TOW #15: Antibiotic use in primary care

School is in full swing, and we have the first cold of the season at our house. As we get flu vaccines in preparation for viral season, it's time to think about antibiotic use and stewardship in primary care setting. Our amazing general pediatrics and hospital medicine chair, Dr. Rita Mangione-Smith MD MPH, has been a lead researcher in informing this topic.

Materials for this week:

Take-home points:

  1. How often are antibiotics prescribed? More than 1 in 5 ambulatory visits for children results in antibiotic prescription. Studies have shown up to 1/3 of patients diagnosed with a common cold receive an antibiotic prescription. This increases up to 60% among patients presenting with bronchitis and other viral illnesses.
  2. What are some harms of antibiotic use from both an individual and a community-based standpoint? Individual harm includes diarrhea, upset stomach, adverse drug reactions, higher rates of resistant bacteria, and harmful changes to the gut microbiome. From a society standpoint, unnecessary antibiotic use contributes to excess health care costs and promotes antibiotic resistance.
  3. What situations trigger physicians to prescribe antibiotics for respiratory infections? Dr. Mangione-Smith and team found physicians were more likely to prescribe antibiotics for children with a cold if 1) they perceived the parent or patient expects it, 2) there is parental anxiety about the child’s illness before the visit, 3) they reported wheezing or rhonchi on exam, and 4) parents had very low SES (perhaps MDs believe it is faster to give ABX than explain what to do instead). Other studies have also found we prescribe more in visits that occur later in the day (consistent with decision fatigue).
  4. What are the principles of responsible antibiotic prescribing? 1) Determine the likelihood of a bacterial infection-use diagnostic criteria and guidelines, as well as tests to determine pre-test probability when possible, such as Centor criteria for sore throat and strep infection; 2) Weigh benefits and risks of ABX treatment to determine whether they should be given, and 3) Use judicious prescribing strategies (i.e., the most narrow-spectrum and effective antibiotic for the appropriate duration – this might include a watch and wait approach, if appropriate).
  5. What methods can we use to counsel family members about antibiotics? As per Dr. Mangione-Smith's research, we are likely to get more questioning of the treatment if we specifically say "antibiotics are not needed" when we summarize the treatment plan, rather than focusing on positive, supportive treatment that parents can implement. When parents suggest a "candidate diagnosis" that might require antibiotics, like ear infection, sinusitis, or pneumonia, we should explain how we will determine the diagnosis based on the exam. Other strategies we can use: align with parents on goals of helping the child get well as quickly and safely as possible, legitimize symptoms and concerns for bringing the child in, and address parent anxiety.

TOW #14: Bone health

While it's been nice and sunny this week, we are heading into the seasons with less of it, so a good time to review optimizing bone health for children. The AAP updated the statement in 2014 about this topic with newer (and higher) RDA levels for vitamin D established for infants and children, due in part to no "safe" sun exposure being considered optimal to recommend.

Materials for this week:

Take-home points:

  1. What are the optimum levels for intake of calcium and vitamin D? Calcium level RDAs increase with age: 700mg for 1-3 yo, 1000 mg for 4-8 yo, and 1300mg for 9-18. Recommended daily vitamin D for children: 400 IU 0-12 months, 600 IU >1 year.
  2. Why are we concerned about these nutrients? In addition to rickets, low Vit D and calcium intake is linked to increased fractures later in childhood/adolescence (and adulthood). Despite the many studies linking low vit D to a host of other conditions, we do not have reliable evidence that they are in fact causally linked.
  3. Who is at highest risk for low levels? Children at higher risk for low vit D include youth with darker pigmented skin, overweight youth, inadequate dietary intake, living in northern latitudes (>33 degrees -that’s us!), taking certain medications (anticonvulsants, steroids, antiretrovirals). Those at high risk for low bone density include children who do not do bone-density strengthening exercise, particularly children who require wheelchairs.
  4. Who should be screened with blood tests? Testing for Vit D levels is not routinely indicated; AAP recommends* only for conditions associated with reduced bone mass (malabsorption syndromes, CP, or on medications that interfere with absorption), or recurrent low-impact fractures. (*note Endocrine society also recommends for children with dark skin or with obesity)
  5. When should we recommend supplements? It's better to receive Vit D and calcium in dietary sources, but there are few sources of vit D in the diet: mainly fortified milk (and some orange juice and yogurts). Supplements are indicated for breastfed babies (until drinking at least 1L per day of fortified formula/milk) and those with low dietary sources or high risk for low bone density. Among children who do not drink much milk (including one of my own), I recommend a multi-vitamin supplement with calcium and vitamin D.

TOW #13: Billing and coding

Oh, billing is such an exciting topic (said no one ever), but it is a fact of life in our system, and oh so necessary to understand. Our Harborview 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 many 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 (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.
  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, 99214 is ~25 minutes with more complexity (including prescriptions, referrals, medical decision making, etc.), and 99215 ~40 minutes for complex visits (residents rarely bill this unless the faculty member has taken this much 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. So, a baby born in the nursery at UW will NOT be new to a clinic if they come to a UW-affiliated clinic. However, 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. 
     

TOW #12: Autism

The emergence of autism spectrum disorder (ASD) is among the most important issues we have seen in pediatrics in the past few decades. Fortunately, wonderful advocacy and investment has helped grow our evolving understanding of the many facets of autism including risk factors, diagnosis and treatment. And, we have much yet to learn.

Materials:

Take-home points:

  • What are the criteria for diagnosing autism? The DSM criteria were revised for DSM-5 and include 2 major categories of symptoms: 1) persistent deficits in social communication and social interaction across multiple contexts, and 2) restricted, repetitive patterns of behavior, interests, or activities. These symptoms must be present in the early developmental period, cause clinically significant impairment, and not be better explained by intellectual disability or global developmental delay. Symptoms are also classified for severity and accompanying intellectual impairment(s).
  • How prevalent is ASD? Prevalence has increased in recent decades with a 2012 CDC prevalence study reporting it to be as high as 1 in 88 in certain areas, and as many as 1 in 54 among boys. The increase in prevalence is due to multiple factors including greater awareness, earlier diagnosis, diagnostic substitution due to the ability to qualify for more services with autism, and broader diagnostic criteria.
  • When should we screen? The AAP recommends formally screening for autism using a tool such as the M-CHAT at 18 and 24 month visits. Reimbursement for screening can be obtained using CPT codes 96110 (Developmental Testing, Limited). We can also begin to screen prior to that, as highlighted by the clinical probes in the Pediatrics in Review article.
  • How should we screen? The M-CHAT-R/F was a revision with a 2-stage screening process to decrease false positives. Low-risk is a score 0-2. Medium risk is 3-7, and high risk is >=8 among the first set of 20 questions. Refer high risk children, and use the follow-ups questions for the medium risk group. If children continue to be >=2 after follow-up questions, they should be referred – they are likely to have ASD (~50%) or a developmental disorder (95%). Using the follow-up questions, the screener is 85% sensitive and 99% specific for ASD.  
  • What resources are available locally? Children under 3 should also be referred to the Birth-to-Three resources while awaiting formal diagnostic evaluation through UW or SCH. We have an impressive local (and very busy) Autism Center at Seattle Children’s. In addition to the clinical resources, the Center hosts a series of free lectures for families and caregivers and a blog. Nationally, the Autism Speaks website has many great resources for families as well.

TOW #11: Scoliosis

Next week is back to school for Seattle schools, so a signal to consider diagnoses that may impact youth in the school setting. Scoliosis (and related conditions) can affect athletics and should be screened for in sports physicals.

Materials for this week:

Take-home points for scoliosis

  1. Epidemiology: Scoliosis is the most common abnormality of the spine. Idiopathic scoliosis is present in 2% of adolescents. There is a genetic basis with first-degree relatives at increased risk (10% prevalence). In about 1/5 of cases, children have either vertebrae that do not develop normally (congenital scoli), an underlying problem in the brain or spinal cord, such as a cyst or a tumor, or a neuromuscular disorder such as cerebral palsy or muscular dystrophy.
  2. Definition: Scoliosis is defined as a lateral curvature of the spine that is 10 degrees or greater on a coronal radiographic image while the patient is in a standing position.
  3. Types: Most cases are idiopathic and defined by age at recognized onset: before age 3 (infantile), age 3-10 (juvenile) and older than 10 (adolescent). There are also congenital forms due to malformations of the spine in utero that progress with age, and neuromuscular scoliosis associated with neuromuscular diseases.
  4. Work-up: Classic findings of scoliosis on examination are shoulder and scapular asymmetry and rib prominence on forward flexion. Use physical exam to help rule out hereditary connective-tissue disorders (e.g., Marfan’s syndrome), neurofibromatosis, or neurologic conditions. Obtain spinal radiography in standing position.
  5. Treatment: Most adolescents can be monitored in primary care. If >25% curvature, may consider bracing but data not conclusive (an RCT is underway). If >45% curvature, surgery is recommended.