Friday, May 24, 2019

Kentucky dropped one spot in latest America's Health Rankings Report for seniors, to 49th; ranked last in health outcomes

By Melissa Patrick
Kentucky Health News

A new report shows that Kentucky continues to be one of the worst states in which to grow old, which isn't great news for the one in six Kentuckians who are already over the age of 65 and the growing number of Baby Boomers who will soon fall into that category.

Kentucky ranks 49th for seniors' health in the most recent America's Health Rankings Report, down one slot from last year. Mississippi is the only state ranked worse. Kentucky has been in the bottom 10 states for senior health since 2013, the first year AHR did the report.

The report looked at 34 measures of senior health that are known to influence health, which were then broken into five categories.

Kentucky ranked in the bottom 10 states in four of the five main categories, 49th for behaviors; 47th for community and environment; 44th for clinical care; and 50th for health outcomes.

Its highest ranking was for senior health policies, 32nd. This ranking was largely driven by positive scores in two categories, one that shows Kentucky has a low percentage of seniors living in nursing homes who require a low level of care, 7.4%; and another that shows the state has a high percentage of seniors with prescription drug coverage, 87%.

Other good news is that only 5.5% of Kentucky seniors are heavy drinkers, though it was 4% three years ago. The state also has a high percentage of seniors who are managing their diabetes, 81.6%.

This year, the report also looked at how many seniors had avoided care due to cost. It found that in Kentucky, 7% of seniors said there was a time in the past year when they needed to see a doctor, but could not because of cost. Nationally, that rate was 5.2%.

It also took a national look at young seniors, between the ages of 65 and 74, and found that compared with 15 years ago, smoking rates are 16% lower, early deaths are 22% lower and those reporting they are in better health is 11% higher. However, the report also found excessive drinking in this age-group is 42% higher, obesity is 36% higher, diabetes is 36% higher and suicide rates are 16% higher.

Ongoing challenges in Kentucky

The report says its purpose is to promote data-driven discussions that can drive positive changes and improve the health of seniors -- and most of Kentucky's data shows a lot of room for improvement.

Kentucky seniors rank No. 2 in smoking, at 12.5%. The report notes that it's never too late to stop smoking, and that even in older adults it has been shown to improve health outcomes.

Kentucky also ranks in the bottom five states for several other measures.

It ranks 47th for physical inactivity, with 36% of the state's seniors reporting they were inactive. Overall, the report found that females are 1.2 times more likely than males to be inactive.

It also ranks 47th for community support expenditures, which are used for funding personal care, meals, transportation and nutrition-education programs for seniors, at $225 dollars per adult aged 60 and older in poverty, compared with the average of $571 dollars for all states.

Kentucky ranked 46th for home-delivered meals to seniors, delivering meals to only 4.9% of its seniors aged 60 and older who have difficulty living independently. The national average for this measure is 8.9%, and the top ranked state for this measure, New Hampshire, delivers meals to 37.5% of seniors in need.

Kentucky ranks as the worst state for its high number of preventable hospitalizations, at 76.6 discharges per 1,000 Medicare enrollees. The national average for this measure is 49.4.

They are also more likely to die early. The report found 2,369 deaths per 100,000 adults aged 65 to 74 in Kentucky, compared to 1,791 nationwide.

Kentucky seniors also suffer from more mental distress than seniors in other states, 10%, compared to 7.9% nationwide.

The state's seniors also rank last among states for volunteerism by seniors, with only 18.9% volunteering, and nearly last, 48th, for the number of seniors reporting high health status, 31.7%. The national average for these measures are 28% and 41.3% respectively.

Chronic disease can lead to mental-health issues, especially among seniors in isolated rural areas like Casey County

"Rural America has some of the highest rates of chronic disease in the nation – the more remote a community, the more heart disease, cancer and diabetes. And there’s a side effect from having a chronic condition many people don’t think about – depression, anxiety and even suicide," Lisa Gillespie reports for Louisville's WFPL. "This is especially true for older adults, who’ve lived their entire lives in places with little access to places to exercise, with diets high in fat and sugar and in a culture that still hasn’t given up tobacco."

Dennis and Gay Pond (WFPL photo)
Gillespie's example is Dennis Pond, 67, of Casey County. "He often feels useless, in large part because his diabetes has caused terrible pain and numbness in his feet, and that affects his ability to drive, to help out around the house, to even go out in the yard," she reports, quoting him: “The pain gets so bad that I actually feel like cutting my feet off or just taking care of myself, if you know what I mean Ending it.” But he doesn't tell his psychiatrist about such thoughts: “When they ask me those questions, I got to try to watch what I’m saying because if I don’t I’ll end up in the psychiatric unit,” he said. “I try to say no, but I have thoughts.”

"His dark thoughts are in part an outgrowth of the toll chronic conditions have taken on him. Every day, he takes blood thinners for blood clots in his lungs, pain medication for his bad back, insulin for his diabetes," Gillespie reports. "Then there’s the nerve damage from his diabetes – what he describes as thousands of needles piercing the bottoms of his feet when he walks."

Pond lives 30 miles from the nearest town and hospital, Gillespie reports, adding, "Rural residents often have a hard time accessing medical care for their chronic conditions and psychiatric care for the attendant mental health issues. That contributes to the increased risk of suicide in rural areas, which are already at higher risk because of a lagging economy and substance abuse. For example, "suicide rates in 2017 were 30 percent higher in Appalachia than in the rest of the country." Within the region, suicides were concentrated in Eastern Kentucky, West Virginia and East Tennessee, areas that struggle with high opioid-addiction rates and poverty.

Gina Piane, a professor at National University in San Diego, was one of the first researchers to link chronic disease and mental health. Giving rural youth more health and nutrition education is a key way to prevent such issues, she told Gillespie.

Psychologist John Fulton, who works in Casey County, said he tries to teach his patients coping skills and recommends that they develop a support system of friends and family if they don't already have one. "I try to say, you know, you’re sitting there focusing on the bad things, and all that’s going to do is drag you down deeper,” Fulton told Gillespie. "[I] try to get them to, you know, turn around and start thinking about, 'Well, I’ll go outside and look at dogs or I’ll watch wrestling on TV' — get their mind off the illness and how bad they feel."

"Fulton also recommends people try to develop a strong support system if they don’t already have one. That’s something Pond does have in his wife, Gay. They married in 2013 after he did work on her house," Gillespie writes. "And there might be hope for Dennis’ pain and diabetes. He’s likely going to get surgery that could increase blood flow in his feet, helping avoid an amputation."

Thursday, May 23, 2019

Kentucky schools lack immunization certificates for thousands of children, worry about immuno-compromised students and staff

American Academy of Family Physicians photo
A Louisville Courier Journal analysis found that as of March, the Jefferson County Public Schools had no record of whether 4,300 students had received their shots for measles, mumps and rubella, despite a law that requires students to hand in those documents within two weeks of enrollment.

That's a story that can be told in school districts across the state.

According to the state Department of Education, in the 2017-18 school year, of the 99,113 first and sixth graders who were supposed to have immunization certificates, 7,738 of them had expired certificates, 5,993 were missing, 241 had medical exemptions and 695 had religious exemptions.

The KDE data is broken down by school and grade to show how many students have a current immunization certificate, including whether it is a provisional, standard, medical or religious certificate. The data are not broken down by type of vaccination, and current-year data aren't posted.

Jefferson County school officials told the Courier Journal that many students may have simply not turned in their immunization documents, but they worry about those who haven't been vaccinated.

"We're putting immuno-compromised children, children too young to get immunized — and pregnant teachers and pregnant moms at risk," Troi Cunningham, an immunization nurse with the state, told reporter Allison Ross about the low immunization rates in some areas.

Public health officials say about 95% of students need to be fully immunized in order to protect vulnerable kids and others who are immuno-suppressed from measles, which is highly contagious.

Jefferson County data shows that it's not just the measles, Ross reports; some schools are also missing immunization records for other diseases, like chickenpox and hepatitis A.

It's a challenge to know what to do when students don't turn in their immunization documentation, Dr. Ruth Carrico, an infectious-disease expert at the University of Louisville, told Ross.

"What do we do when a child is not vaccinated? Where do they go?"she asked. "If they get sent home, they miss out on education. If we don't send them home, they may not realize we really mean it that you need that vaccination."

Earlier this year, the Northern Kentucky Health Department barred students who had not been vaccinated against the chickenpox from attending school and all extracurricular activities at a private Catholic school because of an outbreak. One of the students sued the health department over the ban, but the courts ruled in the health department's favor.

Eva Stone, district health coordinator for JCPS, told Ross there are several obstacles to getting children immunized, including a lack of access to medical care; that very few health-care providers will give vaccines to children on Medicaid, which forces parents to take their children somewhere else, like the local health department; and that parents have told her that doctor's offices charge for copies of updated immunization records.

"This is a community issue," Stone said. "How do we make sure children have access to health care?"

Cunningham, the nurse with the health cabinet, told Ross that the state is trying to encourage pediatricians and other health-care providers to use the state's immunization registry to keep track of patients' vaccinations.

Bevin and Trump agencies argue work requirements in other public-assistance programs pave the way for likewise in Medicaid

The administrations of President Trump and Gov. Matt Bevin argue that Kentucky's proposed Medicaid program, which includes work and other "community engagement" requirements, should be upheld because the new rules would be no different than what is already required of people who receive federally funded food assistance, Darla Carter reports for Insider Louisville.

In briefs filed last week with the U.S. Court of Appeals for the District of Columbia, they maintain that Health and Human Services Secretary Alex Azar used proper judgment to approve the state’s new Medicaid plan, which called for a waiver of the traditional Medicaid rules to require some "able-bodied," non-elderly Medicaid recipients to work or participate in a list of approved community engagement activities 20 hours a week to get their health benefits.

The official name for the state's new Medicaid plan under the Section 1115 waiver is Kentucky HEALTH, for "Helping to Engage and Achieve Long Term Health." The administrations liken the work rules to those already in use by food-aid programs such as the Supplemental Nutrition Assistance Program, formerly food stamps, and Temporary Assistance for Needy Families (TANF), generally known as "welfare."

“There is no reason why a Section 1115 waiver cannot test a community-engagement program in Medicaid, given that SNAP and TANF already have work-oriented programs,” the state argues in its brief. “Surely Section 1115 allows the secretary to test whether long-standing work-oriented programs from other public-assistance programs will work in Medicaid."

Carter reports in detail about the brief, which is part of an appeal from the March decision by District Judge James Boasberg that stopped similar plans proposed by Kentucky and Arkansas. This was the second time that Boasberg had vacated the federally approved plan and sent it back to the Department of Health and Human Services for further review. He said both times that HHS had not sufficiently considered the state's projection that its Medicaid rolls would have 95,000 fewer people in five years with the rules than without them, in large measure for failing to follow the rules.

The state takes issue with Boasberg's criticism that Azar failed to estimate the number of Medicaid recipients who would shift to other coverage because of Kentucky HEALTH, saying Azar is not required to know results in advance because that would defeat the purpose of the demonstration.

The new filing argues that Boasberg "was influenced by portrayals of the food-aid work requirements being counterproductive to low-income people, making him skeptical that a demonstration project like Kentucky HEALTH could lead to employment," but Congress disagrees, Carter reports.

The Kentucky Center for Economic Policy and Kentucky Voices for Health have reported that since last year, about 21,400 people have lost their SNAP benefits because of a work requirement in Kentucky.

Samuel Brooke, a deputy legal director at the Southern Poverty Law Center, which represented the 16 Kentucky Medicaid recipients who filed suit against Bevin's plan, said May 22: “When the waiver briefly went into effect in Arkansas, everyone saw the devastating effect it could have – thousands lost coverage in a matter of months. We are confident the appeals courts will similarly agree with the district court that the Medicaid program is designed to provide access to health care, and efforts to undercut that are contrary to Congress’s intent.”

In addition to arguing that Azar was within the scope of what is allowed and that his rationale was "careful and well-reasoned," the state says he was right in concluding that Kentucky HEALTH is likely to help sustain the state’s Medicaid program. Bevin issued an executive order last year that ends the expansion of Medicaid to people who earn up to 138% of the federal poverty line six months after any final court decision that blocks his plan.

Wednesday, May 22, 2019

Ky. has new tool to track the ongoing changes to its Medicaid program, including county-by-county enrollment numbers

Kentucky has a new website that shows an up-to-date timeline of all the changes in the state's Medicaid program since 2014; provides links to Medicaid resources such as contracts, court documents, state notices and research; and provides a place for people to share stories about how changes to the program have affected them or their loved ones. It also provides Kentucky-specific Medicaid data, including county-by-county enrollment.
Screenshot showing example of looking up county-by-county data on the Kentucky Medicaid Tracker
The Kentucky Medicaid Tracker is a combined project of the Kentucky Center for Economic Policy, the Kentucky Equal Justice Center and Kentucky Voices for Health.

Each of these nonprofit organizations are part of InsureKY, which describes itself as a statewide coalition of nonprofits formed to promote more affordable insurance, better care and stronger consumer protections for all Kentuckians. They support the 2014 expansion of Medicaid.

Kentucky Medicaid has seen many changes since then-Gov. Steve Beshear announced in 2013 that the state would  expand Medicaid to Kentuckians with household income up to 138% of the federal poverty line, under the 2010 Patient Protection and Affordable Care Act. Prior to the expansion, the program was limited mainly to very poor pregnant women and children, disabled people and low-income elderly in nursing homes.

Since its implementation in 2014, about half a million Kentuckians have been added to the Medicaid rolls, most of them working.

Under Republican Gov. Matt Bevin, the state asked for a waiver of federal Medicaid rules to make changes that included, among other things, work and other "community engagement" requirements for most of the "able-bodied" individuals who gained coverage through the expansion. InsureKy has strongly opposed these changes, mainly on grounds that they would create barriers to care.

The latest entry on the timeline notes that a federal judge once again blocked Bevin's proposed changes. His administration and that of President Donald Trump have appealed the ruling. The judge struck down a similar program in Arkansas at the same hearing.

Monday, May 20, 2019

McConnell files bill to raise legal age to buy tobacco products to 21, with some provisions Kentucky health advocates wanted

By Melissa Patrick and Al Cross
Kentucky Health News

Senate Majority Leader Mitch McConnell today introduced his promised bill to raise to 21 from 18 the legal age to buy tobacco products in the United States, in response to what he called a public-health epidemic of electronic-cigarette use by teenagers.

Senate Majority Leader Mitch McConnell talks tobacco.
"Youth vaping is a public health crisis," McConnell said during a floor speech to introduce the bill. "It's our responsibility as parents and public servants to do everything we can to keep these harmful products out of high schools and out of youth culture. We need to put the national age of purchase at 21."

Most adults who smoke start before they turn 21, so increasing the tobacco age to 21 will keep youth from starting, save lives and improve public health, says the Institute of Medicine. McConnell said he would make enacting the bill one of his highest priorities.

McConnell's co-sponsor is Sen. Tim Kaine, D-Va. "As senators from two states with a long history of tobacco production and consumption, [they] have seen this phenomenon firsthand, and heard the compelling stories from concerned constituents throughout their states," said a short explanation of the bill and the reasons for it. The bill is called the Tobacco-Free Youth Act.

McConnell gave a detailed history of how tobacco helped shape the nation and Kentucky. He said the state had almost 30,000 tobacco farmers when he helped end the federal tobacco program in 2004, but now has only 2,600.

"For many in Kentucky, tobacco made the American dream possible," he said, but also talked about the negative impact tobacco has had on Kentuckians' health. The state leads the nation in cancer and the percentage of cancers tied directly to smoking. "Our state once grew tobacco like none other — and now we’re being hit by the health consequences of tobacco use like none other," he said. "We’re proud of our past, we’re proud of who we are, but Kentucky farmers don’t want their children to get hooked on tobacco products while they’re in middle school or high school anymore than any parent anywhere wants that to happen. . . . The health of our children, literally, is at stake.”

According to the Kentucky Incentives for Prevention survey, teen use of electronic cigarettes in Kentucky nearly doubled from 2016 to 2018. The survey found that 26.7% of the state's high-school seniors reported using e-cigarettes in the 30 days before they were surveyed in 2018, up from 12.2% in 2016. Among 10th graders, it increased to 23.2% from 11.3%; eighth graders jumped to 14.2% from 7.3%; and sixth-grader use increased to 4.2% from 2.3%.

McConnell pointed to a nationwide survey that found the use of tobacco products increased by nearly 40% between 2017 and 2018, driven almost entirely by vaping. "The brain is still developing at this young age. When teenagers use tobacco, they're quite literally altering their brain chemistry and making it more susceptible to addiction," he said.

Enforcement is up to the states

Federal law does not establish a penalty for violating the current age limit of 18, but leaves enforcement up to the states and makes certain federal grants dependent upon enforcement.The McConnell-Kaine bill would leave that system in place. Laws in Kentucky and many other states have penalties for under-age youth who buy, possess or use tobacco products.

Advocates will have to work with state legislators to remove those laws, said Bonnie Hackbarth, vice president for communications at the Foundation for a Healthy Kentucky, which has endorsed McConnell's bill.

"Our interest was to make sure that there was nothing in the federal bill to impose penalties on the actual purchaser, but to rather put those penalties on the retailers where they should be and that is the way the bill is written," Hackbarth said. "That would be our goal, that the penalties would be on retailers and not the purchasers."

Foundation President and CEO Ben Chandler said in a news release, “Since Sen. McConnell stood in our offices just last month and announced plans to file this bill, new data has come out showing that youth e-cigarette use in Kentucky doubled over the past two years. We’re gratified that the provisions we sought to help reduce this explosion in youth vaping and other tobacco use have been included in the bill: It covers all tobacco products, including e-cigarettes as well as heated products; it prohibits sales to everyone under age 21, with no military exemption; it puts responsibility for compliance where it should be – on retailers, and it preserves the right of states to enact stricter laws.”

Chandler added, “We urge Congress to pass this bipartisan bill quickly and states to begin getting their own T21 bills in order. Every extra day it takes to put this important legislation into effect is an opportunity for thousands more kids to access a tobacco product that can damage their developing brains now and cause debilitating health issues throughout their lives.”

The bill has already received the support of several organizations, but others are being more cautious before they give it their approval.

"Increasing the minimum sale age for all tobacco products to 21 offers a common-sense way to keep harmful tobacco products out of reach of our kids and prevent life-long addictions to nicotine," Dr. Terry Brooks, executive director of Kentucky Youth Advocates, said in a release. "We urge Congress to support this bipartisan bill and for our leaders in Frankfort to begin work aligning state law to protect more youth from the lasting harms of tobacco use."

Some advocates want more

The American Lung Association also supports the bill, though it calls for more action, including a ban on flavored tobacco products, restricting online sales of the products and increasing funding for the Centers for Disease Control and Prevention's Office on Smoking and Health.

The Campaign for Tobacco-Free Kids said it was still evaluating the bill to make sure it is strong enough, including strong enforcement penalties on retailers, no exemptions and no "special interest provisions that block other policies needed to protect kids and public health, such as prohibitions on flavored tobacco products."

With the support of McConnell and Kaine, the bill is expected to have little trouble in the Senate, but its House prospects "are unclear," The Wall Street Journal reports. "House Democratic aides said they are still reviewing it, though they pointed to more expansive legislation introduced in the House that would also restrict flavored e-cigarettes and regulate marketing to young people, among other measures, in addition to raising the age for purchasing tobacco. Legislation that takes similar measures—but doesn’t raise the purchasing age—has received bipartisan support in the Senate."

McConnell's bill addresses some of the advocates' concerns. It does not exempt people in the military, as he originally said it would, and it would allow states to pass stronger tobacco laws.

McConnell told Deborah Yetter of the Louisville Courier Journal that he was aware of health advocates' concerns that tobacco companies support the legislation only because it could shield them from more aggressive enforcement and a possible ban on flavorings.

"Just the fact that they're for it doesn't mean it's a bad idea," he said. "This is just a floor, not a ceiling. I don't think it relieves them of any of the battles they're going to have to fight at the state and local levels in the future."

A bill to raise the legal age to buy tobacco products in Kentucky failed in the last session of the legislature, after opponents said it would hurt the tobacco industry. The bill, and similar legislation passed in Virginia and 13 other states, is backed by Virginia-based Altria Group, the nation's largest cigarette maker. Altria recently bought 35% of Juul Labs, maker of the most popular e-cigarette.

Friday, May 17, 2019

Study suggests kids with hypertension more likely to have heart disease as adults; Ky. teens 3rd in U.S. in top risk factor, obesity photo
By Melissa Patrick
Kentucky Health News

Just like adults, children can have high blood pressure. The only way to know is to check for it, and it's important because children with hypertension are more likely to grow up to be adults with heart disease -- the number one killer of adults in Kentucky. And in the biggest risk factor for heart disease, obesity, Kentucky high-school students are the third most likely in the U.S. to be obese.

"Children don't have a lot of symptoms with high blood pressure, so we don't know they have it until we check," said Dr. Donna Grigsby, chief of general pediatrics at UK HealthCare. " If they don't get it under control when they are young it's likely to persist into adulthood. . . . There are a lot of long-lasting consequences to living with high blood pressure that is not well-managed."

Untreated hypertension in adults can lead to heart disease, heart failure, vision loss, stroke and kidney disease.

Grigsby noted that the American Academy of Pediatrics issued new blood-pressure guidelines for children in 2017, and that diagnosing hypertension in children is a little trickier than diagnosing it in adults because it varies by a child's age, height and gender. She stressed that health-care providers have to do more than just take a child's blood pressure; they also have to interpret it.

A recent study in the American Heart Association journal Hypertension suggests kids with hypertension are at a higher risk of heart disease as adults.

Using data from nearly 4,000 children who were followed for 36 years, the study found that the newer guidelines classified 11% of children as having hypertension; the old guidelines classified 7%.

It also found that 19% of the children with high blood pressure according to the new guidelines had an enlarged heart (left ventricular hypertrophy, or LVH) as adults. Under the old guidelines, it was only 12%.

Sperling's Best Places map
A possible pitfall in the study was that all of the children in this study come from one community: Bogalusa, Louisiana, just across the Pearl River from Mississippi, a town of 12,000 with a 57% white and 41% population. Also, the study used no information about actual heart attacks and stroke.

Overall, the study found that 8% of the children who were reclassified to having high blood pressure under the new guidelines were more likely than those without hypertension to develop heart disease as adults; and the children who were reclassified to the lower blood-pressure categories with the new guidelines had similar results as those who had never been diagnosed with hypertension.

"Children who were reclassified to higher blood pressure categories based on 2017 guidelines were at increased risk of hypertension, metabolic syndrome and LVH in later life," the report says.

Metabolic syndrome is a group of risk factors that raises a person's risk for heart disease, stroke and diabetes. They include high blood pressure, excess fat around the waist, high blood-sugar levels, high triglyceride levels and low levels of good cholesterol, or HDL. Having any three of these risk factors produces a diagnosis of metabolic syndrome.

Grigsby said all children should start having their blood pressure checked at age 3, and children who are considered at higher risk of developing high blood pressure should have it done sooner, including those who were born prematurely or who have kidney or heart disease.

The Centers for Disease Control and Prevention reports that an estimated 1.3 million youth between the ages of 12 and 19 have hypertension under the new guidelines, which is about 4% of the population. For example, the CDC says that in a classroom of 30, one would have high blood pressure and about three more would have "elevated blood pressure," once called "prehypertension."

Kentucky-specific data were not available, but the primary risk factor for high blood pressure in children is obesity, and that's a real problem in Kentucky. According to the State of Obesity report, one in five, or 20.2%, of the state's high-school students are obese, the third highest in the country.

"The children that we worry about are the children who are overweight and obese because we know that is a big risk factor for having high blood pressure," Grigsby said.

She said high blood pressure in children is primarily treated with lifestyle changes, like decreasing screen time, increasing activity, and improving diets -- and these changes are most successful when the whole family makes them.

"Instead of diet and weight loss, we talk a lot about healthy lifestyles because this is a change that they are going to have to be able to sustain," she said.

The Kentucky Department for Public Health suggests the 5-2-1-0 prescription to significantly reduce childhood obesity, which says to eat five or more servings of fruits and vegetables each day; limit screen time to no more than two hours a day; be physically active for at least one hour a day; and drink zero sweetened beverages. The website offers free resources to help meet these goals.

Most Ky. hospitals got an average patient safety score, one failed; low scoring hospitals have increased risk of "avoidable death"

By Melissa Patrick
Kentucky Health News

For the second grading period in a row, a nonprofit group that rates hospitals has given Cs to most of the 52 Kentucky hospitals it rated; and for the first time since 2015, one hospital got an F, along with only nine other hospitals nationwide. In the percentage of hospitals with A grades, Kentucky continues to rank 33rd among the states.

The Leapfrog Group, a nonprofit group based in Washington, D.C., rated more than 2,600 hospitals. Most of Kentucky's 129 hospitals were not rated, since rural hospitals with "critical access" status don't have to report quality measures to the federal government.

Leapfrog gave As to 11 Kentucky hospitals, or nearly 21% of those graded, lower than the national average of 32%. It gave Bs to 10, Cs to 25 , Ds to 5 and an F to 1. With the exception of the one failing grade, these numbers are similar to the fall report.

Methodist Hospital of Henderson was one of only nine hospitals nationwide that got a failing grade, putting it in the bottom 1% of hospitals scored. Leapfrog shows that the hospital's score has dropped steadily since the spring of 2016 when it got an A; that was followed by two Bs, two Cs, a D and an F.

The twice-yearly grades are calculated using 28 performance measures of patient safety that indicate how well hospitals protect patients from preventable medical errors, accidents, infections and injuries. The report uses data from the Centers for Medicare and Medicaid Services, Leapfrog's own survey, and other supplemental data sources. Hospitals are only graded if they have submitted adequate data for evaluation.
The Leapfrog Group Hospital Safety Grade website is easy to use and offers
information on 52 Kentucky hospitals.
The Leapfrog site offers details on each of the measures under headings titled infections, problems with surgery, practices to prevent errors, safety problems, doctors, nurses & hospital staff. It also includes an easy-to-read, color-coded scale that indicates how the hospital is performing.

For example, Methodist Hospital of Henderson scored below average on 16 of the measures, average on one measure, and above average on nine; and two measures weren't evaluated.

Only two other Kentucky hospitals have ever received a failing grade from Leapfrog: Saint Joseph East in Lexington in fall 2015 and Taylor Regional Hospital in Campbellsville in the spring 2013.

According to the Leapfrog researchers, hospitals with grades lower than an A can put patients at an increased risk of "avoidable death." The news release says patients at D and F hospitals face a 92% greater risk of avoidable death; patients at C hospitals on average face an 88% greater risk of avoidable death; and patients at B hospitals on average face a 35% greater risk of avoidable death.

Leapfrog estimates that 160,000 lives are lost every year from avoidable medical errors that are accounted for in its grading process. It says that's a significant improvement from 2016, when it estimated the number to be around 205,000.

“The good news is that tens of thousands of lives have been saved because of progress on patient safety,” Leah Binder, president and CEO of the Leapfrog Group, said in the release. “The bad news is that there’s still a lot of needless death and harm in American hospitals.”

High scorers

St. Elizabeth Healthcare-Edgewood has received As on every Leapfrog report card since spring 2014, the first year it was graded.

Other hospitals on the A list are: St. Elizabeth hospitals in Florence and Fort Thomas; Baptist Health Lexington; Clark Regional Medical Center in Winchester; Georgetown Community Hospital; Harrison Memorial Hospital in Cynthiana; Norton Audubon Hospital, Norton Brownsboro Hospital and Norton Women's & Children Hospital, all in Louisville; and Whitesburg ARH Hospital.

Norton Brownsboro and Norton Women's & Children hospitals were the the only two on this list to change their status since the last grading period, both moving up from a B.

Low scorers

The five hospitals that got Ds are: Taylor Regional Hospital, Hazard ARH Regional Medical Center; Highlands Regional Medical Center in Prestonsburg; Jewish Hospital in Louisville; and the University of Louisville Hospital.

This was the first D assigned to the Hazard hospital, which since the spring of 2016 had received Bs and Cs. Taylor also moved from a C to a D.

Jewish and the U of L hospital have received Ds since the spring 2016.

U of L Hospital, which separated from KentuckyOne Health on July 1, 2018; KentuckyOne Health, which owns Jewish and Sts. Mary & Elizabeth Hospital; and Baptist Health, on behalf of several of its hospitals across the state, sent statements to Darla Carter of Insider Louisville saying they took issue with the grades, namely because they are based on older data.

“We have reviewed our (publicly) reported data since July 2017, and utilizing the Leapfrog Group’s own calculator for scoring with that data, our calculated grade would have been a C,” Dr. Jason Smith, chief medical officer of U of L Hospital, told Insider Louisville. “This improvement is in line with what we anticipated our ranking would be at this point when we re-assumed oversight of our hospital in July 2017.”

Shifts up and down

TriStar Greenview Regional Hospital in Bowling Green dropped to a grade of B, after receiving five As in a row.

Others on the B list include: Baptist Health Paducah, which maintained its B from the last grading period after getting four Cs in a row; Frankfort Regional Medical Center, which maintained its B from the last period after receiving five As in a row; and Mercy Health Lourdes in Paducah, which maintained its B from last time after getting two Ds and three Cs. The two University of Kentucky hospitals got Cs for the second straight grading period, after getting four Bs in a row.

Three hospitals on the C list dropped from a B in the last grading period: Jackson Purchase Medical Center in Mayfield, Harlan ARH Hospital and T. J. Samson Community Hospital in Glasgow. Saints Mary & Elizabeth Hospital in Louisville got its second C in a row, after having received a D grades since spring 2016.

The Leapfrog Group says its analysis was developed under the guidance of the nation's leading patient-safety experts and is peer-reviewed. Click here to see all of Kentucky hospital's Leapfrog hospital safety grades. Click here for Leapfrog recommendations on how to use the grades.

Thursday, May 16, 2019

Infection-control activist calls for timely outbreak notifications, comprehensive tracking, aggressive containment and vaccines

OPINION By Dr. Kevin Kavanagh

I live in Kentucky, a state with the nation’s largest hepatitis A outbreak, an emerging measles outbreak and a governor who said he exposed his children to chickenpox rather than get them vaccinated. In the past year, two heads of infection control in Kentucky’s Department of Health have left the position. The first one was asked to leave after he expressed the need for an urgent increase in infection control funding.

Dr. Kevin Kavanagh
I am a firm believer that we must learn from history or be doomed to repeat it. Unfortunately, the United States and many other nations appear not to have learned this lesson with regard to public health and are heading down a dangerous path.

The recent book The Pandemic Century by Mark Honigsbaum examines a number of major disease outbreaks around the world and draws lessons about how some of them were mismanaged. But one can see many disturbing parallels in the handling of today’s epidemic of drug-resistant bacteria and viruses.

One of the most important is that when infections spiral out of control, governments worry too much about avoiding accountability, often downplaying the severity of an outbreak until it is too late. In the severe acute respiratory syndrome epidemic of 2002 and 2003, for example, the Chinese government initially withheld information about an outbreak in Guangzhou, which delayed the discovery that the infection was not caused by the flu, but by a more dangerous pathogen.

In the ebola epidemic of 2014, the government of Guinea, a country with very limited health resources, initially insisted that only laboratory-confirmed cases be counted, this led to a drop in reported cases and a false sense of security, delaying the mobilization of resources and fueling the spread of the virus.

And as the 2015 Zika epidemic was taking hold, resulting in the births of babies with the neurological condition microcephaly, the Brazilian Ministry of Health changed the definition of microcephaly from a head circumference of 33 centimeters to 32 centimeters, effectively reducing the numbers of cases.

The United States also falls victim to the practice of mathematical case reduction. Several years ago the Centers for Disease Control and Prevention doubled the amount of bacteria required to be present before a urinary infection must be reported to health officials. Bladder infections associated with a catheter and caused by any type of yeast are no longer reported, which technically includes the deadly superbug Candida auris.

The definition of hospital-acquired methicillin-resistant Staphylococcus aureus (MRSA) infections has been changed from patients who developed an infection after two days of hospitalization to after three days. And the number of “community-acquired” infections occurring in the first three days of hospitalizations are not released to the public.

And instead of fixing a requirement that hospitals keep logs of infectious disease cases, in 2012 the U.S. eliminated this requirement and used our current spotty federal tracking system as justification.

In past epidemics, the cause and mechanism of the spread of infection and even vaccines were desperately sought after, but academic pride and competition often impeded science. No better example was the Spanish flu epidemic, which killed more soldiers in World War I than the war itself. Academic pride perpetuated the myth that the primary cause was a bacteria and not a virus. In the past few decades, other powerful factors, industrial profits and conflicts of interest, have emerged.

Finally, local beliefs, lack of education and mistrust create the breeding ground for pandemics. This was evident in the 2014 ebola outbreak, when the general population believed that the infection was a government plot and that health-care workers were purposely spreading the infection. In addition, they firmly embraced social customs and burial practices that were fueling the epidemic.

In some respects, this type of misinformation and paranoia is held by many who refuse to vaccinate their children. Often standing behind a shield of “religious freedom” or “personal belief,” such parents are allowing their children to act as reservoirs to spread dangerous pathogens. I have a niece who had a heart transplant and is immuno-compromised, and it terrifies me that the anti-vaxxers could jeopardize her life.

Americans over 65 still remember the ravages of epidemics and how vaccines were transformative. I still vividly recall being deathly sick with measles as a young child. I would not wish this on anyone. When the vaccines came out, there was a public rush to get them, and we all stood in long lines. But as memories faded, a suspicion of vaccines grew and dangerous pathogens re-emerged.

The public needs timely notification of infectious disease outbreaks, and epidemics need to be comprehensively tracked and aggressively confronted. All states should mandate vaccinations and eliminate religious exemptions. Our collective health depends on having public policy fully aligned with good science.

Physician Kevin Kavanagh of Somerset is founder and chairman of Health Watch USA, a nonprofit patient-advocacy and health-care policy research organization. Kavanagh wrote this opinion piece for the Los Angeles Times.

Wednesday, May 15, 2019

Hepatitis outbreak is declining in Ky., but we are still finding more in a week than we once got in a year; 57 have died from it in state

The good news about hepatitis in Kentucky is that the number of hepatitis A cases is dropping. The bad news is that there are still as many cases each week as were once seen in a year's time, and the state is by the far the leader in deaths from the liver disease.

According to the state's weekly report, the number of hepatitis A cases in Kentucky has dropped to around 20 per week for several weeks, a huge improvement from the height of the outbreak in the last months of 2018, when more than 100 new cases were being reported every week. But before the outbreak, which was declared in November 2017, the state averaged about 20 cases a year.

Since August 2017, the report shows that 4,621 Kentuckians have been diagnosed with hepatitis A and 2,233, or 48% of them, have been hospitalized. The primary risk factors for getting this highly contagious disease remains illicit drug use and homelessness.

The 57 deaths reported in Kentucky account for about one-third of the 170 deaths reported to the Centers for Disease Control and Prevention since 2016 in 22 states. "West Virginia and California, by comparison, each has had 21 deaths in their outbreaks. Michigan has had 28, and Indiana 4," Chris Kenning reports for the Louisville Courier Journal.

Four Kentuckians died from the disease in the week ending May 4, says the latest state report. It notes that deaths are identified through periodic reviews of death records and includes anyone who dies with documentation of hepatitis A as a contributing factor to the death -- even if it wasn't the primary cause of death, which is often the case among drug users.

Hepatitis A has been diagnosed in 108 of the state's 120 counties, with 15 reporting new cases in the week ending May 4.

The state's initial response to the outbreak has been criticized for not being aggressive enough.

Kenning notes that a Courier Journal investigation found that the state's former infectious-diseases chief, Dr. Robert Brawley, "recommended $6 million for vaccines and $4 million for temporary workers to help thinly staffed local health departments deliver vaccines to hard-to-reach drug users. He also called for a public health emergency declaration to help pave the way for federal assistance. Instead, Department for Public Health Commissioner Dr. Jeffrey Howard, citing limited funding and the local reserves that some health departments had, sent $2.2 million in state funds to local health departments and declined to seek an emergency declaration."

Howard and other state officials have defended their actions, citing that logistical challenges were greater than a need for more money as the outbreak spread to rural Kentucky.

Brawley, who was allowed to resign in lieu of being fired on June 4, 2018, has maintained his position that the state has not acted aggressively enough. (Since Brawley left, the state has fired Dr. John Bennett, who had been the state's infectious-disease manager since last fall.)

"The Kentucky public should be outraged about the slow-motion public health response that has caused the hepatitis A outbreak to continue into 2019," Brawley told Kenning on May 14. "I am saddened that 57 Kentuckians have died after developing acute hepatitis A and where hepatitis A was a risk factor for their deaths."

In late March, a legislative measure directing the state to review its response to Kentucky's outbreak failed to pass. The Cabinet for Health and Family Services has said it plans to review its response.

Meanwhile, the state has hired a roving team of nurses to administer vaccines in rural county jails and the state is providing more vaccine storage equipment, money and expertise to a handful of currently hard-hit counties, Kenning reports.

Specifically, Kenning reports that the Pulaski County Jail has been vaccinating its jailers, and that the state health department has awarded $46,000 to Jessamine, Bell and Christian counties, which had requested extra support; and that a roving team of nurses will soon be in the Lake Cumberland area.

"The department is continuing to coordinate with local health officials to ensure that resources are available and prevention efforts continue," Howard said in a statement to the Courier Journal on Tuesday. "We want to reiterate that though cases are declining, this is not a time to be complacent. Rather, we must continue to promote prevention including appropriate hygiene practices and vaccination."

Brawley said, "While the number of reported cases has fallen in recent weeks, I expect that the Kentucky hepatitis A outbreak will continue for at least six more months and will have a total of more than 5,000 cases before the outbreak is declared over."

Tuesday, May 14, 2019

UK College of Public Health researchers start the Journal of Appalachian Health, free to all, free to share

Researchers in the College of Public Health at the University of Kentucky have started the Journal of Appalachian Health, an online, peer-reviewed journal, saying their overall objective "is to improve the health status of the population of Appalachia through the rapid dissemination of knowledge of their health problems and evidence-based solutions to them." The journal is available free to all readers, and all users are free to copy and distribute the material in any medium or format; and can remix, transform, and build on the material for any purpose.

"There is knowledge in the pages of Appalachia’s hills," the editors write in the first issue. "This journal is positioned to find and publish those translations. It grows from a need to provide an outlet for scholarship about Appalachia’s health so that knowledge, and occasionally wisdom, is shared with those who care about and are committed to improving the region’s health."

The journal's first article reports that children 7 to 9 years old in parts of Appalachian Ohio are almost five times as likely to be exposed to secondhand smoke as children in the nation, and that parents likely under-report the prevalence of smoking in their homes, based on blood samples taken from 404 children.

The journal is open to essays and commentaries as well as research reports. Jill Crainshaw of the divinity school at Wake Forest University writes about the experiences of students who have taken "a multicultural contexts course that includes a 10-day sojourn in the mountains of North Carolina. . . . The health and well-being of human communities are connected to the health and well-being of the geographic places where people live, work, and play."

Ky. health policy forum Sept. 23 will focus on medical marijuana, a topic that is sure to come up again in the next legislative session

By Melissa Patrick
Kentucky Health News

The Foundation for a Healthy Kentucky's annual policy forum this fall will be dedicated to the topic of medical marijuana in hopes of separating what is fact and what is myth, and to better understand how legalizing it would affect public health and society as a whole in Kentucky.

"It's our judgment that there is a lot of misinformation out there, a lot of confusion about what the facts really are," said Ben Chandler, president and CEO of the foundation. "And we are going to try to shine a light on those facts as best we can."

National Conference of State Legislatures map
The Howard L. Bost Health Policy Forum is sponsored by the foundation in memory of the physician who helped create Medicare and Medicaid, developed the Appalachian Regional Hospital system, improved mental health services in Kentucky and created the vision for the foundation.

It will be held at the Marriott Griffin Gate Resort in Lexington on Monday, Sept. 23. The full agenda and registration for the event will be available soon, a foundation news release said.

The topic is timely. In the last legislative session, Kentucky legislators were able to get a bill  to legalize medical marijuana out of committee for the first time. And though it wasn't called up for a House floor vote late in the session, and key Senate leaders maintained their opposition to it, its sponsors have vowed to try again next session.

"We're going into the interim with this momentum behind us," bill sponsor Rep. Jason Nemes, R-Louisville, told the Lexington Herald-Leader in March. "And we'll be back again next year."

Chandler noted that 34 states have already legalized medical marijuana and that Canada and 10 states have legalized recreational marijuana.

"That tells me that this thing has gained an enormous amount of momentum and whether the opponents of it like it or not, they are going to have to deal with it," Chandler said. "It's important for policy makers to know the pros and cons of the issue. . . . What is truth and what is myth? I think we can all use a dose of that, including myself."

Andrew Freedman will keynote
Chandler told Kentucky Health News that the foundation has no position on the issue. He said in the release, "This forum is not about changing minds for or against legalizing medical marijuana; it's about making sure that the practical public health implications are understood and considered in the policy-making process. The bottom-line goal in any policy decision on this topic ought to be protecting and improving public health."

The forum's keynote speaker will be the former Colorado "marijuana czar," Andrew Freedman. He served for three years as Colorado's first director of cannabis coordination, creating the state's regulatory framework for implementing legalized adult-use and medical marijuana. He is the co-founder of Freedman & Koski, a cannabis consulting firm, and works with states and Canada as they consider or implement marijuana legalization programs. Freedman will talk about the impact of legalizing marijuana on a variety of public-health aspects.

Other speakers will focus on the impact of loosening marijuana restrictions on several at-risk populations, including children, those with mental-health issues and those in the criminal justice system. Speakers will also address its impact on accidents, poisonings, crime, state revenues and costs.

Speakers will also address what kind of provider and public education is needed if medical marijuana is legalized, how the quality and dosage of medical marijuana products can be controlled, in what form medical marijuana products should be made available, and gaps in research about medical marijuana and its impact, among other topics.