexpected

“This was very unexpected,” McLeod said.

During the closing days of the 2013 session, there was also a measure floated to eliminate the task force. But that effort was opposed by several members of the House, including the late Rep. Jim Fulghum (R-Raleigh), who died last week. Fulghum, a physician, was also on the task force.

“Last year, we thought that the legislature had decided that it was of value when the decision was made to continue,” McLeod said. “We were just very surprised to see this language come back.”

McLeod rattled off a list of legislative accomplishments since the creation of the committee in 1991, including regulations around bicycle helmets and seat belts, strengthening the child-abuse response system, anti-poisoning measures and programs to reduce the infant mortality rate.

“It has helped crate a tremendous focus on improving outcomes for kids and reducing fatalities,” she said.

McLeod made the point that all of the members of the task force – including McLeod, who leads a group that advocates for policies to help children and families – are volunteers. The only expenses for the task force are for one employee who has a salary of $62,585.

“We have been able to harness experts from all over the state that give of their time to look at systems and policies and practices to determine what changes are needed to continue to drive down fatalities,” she said. “It would be a huge loss for us to lose the task force.”

Despite a precipitous drop in deaths of children under 17 years old and historically low infant mortality rates, North Carolina continues to lag behind other states in child death.

“To lose the momentum and the energy and the focus that has been created over the years of the task force, would be a tragic loss,” McLeod said.

She also bemoaned the loss of Fulghum, who fought to save the task force last year.

“He was a brilliant man who understood from a medical perspective what was in the best interest of children. In addition, he understood the political as well as the policy components across a myriad of services that drive outcomes,” McLeod said.

“He understood that there’s no silver bullet, you need multiple approaches to change the rate of fatalities in kids.”

Rep. Jim Fulghum Dead at 70

The retired neurosurgeon was a freshman representative who spent most of his time in the legislature focused on health care issues.

By Rose Hoban

Several weeks ago, word started floating through the General Assembly on Jones St. that Rep. Jim Fulghum (R-Raleigh) was seriously ill. But no confirmation of the rumors came until a member of the House of Representatives asked on the floor about Fulghum’s condition.

Rep Jim Fulghum (R-Raleigh) speaks with Cary group home resident Robert Bullock at the rally outside the General Assembly Wednesday afternoon.

Rep Jim Fulghum (R-Raleigh) speaks with Cary group home resident Robert Bullock at a rally outside the General Assembly in 2013. Fulghum became involved in the effort to save funding for group homes for people with mental illness. Photo credit: Rose Hoban

“He is ill, and I would ask you to keep him in your prayers,” responded House Speaker Thom Tillis (R-Cornelius).

The same day, July 3, Fulghum filed a letter with the state board of elections withdrawing his candidacy for this fall.

This weekend, Fulghum’s family announced he died from complications related to cancer. He was 70 years old.

“As a medical doctor, Jim had a professional and personal passion for helping those in his community and state. Wake County and all of North Carolina lost a great man today,” wrote Gov. Pat McCrory in a statement Sunday.

Fulghum was instrumental in pushing through the House a number of bills related to health care, in particular children’s health, which included a bill to assure newborns are tested for heart disease and one restricting access to electronic cigarettes. He also helped save the state’s Child Fatality Task Force from elimination during last year’s budget fight.

In a statement, Tillis wrote that Fulghum’s “leadership as a legislator was second only to his compassion and expertise as a doctor serving his constituents and the state of North Carolina.”

Fulghum also co-sponsored a bill banning tanning bed use by teens and one to provide epinephrine pens in North Carolina schools. Both bills passed the House last year but continue to languish in the Senate.

“Not only did we lose the expertise of our only physician legislator, we lost a strong advocate for North Carolina’s children,” said Annaliese Dolph, a lobbyist who represents advocates for children and people with disabilities. “Rep. Fulghum was a very kind person and will be sorely missed.”

Fulghum was planning a run for the state Senate to replace long-serving Sen. Neil Hunt (R-Raleigh), who is retiring this year. After Fulghum’s withdrawal, Wake County Republicans chose John M. Alexander Jr. as a replacement candidate.

Walking to D.C. to Save Belhaven Hospital

What seemed to be a promising agreement between Vidant Health Systems, the NAACP and the town of Belhaven to keep Vidant Pungo hospital open has failed. Efforts are now underway to re-open the hospital in Belhaven.

By Hyun Namkoong

Adam O’Neal is a man on a mission. The Republican mayor of Belhaven walked for almost 20 miles in the pouring rain yesterday from Plymouth to Merry Hill to get to Washington, D.C., where he hopes to talk to lawmakers about the June 1 closure of the Vidant Pungo hospital.

If everything goes as planned, his 14-day, 273-mile trek on foot will put him in the nation’s capital on July 28.

What had been championed as a “historic agreement” between the NAACP and Vidant Health System to transfer ownership of the hospital from Vidant to a community-based board has fallen through, and the NAACP has re-filed a Title VI complaint to the U.S. Department of Justice.

Both phone and email inquiries to several Vidant representatives were unanswered Tuesday evening.

The NAACP asserts in the re-filed Title VI complaint that the closure of the hospital would affect “poor African American and Latino residents of Beaufort and Hyde counties.”

Portia Gibbs' family maintains she died waiting in an ambulance because the closest hospital, Pungo Regional, has been shuttered.

Portia Gibbs’ family maintains she died waiting in an ambulance because the closest hospital, Vidant Pungo, has been shuttered. Portrait screenshot from YouTube video

Title VI of the 1964 Civil Rights Act “prohibits discrimination on the basis of race, color, and national origin in programs and activities receiving federal financial assistance.”

During a press call on the second day of O’Neal’s walk to D.C., he and Rev. William Barber, president of the N.C. chapter of the NAACP, said that people will die as a result of the hospital’s closure. They asserted that 48-year-old Portia Gibbs was the first person to die from delayed care since the hospital’s doors shut.

“A lady spent an hour in the back of a paramedic’s ambulance in Swan Quarter, North Carolina instead of being transferred to Belhaven,” O’Neal said. He said it would have taken 25 to 30 minutes to get the woman to Belhaven.

According to O’Neal and Gibbs’ family’s statements on a YouTube video, she died waiting for a helicopter to airlift her to Norfolk, Virginia.

With the closure of the hospital in Belhaven, the nearest emergency room to Gibbs’ home in Hyde County is 75 miles away. There is no hospital in Hyde County.

Barber cited delays in both delivering information and the $1 million grant from Vidant to facilitate the transition process, as well as Pantego Creek LLC’s unexpected decision to not cooperate with the transfer of ownership, as key reasons for re-filing the Title VI complaint on June 24.

Pantego Creek LLC is the organization created in 2011 that entered into an agreement with Vidant to assume control of the hospital. The LLC informed the community-based board on June 16, two weeks before the date of the mutually agreed upon transfer of ownership, that it would not transfer control of the hospital to the board.

Barber said that he and O’Neal have signed and sent letters to state leadership including Gov. Pat McCrory and Speaker of the House Thom Tillis asking for help, but have yet to receive a reply.

O’Neal said that he supports Medicaid expansion and that it would’ve helped the hospital and the residents of Belhaven.

“We are serious about this issue,” Barber said. “We are asking for the federal government to use its muscle and stop [Vidant] from doing what will cause irreparable damage onto this community.”

What Bites In St. Lucia Doesn’t Stay In St. Lucia

By Hyun Namkoong

Chikungunya virus is as foreign as it sounds, but the Centers for Disease Control and Prevention has already confirmed seven cases of this unwelcome guest in North Carolina.

Chikungunya outbreaks have been largely confined to Africa, Asia and Europe. But in 2013, the virus made its way over to the Americas, first showing up in the Caribbean and then latching onto unwitting American tourists least expecting a case of chikungunya on their holiday. According to the Pan American Health Organization, the Caribbean outbreak is now at about 355,000 suspected and confirmed cases centered primarily in Haiti and the Dominican Republic, Guadeloupe and Martinique, as well as a handful of cases each in Trinidad and Puerto Rico.

commonly known as the Asian Tiger mosquito, Aedes Albopictus is capable of transmitting chikungunya. Photo courtesy Wiki

Commonly known as the Asian tiger mosquito, Aedes Albopictus is capable of transmitting chikungunya. Photo courtesy Wikimedia creative commons

Aedes Albopictus (commonly known as the Asian Tiger mosquito)  engorged from having a blood meal.

Aedes Albopictus engorged from having a blood meal. A. Albopictus are capable of transmitting chikungunya and are endemic throughout the Carolinas. Photo courtesy Wikimedia creative commons

The chikungunya virus is transmitted through infected mosquitoes. The virus has no known vaccine or cure, and although it isn’t lethal it can be painful. Common symptoms include fever and joint pain. Most people feel better within a week, but for some the joint pain can last months, even years.

Hopping on a plane is easier now than ever before, and public-health officials are cautioning travelers to prepare for more than an exchange of culture when they cross borders. The N.C. Department of Health and Human Services is advising North Carolinians who visit tropical islands or other nations where the virus is known to exist to see a doctor if they start feeling any symptoms of chikungunya within two weeks of returning home.

According to the Trinidad Express newspaper, James Hospedales, executive director of the Caribbean Public Health Agency, said the outbreak appears to be spreading to one new country per week.

According to DHHS, “There is no evidence that any mosquitoes in North Carolina carry the chikungunya virus,” and confirmed cases have been people who traveled to the Caribbean or other infected areas.

But it is possible for the virus to get transmitted into local mosquitoes, which could result in an outbreak of chikungunya across the state. The Aedes albopictus, better known as the Asian tiger mosquito, is commonly found in North Carolina and could transmit the virus to humans.

Though it may be unlikely that the state will be swarmed by chikungunya-infected mosquitoes, the old public-health adage “better safe than sorry” is why DHHS is advising residents to take preventative measures against chikungunya by making breeding conditions less favorable for mosquitoes.

These measures include throwing out standing water, keeping gutters clean and using screened doors and windows. People are also advised to avoid being outdoors in the morning and early evening when the Aedes mosquito is most aggressive.

ASIAN tiger mosquito distribution map

Map courtesy Centers for Disease Control and Prevention, 2013.

UPDATE: On July 17, CDC officials announced the first confirmed case of chikungunya acquired without travel to the Caribbean. A man in Florida was diagnosed with the disease who had not recently traveled outside the country.

“CDC officials believe chikungunya will behave like dengue virus in the U.S., where imported cases have resulted in sporadic local transmission but have not caused widespread outbreaks,” said an agency press release.

“None of the more than 200 imported chikungunya cases between 2006 and 2013 have triggered a local outbreak. However, more chikungunya-infected travelers coming into the U.S. increases the likelihood that local chikungunya transmission will occur.”

Lawmakers Call for Action on Reducing Suicides

By Jasmin Singh

The North Carolina House of Representatives passed a resolution Wednesday authorizing legislative staff to study ways to prevent suicide among minors and veterans in the state.

Lawmakers listened as Rep. Carla Cunningham (D-Charlotte), one of the resolution’s sponsors, struggled to contain her emotions as she described her son’s struggle with mental illness and developmental disabilities.

Rep. Carla Cunningham (D-Charlotte). Official NCGA portrait

Rep. Carla Cunningham (D-Charlotte). Official NCGA portrait

“My experience of my son’s suicidal ideation and unpredictable paranoid behavior at a young age was quite difficult for a young mother like myself,” Cunningham said.

The resolution’s easy passage means it’s more likely the legislature will fund a study of the issue during the interim period before next year’s long session, which begins in January.

In North Carolina, there were a total of 3,536 suicides and 19,754 self-inflicted injury hospitalizations between 2009 and 2011, according to “The Burden of Suicide in North Carolina,” a report prepared by the state Department of Health and Human Services in 2013.

The resolution recommends requiring health care providers to complete training in suicide-assessment treatment and management as part of their continuing-education requirements. Other professionals, such as social workers, educators and coaches who are in contact with people at risk for suicide, would also have to be trained in prevention.

Cunningham said people that care for loved ones with suicidal thoughts go through difficulties on a daily basis.

“I was reminded of the loneliness and the frustration many families endure during these unpredictable times,” she said. “This journey is a difficult walk, and I still today cannot understand what my son experienced in his mind or what his thoughts were day to day.”

A complicated issue

Rep. Grier Martin (D-Raleigh), a veteran of the war in Afghanistan, addressed the issue of suicide among military personnel.

“As you expect, folks deployed to a combat zone are suffering from suicide,” Martin said. “But we are finding out that those deployed to a noncombat zone are also suffering.”

Between 2009 and 2011, a total of 505 North Carolina veterans died from suicide, with a suicide rate 150 percent that of the general population, according to the DHHS report.

Rep. Craig Horn (R-Weddington), also a veteran, said that while leading a first-aid group in the military, he saw too many lives lost to suicide.

“You lift down a guy you’ve just been on parade or maybe worked with just an hour ago,” he said. “I had to take him down from a shower stall where he had taken his own life.”

Horn said war is a terrible thing, but that there was something much worse.

“The most terrible thing is to be without hope,” he said. “There are those out there – friends, family, neighbors, people we meet on the street – that are actually living a nightmare inside themselves.”

About a third of veteran suicide victims were receiving treatment for mental illness at the time they took their lives, the DHHS report said.

Map of suicide rates for ages 10 or older by North Carolina county of residence (2009-2011).

Map of suicide rates for ages 10 or older by North Carolina county of residence (2009-11). Map: NC DHHS

Too many young people

Rep. Beverly Earle (D-Charlotte) said an alarming number of young people are committing suicide.

“Suicide and suicidal behaviors are serious problems in the community,” she said. “They can be devastating and detrimental to the victim and to the families.”

According to the DHHS report, among young people between the ages of 10 and 24 there were 422 suicides and 5,167 self-inflicted injury hospitalizations between 2009 and 2011.

More than half of suicides among youth and young adults were carried out using firearms.

“This isn’t a bill about guns, but it is about guns,” Earle said.

“Even more disturbing, in my opinion, is a survey that shows one in every five high school students has considered suicide and one in 12 has attempted,” she said.

The most common circumstance for victims aged 10 to 24 was a crisis within the past two weeks. Mental health circumstances were also common in youth and young adults, including a depressed mood, with almost a third having a current mental health problem and around a third having had mental health treatment in the past.

‘Many others that walk this journey’

Cunningham said she is still learning from her son’s battle.

“I just know that I was allowed to walk this journey with him to a place of hope, courage, lighthearted laugher, smiles and eventually adulthood,” she said.

Cunningham said she is grateful for the help she received for her son but knows there are “many others that walk this journey.”

“Some finish the journey and survive, and others endure the hurt and loss,” she said.

Rep. Chris Whitmire (R-Rosman) said there is some good news.

“Most suicide victims do illustrate symptoms that if recognized can lead to some interventions that ultimately can mitigate or prevent the devastating effects,” he said. “This is an awareness of a means to potentially prevent great tragedy.”

Cunningham said lawmakers should become “the beacon of light” to protect those most vulnerable – youth and veterans.

“Let us seize the moment to lift the burden of suicide in North Carolina by educating as many health care providers, police officers, educators, social workers, clergy and community advocates that touch the masses of the people of our great state,” she said.

North Carolina suicides 2009-11:
Statewide – 3,536
Youth – 422
Veterans – 505

Self-inflicted injury hospitalizations 2009-11:
Statewide – 19,754
Youth – 5,167

Self-inflicted injury ED visits 2009-12:
Statewide – 38,605
Youth – 13,331

Source: “The Burden of Suicide in North Carolina”

Big Money, Big Research for Global Health at UNC

By Hyun Namkoong

The evaluation of how well public-health dollars are spent in nations across the globe received a major boost yesterday, with the announcement of the second-largest research grant UNC-Chapel Hill has ever received.

A group of deans, researchers and politicians gathered at the Carolina Inn for Chancellor Carol Folt’s announcement of a $180 million grant from the U.S. Agency for International Development.

UNC-Chapel Hill Chancellor Carol Folt and TKTK celebrate their U.S.AID grant with a cake and balloons.

UNC-Chapel Hill Chancellor Carol Folt and MEASURE Evaluation project director Jim Thomas celebrate their U.S.AID grant with a cake and balloons. Photo credit: Hyun Namkoong

The recipient is the university’s Carolina Population Center for its Monitoring and Evaluation to Access and Use Results Evaluation project, more commonly known as MEASURE Evaluation.

“[Funding] is for phase four of this project and it will keep the work going for another five years,” Folt said.

The MEASURE Evaluation project is the U.S. AID’s flagship program for identifying gaps in data, collecting and analyzing data and making decisions to fund projects based on data.

In the past, many projects had been funded based on political favors or hunches, according to Jim Thomas, MEASURE Evaluation project director and an associate professor of epidemiology at UNC-Chapel Hill’s Gillings School of Global Public Health. Better data has helped change that paradigm throughout the developing world.

The goal of the project is to measure and evaluate public-health programs worldwide to ensure government dollars in 80 countries are used wisely.

The overall emphasis of phase four, Thomas said, “is to build sustainability so that these [health information] systems can continue on long term without us.”

Sustainability has long been identified as a priority of public-health projects, particularly those implemented in low- and middle-income countries.

Among those attending the press conference were Rep. David Price; Aldona Wos, secretary of the state Department of Health and Human Services; and representatives from the office of U.S. Sen. Richard Burr.

The MEASURE Evaluation project began in 1997 and has received funding from a number of sources, including the President’s Emergency Plan for AIDS Relief.

The project has developed several methodologies for collecting data to better inform public-health programs and policies, especially in the areas of reproductive health, HIV/AIDS and other infectious diseases.

“Monitoring and evaluation – what’s important here is that not only are we applying a toolkit, we’re inventing the toolkit,” said Barbara Entwisle, vice chancellor for research at UNC-Chapel Hill.

Benefits to the state

While the focus of MEASURE Evaluation is on global health and strengthening health information systems worldwide, Folt and Thomas believe that North Carolinians will benefit from the $180 million grant.

“It’s a global project with a lot of local influence,” Folt said. “It’s supported more than 100 jobs here in North Carolina.”

Folt also said that research at UNC has led to the creation of spinoff companies such as FHI 360, which is headquartered in Durham.

MEASURE Evaluation has worked on public-health projects for infectious diseases such as HIV/AIDS in South Africa and tuberculosis in Latin America, both of which can result in epidemics, or even pandemics.

“Epidemics that are controlled worldwide are less able to affect our own country,” Thomas said.

He also said that the Triangle has become a hub for global-health research similar to how Wilmington has become a hub for the film industry.

When asked about how phase four of the MEASURE Evaluation project might directly affect and translate into health improvements for North Carolinians, Thomas said, “We don’t have [anything] in place for making sure that it translates, but that’s something that we would be very much open to talking about.”

“For decades, I did work domestically in epidemiology in the public sector,” he said. “I would be very interested in talking to anyone who wanted [to learn] about how we could translate some of these things that we’re doing in MEASURE Evaluation to benefit, in particular, some of the rural areas of the state.”

NC Hospitals Among Those Facing Medicare Crackdown on Patient Injuries

By Jordan Rau

Kaiser Health News

During a hernia operation, Dorothea Handron’s surgeon unknowingly pierced her bowel. It took five days for doctors to determine she had an infection. By the time they operated on her again, she was so weakened that she was placed in a medically induced coma at Vidant Medical Center in Greenville.

Comatose and on a respirator for six weeks, she contracted pneumonia. “When they stopped the sedation and I woke up, I had no idea what had happened to me,” said Handron, 60. “I kind of felt like Rip Van Winkle.”

Dorothea Handron was so weakened by complications from a hernia operation that she was placed in a medically induced coma at Vidant Medical Center (Photo by Jim R. Bounds/AP Images for KHN)

Dorothea Handron was so weakened by complications from a hernia operation that she was placed in a medically induced coma at Vidant Medical Center (Photo credit: Jim R. Bounds/AP Images for KHN)

Because of complications like Handron’s, Vidant, an academic medical center, is likely to have its Medicare payments docked this fall through the government’s toughest effort yet to crack down on infections and other patient injuries, federal records show.

A quarter of the nation’s hospitals – those with the worst rates – will lose 1 percent of every Medicare payment for a year starting in October. In April, federal officials released a preliminary analysis of which hospitals would be assessed, identifying 761. When Medicare sets final penalties later this year, that list may change because the government will be looking at performance over a longer period than it used to calculate the draft penalties.

Vidant, for instance, says it lowered patient injury rates over the course of 2013, and Handron praises their efforts.

The sanctions, estimated to total $330 million over a year, kick in at a time when most infections measured in hospitals are on the decline, but still too common. In 2012, one out of every eight patients nationally suffered a potentially avoidable complication during a hospital stay, the government estimates. Even infections that are waning are not decreasing fast enough to meet targets set by the government. Meanwhile, new strains of antibiotic-resistant bacteria are making infections much harder to cure.

Clifford McDonald, a senior adviser at the federal Centers for Disease Control and Prevention, said the worst performers “still have a lot of room to move in a positive direction.”

Are The metrics right?

Medicare’s penalties are going to hit some types of hospitals harder than others, according to an analysis of the preliminary penalties conducted for Kaiser Health News by Ashish Jha, a professor at the Harvard School of Public Health. Publicly owned hospitals and those that treat large portions of low-income patients are more likely to be assessed penalties. So are large hospitals, hospitals in cities and those in the West and Northeast.

Preliminary penalties were assigned to more than a third of hospitals in Alaska, Colorado, Connecticut, the District of Columbia, Nevada, Oregon, Utah, Wisconsin and Wyoming, Medicare records show.

“We want hospitals focused on patient safety and we want them laser-focused on eliminating patient harm,” said Patrick Conway, chief medical officer of the Centers for Medicare & Medicaid Services.

The biggest impact may be on the nation’s major teaching hospitals: 54 percent were marked for preliminary penalties, Jha found. The reasons for such high rates of complications in these elite hospitals are being intensely debated.

Leah Binder, CEO of The Leapfrog Group, a patient-safety organization, said academic medical centers have such a diverse mix of specialists and competing priorities of research and training residents that safety is not always at the forefront. Nearly half of the teaching hospitals – 123 out of 266 in Jha’s analysis – had low enough rates to avoid penalties.

The government takes into account the size of the hospital, the location where the patient was treated and whether it is affiliated with a medical school when calculating infection rates. But the Association of American Medical Colleges and some experts question whether those measures are precise enough.

“Do we really believe that large academic medical centers are providing such drastically worse care, or is it that we just haven’t gotten our metrics right?” Jha said. “I suspect it’s the latter.”

Medicare assigned a preliminary penalty to Northwestern Memorial Hospital in Chicago, for instance, but Gary Noskin, the chief medical officer, said hospitals that are more vigilant in catching problems end up looking worse. “If you don’t look for the clot, you’re never going to find it,” he said.

Another concern is there may be little difference in the performance between hospitals that narrowly draw penalties and those that barely escape them. That is because the health law requires Medicare to punish the worst-performing quarter of the nation’s hospitals each year, even if they have been improving.

“Hospitals that have been working hard to reduce infections may end up in the penalty box,” said Nancy Foster, vice president for quality and public safety at the American Hospital Association.

Third leg Of Medicare’s pay-for-performance

The Hospital-Acquired Condition (HAC) Reduction Program, created by the 2010 health law, is the third of the federal health law’s major mandatory pay-for-performance programs for hospitals. The first levies penalties against hospitals with high readmission rates and the second awards bonuses or penalties based on two dozen quality measures. Both are in their second year. When all three programs are in place this fall, hospitals will be at risk of losing up to 5.4 percent of their Medicare payments.

In the first year of the HAC penalties, Medicare will look at three measures. One is the frequency of bloodstream infections in patients with catheters inserted into a major vein to deliver antibiotics, nutrients, chemotherapy or other treatments. The second is the rates of infections from catheters inserted into the bladder to drain urine. Both those assessments will be based on infections during 2012 and 2013.

Finally, Medicare will examine a variety of avoidable safety problems in patients that occurred from July 2011 through June 2013, including bedsores, hip fractures, blood clots and accidental lung punctures. Over the next few years, Medicare will also factor in surgical-site infections and infection rates from two germs that are resistant to antibiotic treatments: Clostridium difficile, known as C. diff, and Methicillin-resistant Staphylococcus aureus, known as MRSA.

Vidant is worse than average in catheter-associated urinary tract infections and serious complications from surgery in the latest statistics Medicare published on its Hospital Compare website. But in more recent data the medical center voluntarily reports on its website, the number of catheter and urinary tract infections dropped during 2013. Joan Wynn, Vidant Health’s chief quality and safety officer, said complications rates are dropping this year as well.

The prospect of penalties is “difficult when you know how much your performance is improved,” said Wynn. She said Vidant has taken many steps to reduce complications; added patients to internal committees; and now reveals on its website the number of infections, patient falls, medication errors and bed sores.

Vidant asked Handron, a retired nursing professor injured in 2009, to tell her experience to the trustees and make a video for the medical staff talking about it. She continues to advise the hospital.

“I know they’re going in the very right direction,” Handron said. “I would have absolutely zero concern about myself or a family member going to Vidant for anything now.”

Nationally, rates of some infections are decreasing. Catheter-related infections, for instance, dropped 44 percent between 2008 and 2012. Still, the CDC estimates that in 2011 about 648,000 patients – 1 in 25 – picked up an infection while in the hospital, and 75,000 died.

Rates of urinary tract infections have not dropped despite efforts. These infections are more likely the longer a line is left in, but sometimes they are not removed promptly out of convenience for the nurse or patient or due to institutional lethargy.

Swedish Medical Center in Seattle, which has higher urinary catheter infection rates than do most hospitals, has given nurses more authority to remove catheters so long as they follow guidelines for when removal is appropriate, said Michael Myint, Swedish’s vice president for quality and patient safety. “Historically, they would just wait for the physician’s order to come through,” he said.

Medicare has been pressuring hospitals for several years to lower rates of injuries to patients. In 2008, Medicare started refusing to reimburse hospitals for the extra cost of treating patients for avoidable complications. A subsequent study by Harvard researchers found no evidence that the change led to lower infection rates.

“With infections, we are moving in the right direction,” said Lisa McGiffert, who directs the patient-safety program at Consumers Union, “but I would not say we are anywhere near where we need to be.”

Patient advocates praise move

Patient advocates say the financial penalties are long overdue, given how little accountability there has been.

Gerald Guske discovered that in 2012, when he went into Martha Jefferson Hospital in Charlottesville, Va. for an artificial hip implant. Doctors later had to reopen the incision and wash out his implant. Guske, a retired electronic technician, was laid up for a month in a rehabilitation facility while strong antibiotics were pumped directly into a vein.

Martha Jefferson told Guske it had followed proper protocols. “Unfortunately, infection is a known risk of any surgery, and even when everything is performed correctly and conditions are ideal, they can occur,” the hospital wrote him afterward. “Infection does not necessarily indicate that something went wrong.”

Martha Jefferson Hospital said it could not discuss the case because of patient privacy laws. The hospital’s infection-control specialist, Keri Hall, said infection rates have been dropping and “we are every day doing what we can to hopefully bring our rates down to zero.”

Guske said he has fully recovered, “other than taking six weeks out of my life,” but he attributes the stress around his complications to a minor stroke his wife suffered. He said state regulators told him they could not take any action because the hospital followed proper procedures. The fear of a financial penalty against a hospital, Guske said, is “the only thing that’s really going to change matters.”

This story originally appeared in Kaiser Health News, an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente. This article was produced by Kaiser Health News with support from The SCAN Foundation.

Legislators Reconsider Who’s Eligible for the Death Penalty

By Jasmin Singh

People with intellectual disabilities who sit on death row may find their sentences commuted to life in prison as North Carolina looks to come in line with a recent Supreme Court decision.

Lawmakers in the House Judiciary Subcommittee C worked on a heavily amended bill on Wednesday that would change a number of judicial statutes. The bill previously only considered the issue of drug testing for welfare recipients, but appeared late Tuesday with a dozen additional sections dealing with justice issues.

execution chamber

Execution chamber. Photo credit: Wootom, flickr creative commons

One of those provisions included changes to the statute prohibiting the death penalty for people who are determined to be intellectually disabled.

The proposed bill is a response to the recent U.S. Supreme Court ruling Hall v. Florida, where the court determined it was unconstitutional to use an IQ test score of 70 or below to determine whether someone was intellectually disabled because it creates the possibility that a person with intellectual disabilities could be executed by mistake.

“This act conforms our state law to that ruling,” said Rep. Ted Davis (R-Wilmington), the bill’s primary sponsor.

The bill also adjusts the language in North Carolina statute to “intellectually disabled” instead of “mentally retarded,” which was the common usage in the past.

“The term ‘intellectual disability’ is compliant with current trends nationally, so I think it’s a good move,” said Rep. Jean Farmer-Butterfield (D-Wilson).

No bright line

“You can’t use a bright line [of] 70 for the IQ score,” said legislative staff attorney Hal Pell. “This ensures that the law and our statutes specifically reflect what the Supreme Court said in Hall v. Florida.”

Pell said a standard error of measurement of plus or minus five IQ points must be taken into account according to the Supreme Court.

Gerda Stein, director of public information for the Center For Death Penalty Litigation, said the Supreme Court ruling addresses the possibility of error in determining who might or might not be intellectually disabled.

Sometimes a defendant would go to court and their lawyer would argue that the defendant was intellectually unable to understand what was happening. Some judges would ignore arguments if the defendant’s IQ score was a point or two above 70, while other judges would give more leeway.

Stein said she believes there are at least three cases in which people lost their intellectual disability claims after nonclinical standards were used to assess the defendant’s disability.

“Hopefully, people can go back and re-litigate those conditions that the Supreme Court made clear,” she said.

Stein said 17 people have been taken off North Carolina’s death row since the enactment of the state’s current statute, passed in 2005, and also because of the Supreme Court decision.

Corye Dunn, an attorney and director of public policy for Disability Rights North Carolina, said an IQ test alone isn’t enough to determine disability.

“We need a more comprehensive medical evaluation of a whole person to understand whether they meet the criteria for being eligible for the death penalty, being able to understand what they did and also participate at their defense at the trial,” she said.

Dunn also said that anytime there is a Supreme Court ruling, it governs whether the state statute changes or not.

“Even if this [statute] didn’t pass, we would still need to comply with this ruling,” Dunn said. “But our judges might have less clear guidance about how to comply with the ruling.”

Both Stein and Dunn agree that the state is moving in the right direction.

“I think we’ve made a lot of progress,” Dunn said. “Everybody is working very hard to make sure the language truly complies with the Supreme Court ruling and also works with the context of our statutory framework.”

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