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Volume 103, Issue 5 (2004)


 
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Editorials

Thomas C. Meyer, MD, Medical Editor, Wisconsin Medical Journal
Multifaceted issue leads to lengthy issue
(full text PDF)

Our Maternal and Child Health issue turned out to be quite lengthy, thanks in large part to the immense efforts of Murray Katcher, MD, who recruited many of the authors. One of these authors is Governor Doyle, who responded graciously to our request for a guest editorial (p 11). His brief but lucid outline of his new KidsFirst initiative introduces issues to which all can relate—early developmental access to high-quality learning opportunities, child safety in its broadest terms, strong families, and an emphasis on health.

Patrick Remington, MD, MPH; David Ahrens, MS
Saving money by spending more
(full text PDF)

Cigarette smoking among pregnant women remains a significant public health problem in Wisconsin. Pregnant women and their newborns face substantial medical risks as a result of this addiction. Infants with pre-natal exposure to cigarette smoke are nearly twice as likely to be pre-term and nearly 3 times as likely to be small for gestational age—all outcomes with potentially significant related co-morbidities.

Eric teDuits, DDS, MS
Comprehensive approach needed to decrease disparities in dental care
(full text PDF)

Oral health continues to be a problem for the lower socioeconomic segments of the population for a variety of reasons. “Filling the Cavities Between Children and Oral Health” (p 74) attempts to stress the importance of good oral health, the need for primary care physicians/staff to help educate patients on early prevention techniques, and the difficulties people have in receiving care.

John R. Meurer, MD, MBA; Jennifer H. Cohn, MLS; Maggie Butterfield, MS; Erin Lee, BA; Cynthia B. Obletz, RN, BSN, AE-C
Efforts to Quit Smoking by Parents of Children with Asthma
(full text PDF)

The objective of this project was to assess the prevalence of (1) tobacco smoke exposure at home among children with asthma and (2) efforts to quit smoking by their parents. We employed a cross sectional survey of 622 parents of children diagnosed by a doctor with asthma. Seventy-five percent of parents reported smoke-free homes. Overall, 85% of parents pledged to keep smoke-free homes, 92% in existing smoke-free homes and 64% in homes with smoke.

Commentaries

Governor Jim Doyle
Improving the health and well being of Wisconsin’s children: The KidsFirst Agenda
(full text PDF)

I would like to commend Wisconsin’s physicians for their continued interest in the health of the people in Wisconsin, and for their willingness to discuss the difficult health issues facing our state. The health of children and their families is an extremely important issue to me. My new KidsFirst initiatives are actions that will be used to improve children’s health.

Original Research

Sarah E. Pierce, BS; Michael Vaughn, MHA; Murray L. Katcher, MD, PhD
Increasing access to affordable contraception: A look at the Wisconsin Medicaid Family Planning Waiver
(full text PDF)

Approximately half of all pregnancies in the United States are unintended. The purpose of the Family Planning Waiver, a Wisconsin Medicaid program implemented in 2003, is to expand access to contraceptive care and other reproductive health services. The waiver provides women with birth control services and supplies, emergency contraception, routine reproductive health exams, and diagnosis and treatment of sexually transmitted diseases. With greater availability of contraception, the expected outcome is a reduction of unintended pregnancies and subsequent therapeutic abortion, which results in a decreased financial burden to the state, as well as an opportunity for women to experience motherhood when they are emotionally prepared to do so.

Elizabeth Oftedahl, BA; Richard M. Pauli, MD, PhD; Sharon Fleischfresser, MD, MPH; Murray L. Katcher, MD, PhD
Wisconsin Birth Defects Registry collecting data
(full text PDF)

Wisconsin Statute 253.12 was enacted in May 2000 to create the Wisconsin Birth Defects Registry (WBDR), replacing the Birth and Developmental Outcome Monitoring Program, a previous birth defects and developmental disabilities reporting system initiated in 1989. In the summer of 2004, the new registry began collecting demographic, diagnostic, and identifying information for children from birth to 2 years of age who are born with reportable birth defects and/or are receiving health care services for them in Wisconsin. This article describes the development of the registry and outlines expectations for reporting of birth defects.

Joanne Selkurt, MD, FAAP
“Back to Sleep” saves babies from SIDS in Wisconsin… There’s still more to do
(full text PDF)

In 1992 the American Academy of Pediatrics issued a policy statement that has resulted in a 50% drop in the annual rate of Sudden Infant Death Syndrome (SIDS). The “Back to Sleep” policy stated that infants should no longer be placed on their stomachs, but rather on their backs when being put into their beds.

Sharon Fleischfresser, MD, MPH
Wisconsin Medical Home Learning Collaborative: A model for implementing practice change
(full text PDF)

A child with special health care needs is defined as having, or are at increased risk for, a chronic physical, developmental, behavioral, or emotional condition that requires health and related services of a type or amount beyond that required by children generally. In Wisconsin nearly 14% of children are identified as having or being at risk for special health care needs. Healthy People 2010 and the federal Maternal Child Health Bureau have challenged each state to “assure access to ongoing comprehensive health care through a medical home” for all children with special health care needs. A medical home is defined as “an approach to providing continuous and comprehensive primary pediatric care.” States are challenged to translate the concepts of medical home to clinical practice activities. This article discusses Wisconsin’s participation in a national Medical Home Learning Collaborative and Wisconsin’s replication of the Collaborative as a means to develop practical strategies for practice implementation of a medical home.

Bobby Peterson, JD
ABC for health: Funding medical home services for Wisconsin children with special health care needs
(full text PDF)

Medical home services for families with children with special health care needs can provide needed help for families struggling to gain access to coverage and needed services. Wisconsin, through Medicaid Early and Periodic Screening, Diagnosis, and Treatment Services, has an opportunity to provide this important and necessary service.

Joy Grotsky, RN, MS; Mary Gothard, BS, CHES; Lisette Khalil, MS; Kate Squire, MPH; Maria Mascola, MD, MPH
Smoking cessation and prevention in women of reproductive age: Resources and partnerships for physicians
(full text PDF)

The importance of smoking cessation and prevention as a women’s issue is clear—physicians who interact with women of reproductive age are in an excellent position to influence women’s decisions to quit smoking. This paper provides information on community resources physicians can offer to their patients to help support their cessation attempts and describes a new partnership opportunity that physicians can become involved with.

Christine Van Mullem, RN, MS; Ann E. Conway, RN, MS, MPA; Kyle Mounts, MD; Donald Weber, MD; Carol A. Browning, MD
Regionalization of perinatal care in Wisconsin: A changing health care environment
(full text PDF)

Wisconsin has recently experienced a rapid increase in the number of neonatal intensive care units (NICUs), from 6 in the 1970s to 18 in 2003. Over the last year, the Wisconsin Association for Perinatal Care (WAPC) convened meetings in response to threats to regionalized care and worsening of perinatal outcomes, noted especially in some racial/ethnic groups. WAPC defined actions to address quality improvement, including adoption of designations for levels of care published by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists, definition of perinatal outcomes sensitive to quality of care, collection and analysis of outcome data, and continued statewide discussions about the status of regionalized care and outcomes. WAPC invites others to join in cooperative efforts to address quality of care and responsible utilization of resources.

Katherine M. Kvale, PhD; Maria A. Mascola, MD; Randall Glysch, MS; Russell S. Kirby, PhD, MS; Murray L. Katcher, MD, PhD
Trends in Maternal and Child Health Outcomes: Where Does Wisconsin Rank in the National Context?
(full text PDF)

Background: The infant mortality rate (IMR), low birth weight (LBW) rate, and first trimester entry into prenatal care (PNC) are indicators that reflect the health of a population. Objective: To examine these indicators in Wisconsin from 1979 through 2001 and compare them to those of the United States, looking at trends and relative rank compared with other states. Methods: Three-year averages for IMR, LBW, and PNC were analyzed for the periods 1979-1981, 1984-1986, 1989-1991, 1994-1996, and 1999-2001 from data sources published by the Centers for Disease Control and Prevention. Wisconsin’s rank relative to other states was compared for the overall, black, and white populations. Results: Wisconsin’s overall IMR was consistently at, or slightly better than, the national IMR. From 1979-1981 to 1999-2001, the US black IMR decreased by 37.4%, while the Wisconsin black IMR declined 12.4%; thus, Wisconsin’s rank among the states fell from third best to 32 among 34 states with a sufficient number of black births. LBW rates for Wisconsin’s black population were consistently at least twice that of the white population. In 1979-1981, early entry into PNC for all Wisconsin women (82.9%) was significantly higher than that of the US population (74.1%). Wisconsin’s early PNC entry rates improved slightly; as other states also improved, Wisconsin’s ranking dropped. Wisconsin’s relative ranks for IMR, LBW, and PNC declined for all 3 indicators from 1979-1991 to 1999-2001. Discussion: Birth outcome disparities in Wisconsin pose challenges for physicians, public health, and private agencies; all must collaborate and act to improve health, housing, employment, education, and the social capital and support that makes up the fabric of our society.

Sunil Sharma MD, FCCP; Rose Franco MD, FCCP
Sleep and Its Disorders in Pregnancy
(full text PDF)

By their third trimester of pregnancy, 97% of women report sleep disturbance. Sleep can be altered during pregnancy due to several reasons, including mechanical and hormonal. The importance of quality sleep and the negative impact of sleep disturbances in pregnancy are under-recognized by both patients and physicians. This is in part due to limited literature on this topic. The true incidence of sleep disorders in pregnancy is not known; however, due to growing awareness of the importance of sleep and sleep disorders in pregnancy, “Pregnancy Associated Sleep Disorders” is now recognized as a distinct clinical entity in the international classification of sleep disorders. In this review we will present a consolidated literature review on sleep changes in pregnancy and sleep disorders that may develop or be worsened in pregnancy.

Marianne Weiss, DNSc, RN; Christine E. Cronk, ScD; Sandra Mahkorn, MD, MPH; Randall Glysch, MS; Sara Zirbel, MSN, RN
The Wisconsin Fetal Alcohol Syndrome Screening Project
(full text PDF)

Problem: Fetal Alcohol Syndrome (FAS) is preventable, under-diagnosed, and under-reported. Wisconsin rates for alcohol use and binge drinking in childbearing-age women exceed the national average. FAS prevalence in Wisconsin has not previously been systematically evaluated.

Methods: The Wisconsin Fetal Alcohol Syndrome Screening Project (WFASSP) used a multi-stage, multi-source prospective population-based screening meth-odology to identify children born in 1998-1999 in Southeast Wisconsin who met a surveillance case definition for FAS. The 4-stage methodology used screening of electronic birth files, abstraction of neonatal medical records, and direct assessment of facial features, growth, and development at age 2 to 3 years.

Results: The FAS prevalence rate was 0.23 per 1000 births. Children directly evaluated had fewer demographic, pregnancy, and maternal substance use risk factors than lost-to-follow-up children. Thirty-two percent of children with weight and head circumference below the 10th percentile at birth were developmentally delayed and 47% had at least one physical growth delay.

Conclusions: The WFASSP methodology identified children who had not previously been diagnosed with FAS. Using the combination of weight and head circumference below the 10th percentile at birth is a useful methodology for identifying children at substantial risk for growth and developmental delays from FAS or other unspecified etiologies.

Maria A. Mascola, MD, MPH; Michael A. Schellpfeffer, MD; Terry K. Kruse, RN, BS; Ann E. Conway, RN, MSN, MPA; Katherine M. Kvale, PhD; Murray L. Katcher, MD, PhD
Pregnancy-Associated Deaths and Pregnancy-Related Deaths in Wisconsin, 1998-2001
(full text PDF)

Background: Although the risk of dying during childbirth or from complications afterward has been greatly reduced during the past 100 years, the current rate of approximately 1 death in 10,000 live births is still too high. The goal of the US Department of Health and Human Services is to reduce this rate by more than half by the year 2010.

Objective: To present Wisconsin data regarding pregnancy-associated deaths and pregnancy-related deaths.

Methods: Cases in which a woman had died during pregnancy or within 1 year of the end of her pregnancy were identified, and case-specific data were collected. The Wisconsin Maternal Mortality Review Team then conducted systematic reviews of the information, summarized issues related to maternal mortality, considered the relationship to pregnancy and factors of avoidability, and made recommendations to improve maternal health and survival. Finally, pregnancy-associated and pregnancy-related mortality ratios were calculated.

Results: From 1998 through 2001, 23 Wisconsin women died as a result of their pregnancy or from complications up to a year later. This gives a Wisconsin pregnancy-related mortality ratio of 8.4 per 100,000 live births. This ratio was higher in African American women and in women who smoked. The primary cause of death was embolic disease. Almost half of the pregnancy-related deaths (48%) occurred during the postpartum period, and nearly one-quarter (22%) were avoidable.

Conclusions: The disparity in pregnancy-related mortality ratios among ethnic groups and the finding of avoidable deaths are areas that should be targeted by health care providers and public health workers. Six areas on which to focus include the following: addressing racial disparities, assuring the performance of autopsies, lifestyle changes related to obesity and smoking, and management of embolic and cardiovascular disease, as well as postpartum hemorrhage.

Nicole Thorsen, Lisette Khalil, MS
Cost Savings Associated with Smoking Cessation for Low-Income Pregnant Women
(full text PDF)

Despite the many health risks associated with smoking during pregnancy, it remains a chief public health concern with a high prevalence evident at the local level. In Wisconsin, the First Breath program was developed to help pregnant smokers quit and served 424 women during its pilot phase in 2001 and 2002. This cost savings analysis included claims associated with First Breath enrollees who were identified within the Wisconsin Medicaid data warehouse. This analysis allowed for a comparison of medical claims for women who quit smoking through the First Breath program versus those who continued to smoke. Three billing categories were included in this analysis: mother’s maternity admissions (maternal DRG), inpatient neonatal care (neonate DRG), and infant’s medical costs for the first 6 months of life. Average Medicaid savings per First Breath enrollee who quit smoking was $1274. Applying this savings to the actual number of women who quit smoking during the pilot study gives a total savings of $137,592 for the Medicaid program. Considering the maximum Medicaid cost of providing cessation services to all First Breath participants, the return on investment associated with the First Breath program is 9 to 1.

Stephanie A. Lutter, MD; Jenifer A. Glatz, MD; Kimberly J. Kastner, MD; Shelly R. Taylor, MD; Earnestine Willis, MD
Filling the Cavities Between Children and Oral Health
(full text PDF)

Oral health care is the greatest unmet health need in American children.1 According to former Surgeon General David Satcher, “Tooth decay remains the single most common chronic disease of childhood—5 times more common than asthma.” Greater than half of all children have dental caries by mid-childhood.

Thomas Schlenker, MD, MPH
Anti-Vaccinationists and Their Impact on Vaccination Coverage in Wisconsin
(full text PDF)

For 300 years, vaccination against serious disease has been a cornerstone of Western medicine, saving lives and preventing disabilities beyond measure.1,2 In the United States, childhood vaccinations against smallpox, diphtheria, pertussis, tetanus, poliomyelitis, measles, mumps, rubella, and haemophilus influenzae have reduced disease from hundreds of thousands of cases per year to nearly zero.3,4 The vaccines in use are effective, safe, relatively inexpensive and constantly improving. Nevertheless, public enthusiasm for and acceptance of them is inconstant. On occasion, apathy and opposition to childhood vaccination have risen to levels that hurt children and endanger public health. In 1989, because of poor vaccination coverage among preschool age children, measles broke out in cities across the country, resulting in more than 50,000 cases and 140 deaths.5 Milwaukee, where only 64% of 2 year olds were vaccinated, suffered 1095 cases, 233 hospitalizations, and 3 deaths.6,7 The size and seriousness of the epidemic caught the attention of physicians and the US public health service who, working together in the years that followed, rebuilt the US immunization system. By 2002, 2-year-old MMR coverage in Milwaukee reached 88%.8 Nationally, measles became a rare disease.9 Reminding us of our not-too-distant problems, Britain has recently suffered a decline in MMR coverage. Similar to the United States during the 1980s, up to one third of 2 year olds are unvaccinated. As a result, London experienced ongoing measles transmission during most of 2003.10 Still, many British parents refuse to allow their children to be vaccinated. This opposition to MMR vaccination, termed a national “collapse of confidence,” was largely instigated by Dr Anthony Wakefield, who published a small study in Lancet in 1998 suggesting that MMR was causally linked to autism.11,12 Wakefield’s claim has since been repudiated by his co-authors, and he, personally, is accused of having concealed a significant financial conflict of interest that may have influenced his work. Nevertheless, Dr Wakefield continues to actively promote the MMR/autism hypothesis13-15 and is joined in the United States by others who have taken up a similar crusade linking autism to vaccines containing thimerosal/ mercury.16,17 As a relative constant, by way of popular magazines, books, and the Internet, a wide variety of alternative medicine providers discourage childhood vaccination in general.18-21 To address whether these dissenting voices significantly influence Wisconsin parents, this study examines trends in vaccination coverage in Wisconsin over the past 14 years and reports the results of a survey of the views of state primary care pediatricians.

Brandt M. Mylott, MD; Theresa Kump; Marilyn L. Bolton; Larry A. Greenbaum, MD, PhD
Rickets in the Dairy State
(full text PDF)

Background: Nutritional vitamin D deficiency rickets occurs when children do not receive adequate vitamin D, which can be obtained from diet or manufactured in the skin when there is adequate sun exposure. A number of reports have described cases of vitamin D deficiency rickets in breastfed infants, but the public health significance of this problem in Wisconsin is unknown.

Objectives: Our objectives were to identify cases of vitamin D deficiency rickets in Wisconsin infants and to determine the percentage of these infants participating in the Wisconsin Women, Infant and Children (WIC) program.

Methods: All cases of rickets due to nutritional vitamin D deficiency seen at Children’s Hospital of Wisconsin or its associated outpatient clinics were identified by retrospective chart review. Data collected included date of birth, age at presentation, race, clinical presentation, diet history, history of vitamin supplementation, x-ray findings, and biochemical studies. The children with nutritional vitamin D deficiency rickets were cross-referenced with the Wisconsin WIC database.

Results: Fifty-one definite cases of nutritional vitamin D deficiency rickets were identified. Skeletal deformities, failure to thrive, fractures, seizures, incidental lab finding, tetany, and refusal to walk were the most common reasons for identifying rickets. All of the children were breastfed and did not receive vitamin supplementation. The infants had a mean age of 13.6 months and 46 (90%) were African American. Thirty-seven out of 51 children (73%) were enrolled in the Wisconsin WIC program.

Conclusion: Vitamin D deficiency nutritional rickets is an important public health problem in Wisconsin. The Wisconsin WIC program may be an important site for intervention strategies.

Elizabeth Oftedahl, BA; Ruth Benedict, OTR, DrPH; Murray L. Katcher, MD, PhD
National Survey of Children with Special Health Care Needs: Wisconsin-Specific Data
(full text PDF)

Background: The National Center for Health Statistics developed and conducted (2000-2002) the National Survey of Children with Special Health Care Needs (CSHCN), a module of the State and Local Area Integrated Telephone Survey (SLAITS).

Objective: The purpose of this paper is to present the Wisconsin-specific data derived from analysis of the national survey and to make a comparison with the United States as a whole.

Results: In Wisconsin, approximately one fifth (21%) of households have CSHCN, and 13.4% of children have a special health care need; US comparison data are 20% and 12.8%, respectively. When examined by type of special need, Wisconsin shows slightly higher proportions of CSHCN in all categories, when compared with US data, with the exception of limitation in activity. Families in Wisconsin with CSHCN are more likely to report being involved with medical decision making and satisfied with services they receive (67%); having a medical home (57%); having adequate insurance; easy use of community-based service systems (81%); and receiving services to make transition to adult life (7.5%).

Conclusion: Though Wisconsin has a slightly higher proportion of CSHCN than the United States as a whole, a greater proportion of Wisconsin families receive important services. These measurements allow us to strive for further improvement through coordination of services in the private health care delivery sector with public health programs.

Your Practice

Daniel Gibson, Financial Consultant
Have 529 plans lost their luster?
(full text PDF)

Are you utilizing a 529 plan for your child’s college education? If so, now is a good time to consider your savings plan options and ensure that this vehicle is still right for you.

Jay A. Gold, MD, JD, MPH
Improving rates of mammographic screening
(full text PDF)

The importance of regular mammograms for women is recognized by all experts. The US Preventive Services Task Force recommends screening mammography, with or without clinical breast examination, every 1-2 years for women aged 40 and older.1 The American Cancer Society recommends that women aged 40 and older have a screening mammogram every year, and that they continue to do so for as long as they are in good health.2 While there remains some controversy about women in their 40s and older women, recommendations for screening mammograms for women in their 50s and 60s are universally accepted.

Your Profession

Philip M. Farrell, MD, PhD
Excellent progress has been made but significant challenges remain
(full text PDF)

When I began as a pediatrician in the 1970s, the dawn of a new era in maternal-child medicine was just beginning. A virtual explosion of information about determinants of health and disease in infants and mothers was occurring. Obstetricians were starting to pay close attention to emerging technology and knowledge that could be used to deliver healthier babies.

Your Society

Editorial Comment excerpted from Wisconsin Medical Journal, 1904;5:285; Arthur J. Patek, AB, MD, Editor
The State Board Active
(full text PDF)

We are glad to note to the credit of the State Board of Medical Examiners another conviction for the illegal practice of medicine in this state. A man styling himself “Doctor Mak” was found guilty at Ashland, but—according to newspaper reports—was given time to leave the county under suspension of sentence.

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