2018-19 TOW #23: Lipid screening

The topic of lipid screening and dyslipidemia treatment remains a controversial one in pediatrics! It depends on whether you are in the camp of not missing anyone who meets potential criteria for intervention vs emphasizing the potential harms of overtesting and overtreating: the age-old epidemiologic debate, not to mention a value-based care question. Nationally, variation in recommendations reflects this debate: the AAP has sided with universal screening, while others, including the US Preventive Services Task Force and the AAFP find insufficient evidence to recommend screening before age 20. Dr. Perri Klass summarized the debate in her NYT blog, quoting Dr. Fred Rivara, MD MPH about his statement against universal screening. The goal this week is to be familiar with some of the recs and the evidence to inform your understanding and decision-making.

Materials for this week:

Take-home points:

  1. Who should be recommended for lipid testing? It depends on if you follow targeted screening vs universal screening, or if you believe in no benefit of screening in childhood. The 2011 NHLBI guidelines recommend targeted screening for children 2-8 years old and adolescents 12-16 years old and universal screening for children 9-11 years old and adolescents 17-21 years old. The repeat is done at age 17-21 to assess after puberty which can alter levels. These same recommendations are endorsed by the AAP. In the targeted approach, screening is indicated in children or adolescents with a positive family history of dyslipidemia or premature cardiovascular disease (CVD) (including parent or 2nd degree relative <55 male, <65 female), an unknown family history, or children with other risk factors for CVD, like obesity, hypertension and diabetes.
  2. If you are screening, what tests would you do? In the NHLBI guidelines, the recommendation for universal screening was to use non-fasting lipids and calculate the non-HDL-C as follows: Non-HDL-C = total cholesterol (TC) – HDL-C. If the non-HDL-C was >=145, then do follow-up with fasting lipid panel. For targeted screening, the rec was getting an average of 2 sets of fasting lipid profiles (FLP) separated by 2 weeks to 3 months (as the individual levels can vary by up to 30mg/dl). Triglycerides (TG) are much more likely to be overestimated with non-fasting draw, but total and non-HDL levels are considered more reliable when non-fasting. All of this seems much more complicated, and in practice, most pediatricians may only obtain one measurement.
  3. What is the first-line treatment for elevated lipids? Initially, we recommend lifestyle intervention, including more fruits, vegetables, fish, wholegrains and low-fat dairy products, with reduced intake of fruit-juice, sugar-sweetened beverages and foods, and decreasing salt. We also recommend physical activity and losing weight, if appropriate. The fact that we essentially recommend this diet for all children is partly why many advocate not testing lipids because it does not change recs unless you have serious disease, which is rare. To treat overall elevated cholesterol or LDL, we focus more on dietary fat intake, but to treat elevated TG, we focus more on sugar and carbohydrate intake.
  4. If children have higher lipid levels that don’t respond to diet or have familiar hypercholesterolemia (FH), what is the treatment? There is more controversy here as well! The NHLBI guidelines do not recommend medication for children under 10 unless they have severe primary hyperlipidemia or a high-risk condition associated with serious morbidity. For children with FH, statin treatment in childhood is associated with improved carotid thickness. For children ≥10 years, starting a statin is recommended for those who have persistent elevated LDL (range from 130-190 based on family history and risk factors) after 6 months of lifestyle changes, with the goal of lowering LDL to below the 95th percentile (≤130 mg/dl). The safety of statins for long-term use has not been adequately studied for children, so we usually consult a specialist before starting statins. Routine monitoring for muscle and hepatic toxicity with CPK and transaminase levels would be done for patients on statins.
  5. When do we refer to a specialist and which one? Referral to a specialist has been recommended for those with LDL ≥250 mg/dl and TG ≥500 mg/dl even before a trial of lifestyle management, or when more than one lipid-lowering medication may be needed (such as a bile acid sequestrant or cholesterol absorption inhibitor). Around the country, different specialists manage lipids; in our region, the Endocrine Division runs the lipid clinic so patients would be referred to them when needed.

2018-19 TOW #17: Community Pediatrics

Some of the R2 are on the REACH Pathway month 1 this block, and it’s a great time to be inspired by many pediatricians in our midst taking leadership roles in advocacy. I’m honored to know some of them as friends from my own residency class (go R’06’s!), including Rupin Thakkar MD who is our current WCAAP president. Rupin recently gave a shout out to our Harborview pediatricians, Drs. Vai Pidaparti R2 and Beth Dawson-Hahn for their immigrant health toolkit. Beth will be giving noon conference this week on her outstanding work advocating for immigrant children. I could highlight hundreds (likely thousands) of examples of pediatricians in our area who have made significant contributions through advocacy.

Materials for this week:

Take-home points for this week:

  1. What are some of the social and environmental needs our patients face that can affect their care? Many children being cared for in community-based pediatric settings, including our residency clinics, face numerous social needs that affect their health: food insecurity, poor housing, parent substance use or mental illness, family violence, and unsafe neighborhoods. Most of these have now been characterized as Adverse Childhood Experiences (ACEs) and are associated with developing toxic levels of stress that can impact long-term health. There is evidence that when we address these needs by helping parents and families, children fare far better over the lifetime.
  2. How do we prioritize addressing these needs? Henize et al. propose that one way to prioritize these is using the Maslow Hierarchy of Needs, i.e., addressing the most basic needs should be the focus before ones higher up on the pyramid. First are Physiologic needs for food and housing, then Safety from violence and mental health problems, then Love/Belonging, with children supported by loving parents who have community support, then Esteem and Respect, with education and employment, and finally, as these other needs met can come Self-Actualization or Achieving One’s Potential. Another helpful way to think about needs is the IHELLP mnemonic: Income, Housing, Education, Legal, Literacy and Personal Safety.
  3. Where do we find the community resources? Bright Futures divides potential community resources among 4 major categories that we should access for our patients: health, development, family support, and adult assistance. In our area two key ways to find needed assistance is through Within Reach and Washington State 2-1-1. Dr. Abby Grant, one of the former REACH residents and now REACH faculty and pediatrician at Harborview prepared this amazing list of community resources for our area.
  4. What are some of the recommended skills for engaging as pediatricians serving the community? The AAP policy statement defines some key skills: 1) working effectively in interdisciplinary settings, 2) partnering with public health, community organizations, and child welfare agencies, 3) recognizing root sources of health and pathology from children’s social, economic, physical, and educational environments, and 4) advocating on multiple levels including at the local, state, and national levels.
  5. If collaboration and partnerships are key to addressing social determinants of health, how do we do this? Henize and colleagues outlined a set of steps: 1) build a case through family-centered needs assessment, 2) organize and prioritize appropriate interventions, 3) work with key community partners to build and sustain interventions, and 4) operationalize interventions in the clinical setting. If you want to learn more about becoming an advocate, the AAP Committee on Community Pediatrics has advocacy training modules available.

Borrowing a line from Hamilton… Look around, look around, at how lucky we are to be alive right now… in our field of pediatrics and surrounded by these inspiring colleagues doing amazing work. I’m glad we have each other for the work that’s still ahead.

2018-19 TOW #2: Coding and Billing

Billing is such an exciting topic (said no one ever!), but it is a fact of life in our health care system, and oh so necessary to understand. Our Roosevelt crew has talked about the need to review this topic, so by semi-popular demand, here it is!

Materials for this week:

Key points:

  1. Why do we need to learn billing and coding? We will probably all be using E/M coding (Evaluation and Management) for the rest of our careers. Incorrect billing is considered fraud, and we have to be aware of the laws in order to do it accurately. UW faculty are required to update our billing compliance training annually to document we understand and are doing it appropriately. Best to learn it and do it right from the get-go.
  2. What are CPT codes? Current Procedural Terminology (CPT) codes or “procedure codes,” are published by the AMA to cover the services and procedures clinicians perform. They capture the human resources (time and cognitive effort) used to provide care and serve as the foundation for reimbursements. For office visits, two general features decide the type of code selected: 1) new vs. established patient, and 2) problem-oriented vs. preventive visit. There are also codes for immunizations and other common office procedures, (e.g., wart treatment, dental screening and fluoride varnish, etc).
  3. What is ICD-10? These are the “Diagnosis codes.” ICD-10 stands for International Classification of Diseases, Tenth Revision, Clinical Modification. The ICD was originally developed as a statistical tool for tracking diseases and trends worldwide. ICD-9 was published in 1978 by the World Health Organization, and used in the US for decades. ICD-10, developed in 1993, uses more codes to increase specificity and was adopted in most of the world before the US implemented it October 2015. We are supposed to be as specific as we can with ICD-10 and to use diagnoses rather than symptoms as often as possible (e.g., “strep pharyngitis” is preferred to “sore throat”).
  4. Do we ever combine preventive and problem-focused codes? Yes, BOTH can be coded when two or more types of E/M services are provided in the same visit. This requires use of a “modifier” – we use “Modifier 25” in primary care. When we see patients for well visits and also address their asthma or treat an ear infection, for example, we can use the CPT codes for “Preventive care, established patient and also add 99212- 99215 (as appropriate). We would include ICD-10-CM codes for both “well child” and the acute condition. Note: some offices have contracted not to use these modifiers because extra charges are incurred for patients; ask your clinic leadership when this is appropriate to use.
  5. What are the main CPT codes for problem-oriented visits? These are 99212-99215 depending on complexity and/or time. 99212 is ~10 minutes, very minor (rarely used), 99213 is ~15 minute visit and is our straightforward acute visit. The 99214 code is for ~25 minutes with more complexity (including prescriptions, referrals, medical decision making, etc.), and 99215 is ~40 minutes for complex visits (residents rarely bill this unless the faculty member has taken substantial time with the patient). Each of these comes with requirements for documentation, thus our EMR templates include appropriate documentation prompts such as for ROS.
  6. When is a patient “new”? This can be confusing. Technically, patients are new to us if our clinical system has not previously seen them for at least 3 years. A baby born in the nursery at UWMC will NOT be new to a clinic if they come to a UWMC-affiliated clinic (like Roosevelt and Harborview,) but they will be new to us if they were born at Northwest Hospital, which has a separate tax ID (ask your clinic manager if you are unsure). If a patient has not been to clinic in 3 years, they would be considered a new patient when we see them.
  7. Why do we need the billing modifier for faculty? This is explained in more detail here but basically, faculty have to attest to providing care with a resident by adding a “GC modifier” or a “GE modifier.” GC indicates teaching physician presence: “This service has been performed in part by a resident under the direction of a teaching physician.” GE indicates that the primary care exemption rule has been used to allow residents to see patients independently in primary care. This can be used for well visits and for acute visits up to a “level 3” (the 99213 code), but cannot be used for level 4 (99214) – faculty must see these patients. All interns must have attendings see their patients for the first 6 months of training.