*"It doesn't matter if the cat is black or white as long as it catches
mice."*

Deng Hsaio P'ing 1904-1997

This a page for sharing "what works" as seen in the published literature
as well as what is done at sites that care for American Indian/Alaskan
Native children. If you have any suggestions, comments or questions
please contact Steve Holve, MD, Chief Clinical Consultant in Pediatrics
at sholve@tcimc.ihs.gov

IHS Child Health Notes

January 2006

# Quote of the month

*"Get a bicycle. You will not regret it if you live."*

Mark Twain

**Articles of Interest**

Cost of Influenza Hospitalization at a Tertiary Care Children\'s
Hospital and its Impact on the Cost-Benefit Analysis of the
Recommendation for Universal Influenza Immunization in Children Age 6 to
23 Months.

J Pediatr. 2005 Dec;147(6):807-11.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?CMD=search&DB=pubmed>

Influenza-associated deaths among children in the United States,
2003-2004.\
N Engl J Med. 2005 Dec 15;353(24):2559-67.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16354892&query_hl=2>

**Summary and Editorial**

By the time you read this influenza will have likely already arrived in
your community.

The first article looks at the cost benefit ratio for influenza
vaccination of all children ages 6 months to 23 months and reports that
vaccinations are cost effective. No surprises there.

The second article reviews 153 influenza-associated deaths in children
from the 2003-2004 winter. Those in practice then will recall that it
was a particularly busy flu season made more difficult by concern that
there were an increased number of childhood deaths related to influenza.

This study confirms that the 2003-2004 flu season was more severe than
usual. The increased mortality is attributed to the finding that the
predominant virus in circulation that year was influenza A (H3N2), a
subtype associated with increased virulence.

The study confirmed that the highest death rate occurred in those less
than 6 months. The death rate was also much higher in those less than 24
months compared to those older. Patients with a designated high-risk
condition were at 5 times the risk of death compared to children without
risk factors. All of this confirms existing guidelines for universal
vaccination of children 6 months to 23 months and those with designated
high-risk disorders.

Of note was that children with chronic neurological or neuromuscular
disorders had an equally elevated mortality rate. This heterogeneous
group of disorders includes "developmental delay, cerebral palsy,
seizure disorders and congenital neurological conditions". These
illnesses are not currently designated to receive the annual flu
vaccination. However, the Advisory Committee on Immunization Practices
recently recommended the annual flu vaccine for all persons with
"conditions that can compromise respiratory function or the handling of
respiratory secretions or that can increase the risk of aspiration."
This would cover most patients with the above diseases.

Of children for whom vaccine status could be determined only 16% had
been immunized against influenza. For high-risk groups such as ages 6
months to 23 months and those with cardio-respiratory disease the flu
vaccination rates were only marginally better at 26%. While vaccination
is not fully protective it continues to be underutilized in children.
Are we doing better in the Indian Health Service?

Lastly, for those who want to keep track of influenza activity in their
communities this winter the CDC has a website that is updated weekly. Go
to:

[**http://www.cdc.gov/flu/weekly/fluactivity.htm**](http://www.cdc.gov/flu/weekly/fluactivity.htm)

**Infectious Disease Updates**.

Rosalyn Singleton MD MPH

**Hepatitis A Vaccine: Nice Success Story - New Recommendations.**

At the October 26 ACIP meeting, ACIP members voted that all children in
the US be vaccinated against hepatitis A vaccine. This Fall the FDA
changed the recommended earliest age for hepatitis A vaccine from 2
years to 1 year. The next version of the RPMS immunization package will
forecast hep A vaccine starting 15 months (the 12 month visit is too
crowded with other vaccines).

Providers in Indian country have led the way in hepatitis A prevention.
IHS and tribal programs have been providing routine hepatitis A vaccine
to American Indian and Alaska Native (AI/AN) children since 1996, when
hepatitis A was first licensed. Routine childhood vaccination has
basically eliminated hepatitis A infection as a public health problem
among AI/AN people. This nice graph from Stephanie Bialek's article
shows the dramatic decline in AI/AN people, from 10-fold higher, to a
rate now similar to the rest of the US.

![](media/image1.wmf){width="5.001388888888889in"
height="3.084722222222222in"}

Reference: Bialek SR. AJPH 2004;94:996-1001

**Recent literature on American Indian/Alaskan Native Health**

Doug Esposito, MD

Comprehensive primary care for children with special health care needs
in rural areas.\
*Pediatrics*. 2005;116(3):649-56.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16140704&query_hl=1>

**Summary**

The authors report results from a medical home demonstration project
conducted in rural Missouri. Although not specific to AI/AN populations,
this study has direct relevance to rural IHS practice environments.

The 6-month intervention consisted of a health care team comprised of a
primary care physician, their office staff, a nurse practitioner (who
worked for the project), a paid parent consultant, the child, and the
family. Each family received a comprehensive evaluation of the child and
family's medical and non-medical needs by the NP, culminating in a
written care plan and letter outlining services available in the
community to meet these needs. In addition, the NP provided consultation
to the rural practices to help improve their capacity to function as a
medical home for children with special health care needs. Family support
services were also provided by the parent consultant.

This study demonstrated a positive effect. Families reported increased
satisfaction with care coordination and increased access to mental
health services for their children. There was also a positive impact on
several aspects of family functioning, including a decrease in family
needs, decreased absences from work, fewer absences from school, and
less family strain. Family satisfaction with their primary care provider
decreased slightly, but an explanation for this unexpected finding was
offered.

Limitations of this study included a lack of a control group.
Additionally, although the counties included in the study were rural,
they were adjacent to metropolitan areas, thus potentially limiting the
study's generalizability to more rural environments. Finally, the study
population was over represented by children with more severe conditions,
single parent families, and children with insurance coverage,
potentially limiting generalizability further.

Overall, though, the study demonstrated a beneficial effect of a medical
home model of care for children with special health care needs residing
in a rural setting.

**Editorial Comment**

There is much buzz in the literature lately regarding the medical home
concept and care coordination (a.k.a. case management). Conspicuously
absent, though, has been data demonstrating a benefit in rural
underserved populations. This paper goes some distance in defining the
benefit we would all expect from wider adoption and application of these
concepts.

It is no secret to those of us who work on rural Reservations that the
services routinely accessible to children and youth with special health
care needs in urban and suburban settings are significantly lacking and
difficult or even impossible to access from our more remote environs.
You can't get what doesn't exist, or what is impossibly distant! For
example, in my own community of Fort Defiance, Arizona, pediatric
specialized speech, occupational, and physical therapy services for mild
to moderately effected children are only accessible through either the
public schools or the Early Intervention Program These services are
routinely stretched thin, and do not provide sufficient hours of
one-on-one contact to achieve optimal (or sufficient) benefit. The
closest place to receive any necessary or medically indicated
supplemental services for us is 40 miles away. The drive is even more
untenable for those living even deeper inside the Reservation, or for
those so cash-strapped as to not have transportation or gas money. Even
if such services were covered by Medicaid, Medicare, or private
insurance, accessing them is truly a daunting prospect.

We are fortunate in that IHS or tribally administered health systems are
more-or-less organized along the lines of the medical home concept. This
was the case even before the concept became trendy! Care coordination is
essentially what we medical providers do, though we certainly could do
it better and more efficiently. More robust and better organized systems
of care coordination are definitely indicated.

The time is now to push for true care coordination on a wider scale in
IHS and rural America. Medical providers working with AI/AN populations
are typically responsible for knowing and understanding all the services
available and how to access them. But, are we really good at that? We
are also responsible for making the phone calls, writing the letters,
tracking down patients, etc., etc. But, are we the best ones to be doing
that either?

I believe that other professions (nurse practitioners, physician
assistants, registered nurses, social workers, etc.) are better
positioned to serve as care coordinators. I would advocate for a
re-evaluation of our system of care, and movement toward one which
relies more heavily on professional non-physician care coordinators.
Numerous studies have demonstrated multiple benefits of such a model.
The difficulty now will be working with the reimbursement world, state
and federal governments and agencies, and our own administrators to help
figure out how to make this all work on a more global scale!

South Central Foundation (SCF) in Anchorage, Alaska, has a fairly robust
system of care coordination. At SCF, each primary care pediatrician is
paired with a nurse case manager. This system works wonderfully and
approaches seamless and efficient family centered care for medically
complex children and children with special health care needs. And,
families love it! Although this system is unlikely to be economically or
administratively feasible in most IHS or rural settings at the present
time, some form of professional care coordination is highly desirable.
We must move in that direction.

**Additional Reading**

Care coordination in the medical home: integrating health and related
systems of care for children with special health care needs.\
*Pediatrics*. 2005 Nov;116(5):1238-44.
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16264016&query_hl=13&itool=pubmed_docsum>

Care coordination services in pediatric practices.\
*Pediatrics*. 2004;113:1517-21.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15121920&query_hl=23&itool=pubmed_docsum>

History of the medical home concept.\
*Pediatrics*. 2004;113:1473-8.
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15121914&query_hl=11&itool=pubmed_docsum>

# Announcements from the AAP Indian Health Special Interest Group 

Sunnah Kim, MS Native American Child Health Advocacy Award -- Call for
Nominations

Each year, the AAP Committee on Native American Child Health presents
the Native American Child Health Advocacy Award to recognize an
individual who has made a major contribution to Native American child
health.

The AAP Committee on Native American Child Health will be accepting
nominations for the 2006 Native American Child Health Advocacy Award
through February 28, 2006. The award will be presented at the 2006 AAP
National Conference and Exhibition to recognize an individual who has
made a major contribution to promoting Native American child health. If
you know of a physician or non-physician who merits this recognition,
please submit a letter of nomination, along with the candidate\'s CV to:

Committee on Native American Child Health\
American Academy of Pediatrics\
141 Northwest Point Blvd\
Elk Grove Village, IL 60007\
Fax: 847/434-8729\
indianhealth@aap.org

## Invitation to Submit Manuscripts

The MCH Journal is planning to publish a supplemental issue titled,
"Research for MCH Practice in American Indian and Alaskan Native
Communities". Investigators are invited to submit manuscripts for
consideration. Manuscripts may report epidemiological studies, research
on health services, intervention trials, and program evaluations.
Submissions that are authored or co-authored by American Indians and
Alaskan Natives are especially encouraged. Additional information can be
found in the attached announcement or by contacting Myra Tucker,
supplement associate editor, at <mjt2@cdc.gov> or 770/488-6267.

**Locums Tenens and Job Opportunities**

If you have a short or long term opportunity in an IHS, Tribal or Urban
facility that you'd like for us to publicize (i.e. AAP Web site or
complimentary ad on Ped Jobs, the official AAP on-line job board),
please forward the information to <indianhealth@aap.org> or complete the
on-line locum tenens form at <http://www.aap.org/nach/locumtenens.htm>

.