Disease Control Bulletin: May 2004
- Vermont Blueprint for Health
- Childhood Lead Poisoning Prevention Program
- Diabetes in Vermont
- Selected Reportable Diseases: January–March 18, 2004
- VDH Develops SARS Response Plan
- Avian Influenza Update
Vermont Blueprint for Health
“[We are] confident threat Americans can have a health care system of the quality they need, want and deserve. But the system as it now stands cannot do the job; trying harder will not work. Changing systems of care will.”
Committee on the Quality of Health Care in America1
The “Vermont Blueprint for Health” is a venture, initiated by Governor James Douglas, which is dedicated to achieving a new health system for Vermont. The Blueprint is several things: it is the vision that health care can be made better for Vermonters; it is a plan that provides the structure and outcomes to achieve that vision; and, it is a partnership of organizations, public and private, that are committed to its implementation.
- To implement a statewide system of care that enables Vermonters with, and at risk for, chronic disease to lead healthier live;
- To develop a system of care that is financially sustainable; and
- To forge a public-private partnership to develop and sustain the new system of care.
The Imperative for change
“An aging population will require effective means of chronic disease prevention and management to help people maintain the best possible levels of health and function.”2 In Vermont, 51 percent of adults responding to the Behavioral Risk Factor Surveillance System (BRFSS) in 2001 reported that they had been told they had at least one chronic disease.3 Chronic disease is defined as a health problem that can be expected to last a year or longer, limit what one can do, and/or require ongoing medical care.4 Consistent with national data, the number of Vermonters reporting chronic conditions increases with age; 82 percent of people over age 65 reported having one or more chronic condition and 20 percent reported four or more.
Care for people with chronic conditions currently represents 78 percent of health care spending, 76 percent of hospital admissions, 72 percent of all physician visits and 88 percent of prescriptions written.4 In Vermont, total health care spending on residents totaled more than $2.5 billion in 2001. This was a 10.5 percent increase ($401 per capita) from 2000.5
Vermonters and their health care providers have achieved some of the best health outcomes and highest level of service in the nation, yet there is still much work to be done. In a recent study of services provided by to Medicare beneficiaries, Vermont ranked second. Yet, 30 percent of eligible people did not receive an ACE inhibitor at discharge following a heart attack, 23 percent of people over 65 had no record of having had a flu shot and 32 percent of women age 52-69 had not had a recent mammogram.6
The existing health care system is poorly equipped to meet the needs of an aging population whose biggest problem is chronic disease. Unlike acute or episodic care, prevention and management of chronic disease requires active self-care management, proactive planned care and a continuous relationship between patient and provider. The result of the mismatch between the care people need and the care they receive is a fragmentation that leads to error, waste, over-utilization, delay and increased cost.1
Implementing this model and achieving the goals of the Blueprint will not be easy. It will require the active participation of all Vermonters in all their roles be they consumers, community leaders and/or health care providers. The Blueprint will start by addressing health care needs for people with diabetes and expand to include other chronic diseases and prevention services.
The model for change
The framework for change is based on the Chronic Care Model. As its ultimate goal, the Model envisions an informed activated patient interacting with a prepared, proactive practice team, resulting in high quality encounters and improved health outcomes. It has six components: community, health system, decision support, delivery system design, self-management education and clinical information systems.7
Health care providers
The Blueprint will benefit providers in several ways. They will receive assistance to obtain a clinical information that will provide timely, critical information to guide action in caring for individual patients; and, their caseload as a whole.
Training and technical assistance will be available to assist participants to maximize the use of the information system and design of the systems that support quality care. Participants in the VPQHC led Diabetes Collaborative have successfully developed new systems to identify their population of patients with diabetes, reach out to those who have not been seen for some time, increase the number receiving laboratory and other services, and improve hemoglobin A1c levels in their patients.
Health systems executives
The Blueprint partnership of purchasers, payers and network executives will explore ways for health systems to support provider practice change. Bridges to Excellence, Anthem Blue Cross of Maine and others have initiated programs that give financial incentives to heath care providers who demonstrate implementation of systems that improve care for people with chronic disease.8,9 The Vermont health plans have already assisted participants in the Diabetes Collaborative to obtain information systems and/or undertake data entry. Other ways to improve efficiency such as adopting common forms and using the clinical information system to report data uniformly will be explored.
People with chronic disease are their own primary care giver and the expert on their own lives. Health professionals support them by lending their expertise as consultants; providing information about the disease; supporting the patient to set their own goals; and, helping them learn to solve management problems themselves.10Maximizing the expertise of both consumer and provider allows for interventions that are better tailored and more successful in improving outcomes. Tools and skill building techniques that help consumers gain confidence in their own ability to care for themselves will be implemented. Media of all types will be used to support consumers in prevention and self-management of chronic disease.
Improving health requires addressing all the dimensions of health, not only the health system and individual.2The social networks and norms or standards in a community have a powerful affect on the health behavior of the individual. Community refers to a diverse group of entities including government units, churches, service clubs, or work-sites. Programs will be put in place to help these groups understand their roles in making healthy choices the easiest choices, to offer services that support healthier behaviors, and to establish linkages between their services and the health sector. Blueprint participants will seek funding to support training, technical assistance and incentives to implement programs and integrate in Vermont communities.
To be successful, the Blueprint must be viewed as an important long-term strategy worthy of support. For many years access to health insurance coverage and the cost of health care have dominated debate in Vermont. The Blueprint will help re-frame that debate to focus on systems change and quality improvement as a strategy for improving health and moderating health care costs.
Good health is fundamental to a good society. Without a certain level of health, people may not be able to participate fully in family, community and work.2 Ill health is also costly. The sickest 1.3 percent of the population requires 33 percent of health care resources.11 A reduction of only 10 percent in the cost of caring for people with chronic disease would reduce health care expenditures in Vermont by more than $200 million per year. By developing systems that enable people to be healthier, Vermont will reap not only the rewards of a more productive citizenry, but also a system of care that is more financially sustainable.
Organizations that are members of the Blueprint Partnership include Vermont’s major insurers, quality improvement organizations, medical schools, government agencies, and professional groups.
For more information about the Blueprint contact Ellen Thompson at the Department of Health 802-863-7606 or firstname.lastname@example.org.
- Committee on the Quality of Health Care in America, Institute of Medicine, In "Crossing the Quality Chasm: Health Care for the 21st Century". 2001.
- The Future of the Public’s Health, Institute of Medicine, 2003.
- Vermont Department of Health. BRFSS 2001.
- Chronic Conditions: Making the case for ongoing care. Partnership for Solutions, Johns Hopkins University for the Robert Wood Johnson Foundation. December 2002.
- Vermont Health Care Expenditure Analysis: 2001. Vermont Department of Banking, Insurance, Securities and Health Care Administration. Montpelier, VT December 2003.
- Jencks SF, Huff ED, Cuerdon T. Quality of care delivered to Medicare beneficiaries, 1998-1999 to 2000-2001. JAMA 289: 305. 2003.
- Improving Chronic Illness Care. http://www.improvingchroniccare.org/change/model/components.html
- Bridges to Excellence. www.bridgestoexcellence.org
- Aligning Policies with High Quality Diabetes Care. Anthem Blue Cross of Maine.>
- Bodenheimer T, Lorig K, Homan H, Grumbach K. Patient self-management of chronic disease in primary care. JAMA. 2002; 288:2469-2475.
- Vermont State Legislature, Joint Fiscal Office. Montpelier, VT 2000.
Childhood Lead Poisoning Prevention Program
Childhood lead poisoning is one of the leading preventable environmental health issues in the United States. Exposure to even small amounts of lead can adversely affect children’s growth and development, interfere with heme synthesis and directly damage the kidneys and central nervous system. Blood lead levels (BLLs) as low as 10μg/dL have been associated with adverse effects on cognitive development, growth, and behavior among children aged 1 5 years.1 The Centers for Disease Control and Prevention (CDC) estimated in 2000 that over 890,000 children in the United States had BLLs ≥ 10μg/dL.
Where children find lead
Children are most frequently lead poisoned by household lead paint dust. Lead dust is created by chipping or peeling paint, opening and closing lead-painted windows, or repairs or renovations to lead-painted surfaces. This lead dust rests on surfaces that children touch and then clings to their hands and toys. Children ingest the dust when they put their hands or toys into their mouths or by mouthing lead-painted surfaces and eating lead-paint chips. Lead exposure can also happen when lead based paint is improperly sanded or scraped. In some instances, children are poisoned by lead-contaminated water and soil.
In the past, lead screening was reserved for children who were recognized to be at high-risk due to factors such as living in an inner city or family history of lead poisoning. This strategy was effective when the goal was only to identify children with BLLs of 40 μg/dL or higher. With the recognition that BLLs10 μg/dL can be harmful, it has become clear that different screening strategies must be used to identify all children with elevated lead levels.
Vermont’s older homes a risk factor
The CDC and the American Academy of Pediatrics have addressed the societal burden of lead poisoning by issuing recommendations for childhood lead screening.2 These recommendations include universal screening for lead poisoning in areas where at least 27 percent of houses were built before 1950. In Vermont, approximately 41 percent of homes where built prior to 1950. This includes both low and high income households. The highest incidence, regardless of household income, occurs in the city of Burlington and Orleans, Caledonia, Washington, Rutland and Windham counties.
In 1998, the Vermont Department of Health established the Lead Screening Advisory Committee which included members of health care groups, state government, parent advocacy groups, and insurance organizations. One charge of this group was the development of blood lead screening requirements. The Lead Screening Advisory Committee reviewed the screening data and housing stock information. Due to the extraordinarily high percent pre-1950 housing and low state screening rates, the Lead Screening Advisory Committee recommended that the Department of Health adhere to the CDC recommendation of universal screening for 1 and 2 year old children. Regardless of exposure risk, the Department of Health recommends that all children be screened with a blood lead test at the 1-year and 2-year well child visits. For children ages 3 to 6 years who have never had a blood lead test, screening is also recommended.
Testing 2-year-olds a priority
All blood lead results are reported to the Department of Health by the analytical laboratory and are entered into a database. As of December 2003, the lead database contained 77,061 blood lead results representing 55,208 Vermont children. In 2003, 68 percent of Vermont 1-year-olds and 13 percent of Vermont 2-year-olds were screened for lead. In 1996, the Lead Screening Advisory Committee believed that a screening goal of 75 percent of 1-year-olds could be reached in one year. Eight years later, we are still working toward that goal. In 1996, 42 percent of 1-year-olds and 19 percent of 2-year-olds were screened for lead. In 2002, 68 percent of 1-year-olds and 13 percent of 2-year- olds were screened.
Vermont data mirrors that found by the CDC in relation to the percentage of children with confirmed BLLs by age group. The September 12, 2003 MMWR reported that children between 12 35 months old had a far greater incidence of BLLs10 μg/dL than any other age group. Vermont data shows that 9 percent of 2-year-olds and 5 percent of 1-year-olds have elevated BLL. This demonstrates the importance of increasing screening rates for 2-year-olds. Normal hand to mouth behavior and increased mobility leads to an increased incidence of lead poisoning in the 2-year-old population. Children who are tested for lead at 11 months or younger often don’t have elevated levels. If those same children are tested at age 24-35 months, data shows that a high percentage of those children will have elevated levels.
Health care providers have many options for referral of patients or families of patients with elevated BLLs. The Childhood Lead Poisoning Prevention Program offers nutrition and housekeeping education in addition to dust, water and soil sampling to parents and guardians of children with elevated BLLs. Home visits are offered to families of children who have a BLL of 15 μg/dL or greater. Educational outreach and environmental investigations are available for severely poisoned children, de ned as those with BLLs of 20 μg/dL or above. The Lead Program at the Vermont Department of Health can be reached at 1-800-439-8550.
- National Research Council. Measuring lead exposure in infants, children, and other sensitive populations. Washington, DC: National Academy Press, 1993.
- Ellis M, Kane K. Lightening the Lead Load in Children. American Family Physician 2000
Diabetes in Vermont
The Behavioral Risk Factor Surveillance System (BRFSS) reports that approximately 27,500 Vermonters over age 18, (5.8 percent of the Vermont population) had a diagnosis of diabetes in 2003.1This is an increase of nearly 7000 adults since 2000 when the rate was 4.4 percent. It is estimated an additional 13,500 Vermonters over age 18 have diabetes but have not been diagnosed yet.
Diabetes Risk Factors
Diabetes is more common among older age groups and people of all ages who are overweight or obese.(Figure 1) Other risk factors include family history and physical inactivity. In 2003, only 51 percent of Vermonters met the requirements for moderate physical activity. Twenty percent were obese (BMI 30+), up from 15 percent reported in 1998.
Mortality and Morbidity
Diabetes was the sixth leading cause of mortality in Vermont in 2002. It was listed as the underlying cause of death of 174 people, a rate of 28.3 deaths per 100,000 Vermonters. In an additional 411 cases diabetes was a contributing cause of death (e.g. cardiovascular disease with diabetes as a comorbidity). Combining all deaths related to diabetes the age-adjusted death rate for males is significantly higher than for females (116 per 100,000 males vs. 76 per 100,000 females).
In 2001, there were 1501 hospital discharges with diabetes listed as one of the causes for hospitalizations per 100,000 Vermonters. As with mortality, male hospitalization rates are higher than females (1,700 per 100,000 males compared to 1,354 per 100,000 females).
Diabetes can result in several severe and life threatening complications. Diabetes during pregnancy elevates the risk of maternal hypertensive disorders, greatly increases the risk of fetal macrosomia, and increases the need for cesarean deliveries. In Vermont, 3.1 percent of births were to women with pre-pregnancy diabetes. Another complication is impaired circulation and sensation in the extremities, which can ultimately result in amputation. According to the 2001 Hospital Discharge data, there were approximately 200 lower extremity amputations among diabetic Vermonters. Kidney disease is also a complication of diabetes. Approximately 10 out of every 1,000 Vermonters with diabetes have end stage renal disease.2
The Department of Health uses the BRFSS to collect data on several measures related to the quality of care received by Vermonters who have diabetes. These measures are detailed in Table 1, with comparisons made to the United States overall rate for white non-Hispanics where applicable.
As Vermont’s population ages and the rate of obesity increases, diabetes is becoming a more important public health problem. Although some of the quality of care measures are approaching goal, enormous challenges remain to reduce complications related to diabetes and to prevent diabetes among susceptible segments of the population.
Continual examination of these and other surveillance data helps determine diabetes program priorities, but it takes collaboration among consumers and diverse community partners to use our collective resources most efficiently. The Vermont Department of Health’s Diabetes Prevention and Control Program (DPCP) continues to lead these efforts. For more information or to contact the Vermont DPCP call 1-800-464-4343.
- Vermont Behavioral Risk Factor Surveillance System. www.cdc.gov/brfss/
- United States Renal Data System www.usrds.org/
Vermont Selected Reportable Diseases: January-March 28,2004
Vermont Department of Health Develops SARS Response Plan
Severe Acute Respiratory Syndrome (SARS) is an acute viral respiratory disease first identified in China in late 2002. This disease ultimately spread throughout much of the world, resulting in more than 8,000 cases and 780 deaths. Since the end of the global outbreak in July 2003, two cases of SARS associated with laboratory exposures have been reported one case in Singapore in September 2003 and one in Taiwan in December 2003. In addition, four other cases, two associated with laboratory exposures and two associated with direct contact with one of the laboratory associated cases, have been reported. The Vermont Department of Health is monitoring this situation closely and will be providing updates to healthcare providers as needed.
In 2003, the Vermont Department of Health, in response to this emerging threat, began to develop a SARS Response Plan. This plan, adapted from guidelines from the Centers for Disease Control and Prevention has since been updated and is now available on the Department’s web site www. healthyvermonters.info for review. The plan, in addition to outlining the steps the Department of Health would take to prepare and respond to SARS, also contains important preparedness and response information for hospitals. We invite you to review this plan and email your comments and suggestions to email@example.com.
Avian Influenza Update
Avian influenza is an infectious disease of birds caused by type A strains of the influenza virus. Infection can result in a wide spectrum of symptoms, ranging from mild illness to a highly contagious and rapidly fatal disease commonly referred to as “highly pathogenic avian influenza” (HPAI). All birds are thought to be susceptible to infection with these viruses, though some are more resistant than others. For example, migratory waterfowl - most notably wild ducks (which are natural reservoir of avian influenza viruses) are resistant, whereas domestic poultry, including chickens and turkeys, are particularly susceptible to the most severe form.
Over the last several months outbreaks of HPAI have been identified in several Asian countries: Cambodia; Indonesia; Japan; Laos; People’s Republic of China; including Hong Kong, SAR; South Korea; Thailand; and Vietnam. All these outbreaks have been due to the avian influenza A (H5N1). Efforts to control the spread of this virus have included the quarantining of infected farms and destructions of infected or potentially infected flocks.
As of April 15, 2004, this outbreak of avian influenza has resulted in 12 human cases and 8 deaths in Thailand and 22 cases and 15 deaths in Vietnam. It is believed that all these cases resulted in contact with infected birds or surfaces contaminated with excretions from infected birds - there is no evidence for person-to-person transmission. Transmission of avian influenza virus from birds to humans has been documented before. The first such occurrence was in Hong Kong in 1997. An outbreak of influenza A (H5N1) among birds result in 18 cases and six deaths in humans.
This present outbreak of HPAI is of enormous public health concern. Influenza A (H5N1) has the ability to mutate rapidly and has now shown its ability to infect humans and cause severe disease and death. Moreover, there is the possibility this virus, through genetic reassortment, could develop into a novel strain with the ability to be easily transmitted from person to person. Such an event could mark the start of the next pandemic.
For further details or updates on the avian influenza outbreak, or to view guidance for travelers and clinicians, please visit the Center for Disease Control and Prevention’s website at www.cdc.gov.
- Centers for Disease Control and Prevention (CDC) www.cdc.gov
- World Health Organization www.who.int/en
Report Disease: Vermont Toll-Free 1-800-640-4374 or 1-802-863-7240
Vermont Department of Health
Division of Health Surveillance P.O. Box 70 Burlington, VT 05402-0070
Agency of Human Services
Paul E. Jarris, MD, MPH
THIS BULLETIN IS PRODUCED BY THE DISEASE CONTROL BULLETIN EDITORIAL STAFF.
Curt Lohff, MD, MPH
Report Disease: Vermont Toll-Free 1-800-640-4374 or 1-802-863-7240