standing behind ohiows children summer … fully funded the prevnar vac - cine program. another...

In This Issue• Case Study: Lower extremity

overuse injuries

• Bike Helmet initiative

• Phase 2 of asthma project

• Coding Corner: Work smarter, not harder

Annual Meeting 2011

Are you attending this year’s

Ohio AAP Annual Meeting?

Make sure you register for

Casino Night on Friday, Aug.

26! Casino Night is a fundraiser

for the Ohio AAP Foundation,

and parents attending Casino

Night can take their children to

a Pajama Party at the same

time!

Casino Night and the Pajama

Party both run from 7-10 p.m.

For a $50 donation to the Ohio

AAP Foundation, adults can

play Blackjack, Texas Hold’em,

What is your first approach to common ill-

nesses in your practice? What should it

be? Join the Ohio AAP at its 2011 Annual

Meeting August 25-27 at Cherry Valley

Lodge to find out the most common prob-

lems that patients present to your office

with and how they can be treated based

on real cases from real patients. You will

also learn about vaccine myths and up-to-date information about com-

mon and uncommon infectious diseases from Robert Frenck, MD,

Cincinnati Children’s Hospital, in his presentation “Case-based Studies of

Common Pediatric Problems.”

Other topics on the agenda for the 2011 Ohio AAP Annual Meeting

include quality improvement, the medical home, and Maintenance of

Certification.

FREE bike helmets to be distributed

Bike safety is a common area of

concern for pediatric health-care

professionals as well as parents

and safety advocates. Each year,

about 300,000 children under the

age of 15 are treated in U.S. hos-

pital emergency rooms for bicy-

cle-related injuries.

As part of the Pre-Annual Meeting

programs, Mike Gittelman, MD,

Cincinnati Children’s Hospital

Medical Center, and Sarah

Denny, MD, Nationwide Children’s

Hospital, chairs of the Ohio AAP Related story on page 8

See Annual...on page 6

See Casino...on page 6

All bets are goodat Casino Night

Maintenance of Certification, Quality Improvement,Payment for Medical Home and more

Newsmagazine of the Ohio Chapter, American Academy of Pediatrics

S

Newsmagazine of the Ohio Chapter

Newsmagazine of the Ohio Chapter

, American Academy of Pediatrics hio Chapter r, American Academy of Pediatrics

, American Academy of Pediatrics

H

, American Academy of Pediatrics

H

Committee on Injury, Violence &

Poison Prevention, will provide

anticipatory guidance around

safety and bike helmets on Thurs-

day, Aug. 25 from 2:45-4 p.m. FREE

helmets will be distributed for use

in your practice.

S T A N D I N G B E H I N D O H I O ’ S C H I L D R E N S U M M E R 2 0 1 1

See Legislation...on page 8

www.ohioaap.org Ohio Pediatrics • Summer 2011

A Publication of the

Ohio Chapter, American

Academy of Pediatrics

Officers

President....Gerald Tiberio, MD, FAAP

President-Elect....Judith Romano, MD, FAAP

Treasurer....Andrew Garner, MD, PhD, FAAP

Delegates-at-large:

Jill Fitch, MD, FAAP

Allison Brindle, MD, FAAP

Robert Murray, MD, FAAP

Executive Director:Melissa Wervey Arnold450 W. Wilson Bridge Road, Suite 215

Worthington, OH 43085

(614) 846-6258, (614) 846-4025 (fax)

Lobbyist:Dan Jones Capitol Consulting Group

37 West Broad Street, Suite 820

Columbus, OH 43215

(614) 224-3855, (614) 224-3872 (fax)

Editor:Karen Kirk(614) 846-6258 or (614) 486-3750

Pediatrics fares well in state budgetRecent legislative activity at the

Ohio Statehouse is driven by con-

sideration of the state’s two-year

$56 billion operating budget.

When the Governor’s budget

proposal was announced on

March 15, it was clear that the

budget would be balanced with

cuts rather than revenue en-

hancements. The expenditure

cuts were focused on three con-

stituencies: primary education,

local governments, and nursing

homes.

In the case of primary education

and Medicaid expenditures asso-

ciated with nursing home care,

consistent funding was only possi-

ble in the last general assembly

because of federal stimulus dol-

lars. The Governor’s budget did

not propose reductions in Medi-

caid expenditures associated

with pediatric care, rather a

number of proposals required as

a result of the Affordable Care

Act should benefit pediatrics.

These proposals include the in-

crease in Medicaid payment for

preventative services up to Medi-

care payment levels and cover-

age for obesity screening ser-

vices. The budget process did

present some challenges for Ohio

AAP; an early review of the bud-

get did reveal the elimination of

immunization funding critical to

pediatrics.

Upon the introduction of the bud-

get bill, HB 153, Ohio AAP and

the Capitol Consulting Group

identified that $2.5 million in fund-

ing for Pnemoccocal Conjugate

Vaccine (Prevnar) had been

eliminated. These funds are vital

to ensuring that underinsured

children have access to this vac-

cine. Funding for Pneumococcal

Conjugate Vaccine had been

cobbled together from unique

sources over the past two bud-

gets, and it was not a complete

surprise that in a budget with $8

billion in cuts this would be left

out of the budget at introduc-

tion.

Ohio AAP advocacy to restore

the Prevnar funding included tes-

timony by Dr. William Cotton, be-

fore the House Finance Commit-

tee and dozens of meetings with

legislators conducted by Capitol

Consulting Group. State Senator

Shannon Jones (R- Springboro)

was exceptionally supportive of

the restoration of these important

funds, authoring the amendment

that fully funded the Prevnar vac-

cine program.

Another budget concern for

Ohio AAP did not arise until the

HB 153 was amended in the

House of Representatives. While

in the House, the budget was

amended to exempt children

enrolled in an Ohio eSchool from

state immunization requirements.

If enacted this amendment

would have exempted more

than 30,000 children from Ohio’s

basic immunization requirement.

Ohio AAP advocated vigorously

for the removal of this language.

The Ohio Senate later stripped the

House amendment from the bill,

maintaining the integrity of Ohio’s

immunization program.

The final budget concern of Ohio

AAP arose in the last step of the

state budget process, the Con-

ference Committee. In the final

week of June, the budget moved

to Conference Committee, a step

in the process intended to recon-

cile the hundreds of differences

between the House and Senate

passed versions of the bill. In Con-

ference Committee an amend-

ment was added to the bill, delet-

ing the BMI screening provisions

enacted through the Healthy

Choices for Healthy Children

Update from the Statehouse

2

The Governor’s budget did

not propose reductions in

Medicaid expenditures asso-

ciated with pediatric care,

rather a number of propos-

als required as result of the

Affordable Care Act should

benefit pediatrics.


President’s Message

Members’ needs priority of retreat

3

The general reader may not be

aware the Ohio AAP Board and

Committee Chairs have an

annual retreat. Strategic plan-

ning sessions have been around

for a long time, initially birthed in

the business world.

Every retreat requires compre-

hensive planning well in ad-

vance. Key components include:

a pre-retreat questionnaire, an

appropriate setting, a skilled

facilitator with adequate know-

ledge of the organization, key

players at the table, and ground

rules for time and efficacy.

I believe the pre-retreat question-

naire is useful to our membership:

1. Please rank the following ob-

jectives in order of importance

• To understand the challenges

facing our organization in

today’s environment

• To discuss directions our or-

ganization should take in the

future

• To discuss the relationship

between the board and staff

and how that relationship

could be improved

• To discuss the relationship

between the board and the

committee chairs and how

that relationship could be

improved

• To discuss our educational

programs, such as the open

forum and Annual Meeting,

and how to improve these

opportunities to better

serve our members.

2. Is there anything not included

in the above that you would like

to accomplish?

3. What are the top three major

issues facing our organization in

the next 3-5 years?

4. What are two suggestions for

ways that we can better serve

our members?

One main focus will be an in-

depth look at the open forums. A

SWOT (Strengths, Weaknesses,

Opportunities and Threats) analy-

sis was utilized as we split up in

work groups.

An abbreviated list of pertinent

points listed:

Strengths:

• CME

• Networking

• Linkages with members/

hospitals

Weaknesses:

• Too didactic

• Too much top down/more

grassroots

• Need more outcome data

Opportunities:

• Professional/personal relation-

ships

• Poll local community for

areas of interest

• Marketing MOC potential

• Multiple practice models

• Being viewed as inclement

(other sources for CME – Internet)

• Economics

Three overriding goals surfaced

from in-depth discussions (Board

members and Committee

Chairs):

1. Membership: Activate; recruit,

engage, retain

2. Provide a value-added experi-

ence for pediatricians at the

local level

3. Build alliances and collabora-

tions

The Open Forums have been in-

stituted to support our member-

ship. The Board and Committee

Chairs used time and talent to

redefine and fine-tune those to

meet member needs.

The retreat questions have been

laundry-listed above. Please note

them and consider providing in-

formation to help us meet your

specific needs/concerns.

The staff is always readily avail-

able. I will be most happy to

communicate with you by any

means you prefer. Collective

thinking/action is quite powerful.

Please help the Ohio AAP to

serve you and advance the

health and well-being of Ohio’s

children.

Gerald Tiberio, MD

Ohio AAP President

President Gerald Tiberio, MD

www.ohioaap.org Ohio Pediatrics • Summer 2011 4

Case Study: Lower extremity overuse injuryEditor’s note: The author of this

case study, Jeffrey R. Peiffer, DO,

is a Sports Medicine Fellow at

Akron Children’s Hospital in Ak-

ron, Ohio. He also serves as a

team physician for the University

of Akron and Walsh University.

History:

Michael is a 16-year-old cross

country and track runner who

participates in year-round training

and competition. His training

schedule consists of 8-12 hours of

running per week. He complains

of eight weeks of worsening left

ankle and foot pain with running.

Mechanism of injury:

There was no specific trauma to

ankle or lower extremity. He had

gradual onset of symptoms with

running activities.

Past Medical History:

Unremarkable with no previous

ankle or foot injuries.

Examination:

Gait analysis showed mild prona-

tion but no major anomalies.

There was no swelling, ecchymo-

sis, or deformity. Arch height was

normal. The ankle joint had nor-

mal plantarflexion, dorsiflexion,

inversion, and eversion. There was

no particular pain produced with

resisted active motion by foot dor-

siflexors or plantar flexors. No

focal tenderness was found on

the malleoli or the base of the fifth

metatarsal. There was mild focal

tenderness over the dorsal aspect

of the medial midfoot. This pain

was described as different than

the pain he has with running. The

anterior drawer test was negative.

5www.ohioaap.org Ohio Pediatrics • Summer 2011

There was no loss of sensation.

Pedal pulses were symmetric and

appropriate.

Since pain was not able to be

reproduced, the patient was

placed on the treadmill for five

minutes until the pain started in

typical fashion. He states that

there is dorsal midfoot pain with

radiation down the medial arch.

Radiographs:

An X-ray is ordered because of

pain around the tarsal navicular.

Left foot AP, lateral, and oblique

views were ordered and revealed

no obvious fracture.

Subsequently a bone scan was

obtained due to strong concern

for stress fracture with his type of

pain and level of activity. The scan

showed highlighted area over

tarsal navicular consistent with

stress fracture.

Treatment:

Patient was placed in a walking

boot and was non-weight bearing

for four weeks. Gradual weight

bearing and then weaning of the

boot was done over the next four

weeks. He had no pain at the fol-

low-up office visits. Follow-up radi-

ographs showed no evidence of

displacement, delayed healing, or

nonunion, therefore no CT scan or

orthopedics consultation was

ordered.

Rehabilitation program:

After the walking boot was totally

weaned off, he received a biome-

chanical evaluation and orthotic

fabrication.

Return to play:

He gradually built up to his previ-

ous running schedule over four

weeks. A total of 12 weeks passed

from diagnosis to full return to play.

He was also advised to take at

least one season off per year to

avoid future overuse injuries.

Jeffrey R. Peiffer, DO

Akron Children’s Hospital

In 2010, the number of people injured by NOT wearing a bike hel-

met was 51,000 - enough people to fill Nationwide Arena in

Columbus two and a half times.

Join Gov. John Kasich and the Ohio AAP in a statewide effort ded-

icated to raising awareness of the importance of wearing a bike

helmet.

Wear Your BikeHelmet to Work or School DaySept. 21, 2011

Casino..from page 1

Annual Meeting...from page 1

6

Beat the Dealer and Wheel of Fortune, as well as enjoy music, partici-

pate in a Wii “Just Dance” contest, enter to win raffle prizes or the 50/50

drawing, and more. The entry fee includes gaming chips to participate

in the games, as well as two drink tickets per adult.

Next door, the children will enjoy a Pajama Party, free of charge!

Children will watch movies, participate in activities, and will be provid-

ed popcorn, water and lemonade. At the end of the night, they will be

read a bedtime story (or two).

For more information on the Ohio AAP Foundation Casino Night and Pajama Party, log onto

http://www.ohioaap.org/foundation/casino-night-fundraiser

Pre-Annual meeting sessions, which start on Thursday, Aug. 25, will focus on

Chapter programs – developmental screening; childhood obesity; Maximizing

Office-Based Immunization (MOBI); and the bike helmet initiative. This day is

FREE of charge for Ohio AAP members and their staff. If you attend the entire

day you’ll earn 6.5 hours of CME and receive free materials valued at more

than $650!

On Friday, Ramesh Sachdeva, MD, American Academy of Pediatrics, will pro-

vide practitioners with the tools to bridge the gap from theory to practice for

quality improvement (QI) through a deeper understanding of the growing

need for QI in practices, and creating strategies to overcome barriers for

implementing successful QI.

A Quality Improvement roundtable discussion will explore Ohio AAP opportu-

nities for QI in the following programs:

• Ounce of Prevention is Worth a Pound of Cure

• Concerned About Development Learning Collaborative

• Chapter Quality Network Asthma Project, Phase Two

The Chapter has also brought together a panel of experts to discuss the med-

ical home. Hear an update on Ohio House Bill 198, which seeks to establish

the medical home model. Learn about new sources of reimbursement and

resources, the benefits of medical homes for patients and future opportunities

for physicians in Ohio. The experts include: Ted Wymyslo, MD, Medical Direc-

tor, Ohio Department of Health; John McCarthy, Ohio Medicaid Director,

James Bryant, MD, Ohio AAP member; and Mary S. Applegate, MD, Medical

Director, Ohio Medicaid.

Following the afternoon programs, an opening reception will be held from

4:30-6 p.m. This is a good time to network with other attendees, guests and

exhibitors. The evening also includes our Foundation fundraiser, Casino Night,

and a new 50/50 raffle.

For more information, and to register, visit our website www.ohioaap.org.

7 a.m. - Members’ Break-fast. Learn about theChapter’s programs,goals, and advocacy ini-tiatives.

9 a.m. - James Brown,

MD, American Board of

Pediatrics, will speak on

projects that have im-

proved care and are

approved for MOC

credit.

10:45 a.m. - Robert

Frenck, Jr, MD, Cincin-

nati Children’s, will speak

on case-based studies of

common pediatric prob-

lems.

12:30-2 p.m. - Annual

Awards Luncheon

Celebrate our members

and advocates who

have been champions

for children in 2011.

2-4 p.m. - Executive

Committee Meeting

All are welcome.

Saturday’sactivities



Accepting the House of Representatives Resolution are, from left,

Terry Barber, MD, Immediate Past President; William Cotton, MD,

Ohio AAP Advocacy Chair; Melissa Wervey Arnold, Ohio AAP

Executive Director; and Gerald Tiberio, MD, Ohio AAP President.

Ohio Househonors OAAPfor Very LargeChapter AwardOn May 18, the Ohio House of

Representatives honored the Ohio

Chapter as the 2010 Outstanding

Very Large Chapter.

The resolution stated, “This presti-

gious accolade is a fitting tribute

to the Ohio AAP for its excellence

in programs that promote the

health and welfare of children.

The Chapter has attained a re-

markable record of service to the

state, and its achievements are a

justifiable source of pride and a

fine reflection not only on the

organization itself but also on its

dedicated members for these in-

dividuals have certainly distin-

guished themselves as conscien-

tious and hard-working Ohioans.

“Over the years, the Ohio AAP

has enhanced the quality of life

within our state, and through its

generous contributions, it has

earned the respect and gratitude

of the many citizens it has so

capably served. We are certain

that as this worthy organization

maintains its commitment to ser-

vice, it will continue in the tradi-

tion of excellence that has long

been the hallmark of the AAP.

“The Ohio AAP is truly deserving of

high praise. We are proud to note

that it is through the unceasing

efforts of organizations such as this

that Ohio has gained a reputation

as a state that is responsive to the

needs of its citizens and has re-

mained a pleasant place in which

to live and work.

“We the members of the House of

Representatives of the 129th Gen-

eral Assembly of Ohio, in adopting

this Resolution, commend the Ohio

AAP on its national accolade and

extend best wishes for ongoing

success.”

The Resolution was initiated by

Representatives Mike Duffey and

Anne Gonzales and signed by

Speaker of the House of Repre-

sentatives William G. Batchelder

and Clerk of the House of Repre-

sentatives Laura P. Clemens.

CATCH Implementation Fund grants will be open Nov. 1, 2011 and

are due Jan. 31, 2012. These grants, of up to $12,000, support pe-

diatricians in the initial and/or pilot stage of developing and imple-

menting community-based child health initiatives that provide:

• Medical home access

• Access to health services not otherwise available

• Connecting uninsured/underinsured populations with available

programs

• Secondhand smoke exposure reduction

Visit www.aap.org/catch/implementgrants.htm for more informa-

tion.

Contact our state CATCH co-facilitators, Jonna McRury, MD,

([email protected]) or Mark Redding, MD, ([email protected])

for support.

CATCH grants available November 1


Bicycle helmet initiative rolls out at Annual Meeting sessionDid you know that helmet use can reduce the risk of

head injury by 85% and severe brain injury by 88%?

Did you also know studies show that patients and

their families listen to their pediatrician and that

what YOU say can actually change behavior?

The Ohio AAP Committee on Injury, Violence and

Poison Prevention has been working on a bike hel-

met initiative to try to increase the rate of bicycle

helmet use among Ohio’s children and make antici-

patory guidance around bicycle safety easier for

you.

Governor Kasich has declared Sept. 21, 2011, “Wear

Your Helmet to School/Work Day.” On this day we

are kicking off a big media campaign encouraging

people to wear their bicycle helmets. We have de-

veloped press kits including talking points, fact

sheets and story ideas and will be working with state

legislators to hold local media events.

We have reviewed the Behavioral Risk Factor Sur-

veillance Survey data from 2008 and 2010, conduct-

ed by the Ohio Department of Health, to get an

idea of how many children are wearing bicycle hel-

mets. We will be doing observation studies this sum-

mer and plan to continue those twice a year to

track change as our initiative progresses.

Pediatricians are an integral partner for success in

this campaign. Many of you have already expressed

interest in participating in our bicycle helmet study

and we are excited to get this under way this fall.

Participating practices will receive a survey to be

distributed to children between the ages of 5 and

14 when they present for well child visits. The survey

will ask about various safety issues, including bicycle

helmet use. Those patients who answer that they do

not use or own a helmet will be randomized to re-

ceive either anticipatory guidance on bicycle hel-

met use, or anticipatory guidance and a bicycle

helmet. These families will receive a follow up call in

a month to see if there has been any change in

behavior in either group. Participating practices will

receive bicycle helmets from the Ohio AAP for distri-

bution.

Please join us on Thursday, Aug. 25 at Cherry Valley

Lodge for the bicycle helmet session. This day of the

Annual Meeting is free for Ohio AAP members and

their staff.

If you are interested in participating, have any ques-

tions, or would like any marketing materials, please

contact Lee Ann Henkin, [email protected].

Sarah Denny, MD

initiative last year. As originally

passed the BMI screening pro-

gram allows for school districts

to opt out of the program, this

amendment would have elimi-

nated the program all together.

Thanks in large part to the advo-

cacy of the Ohio Business

Legislation...from page 2 Roundtable, a coalition partner

on the Healthy Choices for

Healthy Children initiative, and

some timely budget bill analysis

by the Capitol Consulting Group,

the Governor vetoed the trou-

blesome amendment.

On June 30, the budget was

signed by Gov. Kasich, marking

the end of another intense bud-

get process. The General Assem-

bly is now off for summer recess;

a recess that likely will last until

September.

Ohio AAP members should be

very proud of these important

accomplishments in a very diffi-

cult budget year.


GUIDELINES FOR PEDIATRICIANS

Overuse injuries in athletesOveruse injuries are a result of progressive repetitive cyclic overloading of tissues. Repetitive microtrauma overwhelms thetissue’s ability to repair itself and will lead to an overuse injury. Injury damage can progress from microdamage (pain) tomacrodamage (swelling, redness, warmth). High velocity cyclic overloading can produce an “overuse” injury in seconds.An example would be a 100 meter sprinter who sprints for 10 seconds and then suffers a hamstring muscle pull. Low veloci-ty cyclic overloading, combined with increasing training volumes, can lead to an overuse injury after weeks or months ofcontinuous stress. An example would be a marathon runner with a one-year history of progressively worsening Achilles ten-dinitis. The body is unable to adequately adapt to the physiological stress placed on it.

Types of overuse injuries1. Tendonopathies (tendinitis, tenosynovitis, tendinosis)

such as achilles tendinitis, epicondylitis2. Medial tibial stress syndrome (shin splints, periostitis)3. Apophyseal injuries such as Sever’s, Osgood-Schlatter’s

and Little league elbow4. Stress fractures5. Muscle soreness and strains6. Bursitis

Factors contributing to overuse injuries

1. Repetitive cyclic overloading of tissue

2. Increased training volume (too much, too soon, too

frequent, too hard)

3. Poor or improper mechanics or technique

4. Improper training techniques

5. Lack of rest to allow the body to adapt to training

6. Improper equipment such as wrong shoes, wrong

racquet size

General Treatment Principles Most overuse injuries are treated successfully by adhering tothe following principles:

1. The principle of P.R.I.C.E.

P = Protection – protect the injured extremityR = Rest – relative rest: cross train or deep-water runningI = Ice – apply ice for 20-30 minutes every 2-3 hrs for first

3 daysC = Compression – apply an elastic wrap to reduce

swellingE = Elevation – raise extremity above the level of the heart

2. Rehabilitation

1. Muscle strengthening2. Improve balance and range of motion3. Flexibility4. Functional sports specific activities5. Cross training sports activities

3. R.E.S.T. = Resume Exercise Below Soreness Threshold

1. Reduce Volume: 25 – 30%

2. Reduce Intensity: 10 – 20%

3. Reduce Frequency: 25 – 50%

4. Correct Biomechanical and Training Errors 1. Obtain a formal biomechanical analysis2. Have your biomechanics and technique evaluated

and corrected3. Use orthotics or a brace if recommended4. Use correct shoes 5. Use proper equipment – correct fit and well

maintained6. Strengthen muscle imbalances7. Adhere to a regular stretching program8. Review training program with an expert

Preventing overuse injuries

1. Localized pain 6. Loss of motion

2. Swelling 7. Loss of function

3. Redness 8. Localized tenderness

4. Warmth 9. Worsened with activity

5. Weakness

1. Educate. Have athletes

carefully monitor their

training progression.

2. Recognize the early signs

of injury

3. Address all injuries, even

minor ones

4. Have athletes include a

daily stretching and

strengthening program

5. Evaluate and correct bio-

mechanical problems

6. Educate on proper

equipment and fit

7. Avoid early specialization

and year-round single

sports competition

8. Instruct on appropriate

warm-up and cool-down

periods with each training

session

Author: Troy Smurawa, MD

Sports Shorts is provided by the Home and School Committee

of the Ohio Chapter, American Academy of Pediatrics

This information is available on the Ohio Chapter, American Academy of Pediatrics’ website www.ohioaap.org


GUIDELINES FOR PARENTS, COACHES, ATHLETES

Physical activity is good for children. Organized sports help chil-

dren build a sense of character, self-esteem, self-discipline and

positive skills that will last into adulthood. But for all the advan-

tages sports can bring, parents need to take caution because

kids are at greater risk for injury than ever before.

While organized sports are much more competitive and kids

are under a lot of pressure, parents should seek a balance.

Some parents are told that for children to be competitive, they

need to focus on a single sport starting at a young age. And

they need to play and work at that sport year round. As a

result, there is no rest and recovery for the parts of the body

they are using. Kids are doing the same drills and repeating the

same movements over and over again, making them suscepti-

ble to an abnormal amount of stress and load. Even worse,

athletes are expected to play through the pain.

Overuse injuries on the riseOveruse injuries have risen steadily over the past 10 years for

young athletes ages 6 to 15. These injuries occur when tissue

(muscle, tendon, growth plates, bone) exceeds capacity to

absorb or accept stress and breaks down, causing pain.

Previously, it would have taken years to reach this capacity, as

in the case of an aging major league baseball pitcher with

arthritis. But in pre-adolescent children, growth plates are espe-

cially vulnerable. They are spongy, cartilage like spots in the

body where bone is still growing and developing. Children

ages 6 to 18 have more than 200 in the body. At first pain starts

only with the activity or just after, but later it begins to hurt with

normal daily activities.

The most common overuse injuries occur in gymnastics, dance

(in particular ballet, especially if they dance “en pointe”),

baseball, softball, soccer and weight training. Training “too

much, too hard, too soon, too frequent” is the most common

cause of overuse injuries in athletes. Gymnasts who practice

15 to 20 hours a week are overloading the growth plates in

their wrists. Little League pitchers who throw more than 100

pitches a week overstress their shoulders and elbows.

Basketball players who are on several teams and work out four

or five nights a week may be overloading their knees. Physi-

cally, these kids appear ‘over the hill’ by age 14 or 15.

These types of injuries sometimes require surgical repair, but

because rest is required before rehabilitation can begin it can

take months to return to activity. Unfortunately, too often, ath-

letes don’t rest or go through rehabilitation so they can get

back in the game and re-injury occurs. If overuse injuries are

severe enough, they can end a child’s participation in a sport.

The typical signs and symptoms of overuse injuries include pain

with movement, swelling, warmth, redness, weakness, difficulty

performing a sport, and pain at rest.

How did this happen? How did this happen? Many parents and coaches see success-

ful athletes making huge salaries or getting college scholarships

and they want the same for their kids. Some are living their

sports dreams through their children. Most parents simply want

to expose their children to the benefits of organized sports as

well as regular fitness and exercise.

The problem is that each child is different and when you push

one to keep up with another, that’s when injuries occur.

1. Rest – complete rest or limited activities2. Apply ice to area 20 – 30 minutes3. Compression with an ace wrap4. Elevation of the affected limb5. Nonsteroidal Anti-inflammatory medication 6. Protective bracing may be helpful in certain

conditions7. A gradual progression back into sports participation

Guidelines for overuse injuries

1. Avoid over-training – carefully monitor your training progression; remember the10% per week

2. Listen to your body and REST when needed; DO NOT try to make-up missed training session

3. Recognize the early signs of an injury4. Address all injuries, even minor ones5. Allow your body time to recover and heal6. Include daily stretching into your program7. Include a strengthening program in your training8. Correct biomechanical problems9. Warm-up and cool-down adequately with each

training session10. Avoid early sports specialization and year round

single sports competition

Tips for preventing overuse injuries

Sports Shorts is provided by the Home and School Committee

of the Ohio Chapter, American Academy of Pediatrics

This information is available on the Ohio Chapter, American Academy of Pediatrics’ website www.ohioaap.org

Author: Troy Smurawa, MD

Overuse injuries in athletes

Using developmentalscreening in your office

12

100’s of Physiciansseeking jobs in Ohio

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and private practices with an online recruitment

program, designed to connect Physicians,

Physician Assistants, and Nurse Practitioners

with jobs in Ohio. Job seekers register for

FREE! Our database of Physicians spans

more than 85 specialties!

Employers, contact us today to learn

more about how the MOO program can

work for you!

800.479.1666www.ohmoo.org


The last Open Forum of the year

was held in May at the University

of Toledo. The 100+ attendees

learned in a presentation about

the Concerned About Develop-

ment Learning Collaborative

(CADLC), a quality improvement

program of the Ohio AAP, how to

How to differentiate the maincauses of delays in languageand social-emotional develop-ment are explained to atten-dees by Jessica Foster, MD.

Cathy Costello from the OhioHealth Information Partnership,explains the use of electronichealth information exchange. See Forum...on page 13

Ohio AAP hard at work for youThe Ohio AAP has been work-

ing with the Ohio Medical

Board and their “Pill Mill” rules.

Initially, the medical board was

going to require mandatory

OARRS (Ohio Automated RX

Reporting System) checks by

doctors who prescribe ADHD

medication at the initial pre-

scription visit and every 12

weeks. After testimony of many

experts (including Ohio AAP)

the medical board has current-

ly decreased the reporting re-

quirement to the initial pre-

scription visit and then yearly.

More frequent checks would

be expected with concerning

patients or parent behavior.

Ohio AAP is also working with

Ohio Medicaid to minimize the

hassle factor associated with

Medicaid prescriptions requir-

ing prior authorization. The for-

mularies were given back to

the Medicaid HMOs and there

will no longer be an Ohio Uni-

versal Medicaid formulary.

Ohio AAP is trying to make

Medicaid HMOs match formu-

laries as much as possible.

differentiate the main causes of

delays in language and social-

emotional development, includ-

ing autism. Attendees also

learned how to complete and

interpret a comprehensive assess-

ment for these delays.

Through CADLC, physicians are

provided with evidence-based

tools that can help identify poten-

tial problems even parents might

miss. Physicians are taught how to

use and interpret the screening

tools without disrupting the busy

office flow.

Presenter Jessica Foster, MD, also


Chapter Quality Network AsthmaProject begins work in August

Physicians across the country turn to ChildLab because we care about your patients as much as you do.

For a complete list of our pediatric laboratory tests and pathology services, visit www.childlab.com or call 800-934-6575.

In an effort to continue the work completed by the

Ohio AAP and the 13 practices who participated in

the Chapter Quality Network (CQN) Asthma Pilot

Project, the Ohio AAP – with funding from the

CareSource Foundation – is launching into phase two

in late August.

The national office of the American Academy of

Pediatrics is providing the Alabama and Ohio chap-

ters, along with Ohio’s Partners for Kids, with tools,

resources and technical support to lead a quality

improvement (QI) effort amongst 10 to 15 member

practices. Chapters will support practices in imple-

menting the National Heart, Lung, and Blood Institute

(NHLBI), National Asthma Education and Prevention

Program (NAEPP), Expert Panel Report 3 (EPR3) asth-

ma guidelines.

In phase two the CQN will focus on

moving toward full population data,

building payor engagement, and

improving parent involvement.

Results of CQN Pilot Asthma ProjectFour AAP chapters were selected to participate in

the CQN Asthma Pilot Project, which began in

September, 2009. The Alabama, Maine, Ohio and

Oregon chapters recruited 49 practices which in-

cluded 282 clinicians to participate in a 12-month

learning collaborative. Rapid improvement in care

processes related to using a validated instrument to

assess asthma control, using the NHLBI stepwise tables

to adjust treatment, assuring that all patients had an

See Asthma...on page 14

told attendees how to organize a

process for linking families with

local diagnostic and evidence-

based intervention services relat-

ed to language and social-emo-

tional development in their area.

(See related story on Page 18.)

Electronic Medical RecordsIn the second part of the pro-

gram, attendees learned how to

implement the use of electronic

health information exchange (HIE)

in order to improve the safety,

quality, accessibility, availability

and efficency of health care for

patients.

The next Ohio AAP Open Forum

meeting will be held in January/

February 2012 in Cincinnati.

Watch the Chapter website and

publications for topics.

Forum..from page 12

asthma action plan, and providing or recommending

a flu shot, were recorded monthly. In September 2009

initial data showed that these four processes, bun-

dled into one measure of optimal care, were adminis-

tered for only 35% of asthma patient visits. At the one

year mark, optimal care was provided at 85% of

patient visits, just shy of the pre-set goal of 90%.

Providing patients with self-management support was

recorded for 60% of patient visits at the start of the

collaborative and rose to 87% by the one year mark.

Other changes in care practices included:

• Performance of spirometry per NHLBI guidelines for

diagnosis or monitoring improved from 49% to 62% of

encounters.

•An increase in the percent of patient visits at which

the patient is provided an updated asthma action

plan – from 49% to 91%.

Of the 216 physicians in the collaborative, 92% com-

pleted the requirements of the project to be award-

ed credit for the ABP’s Maintenance of Certification

Part 4.

CQN2 MissionThe CQN Asthma Project, Phase Two (CQN2) works at

the practice, state and national levels to build a net-

work of AAP chapters and enhance their ability to

lead a quality improvement collaborative to achieve

measurable improvements in the health outcomes of

children.

The CQN2 provides chapters and partners with tools,

resources and technical support to lead this quality

improvement (QI) effort. The Ohio AAP will gain QI

knowledge and work to increase their capacity to

support member practices in QI efforts. The Academy

has received ABP MOC QI project approval so that

participants can receive part 4 Performance in Prac-

tice credits for completion of the project.

In phase two, the CQN will focus on moving toward

full population data, building payor engagement,

and improving parent involvement.

For more information on CQN2, please contact,

Chapter Project Manager, Heather Hall at (614) 846-

6258 or [email protected].


SERVING STUDENTS WITH LANGUAGE-BASED LEARNING DIFFERENCES AND ATTENTION DEFICIT DISORDERS

TEACH | IGNITE | INSPIRE

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Asthma...from page 13

• At the one year mark op-

timal care was provided at

85% of patient visits up from

35%

• Providing patients with

self-management support

was recorded for 60% of

patient visits at the start of

collaboration and rose to

87%

• Performance of spirome-

try per NHLBI guidelines for

diagnosis or monitoring im-

proved from 49% to 62%

• An increase in the per-

cent of patient visits at

which the patient is provid-

ed an updated asthma

action plan went from 49%

to 91%

Asthma PilotProject at a glance

District V Report

One of my personal heroes, and

very possibly one of yours, is

Marion Wright Edelman, founder

and presi-

dent of

the Chil-

dren’s

Defense

Fund. She

says, “In-

vesting in

[children]

is not a

national

luxury or a

national

choice. It's a national necessity.”

In this era, as we continue to strive

to improve the health and well-

being of all children, this concept

remains important to direct our

cause.

The American Academy of Pedi-

atrics has as its purpose: “Ded-

cated to the Health of All Chil-

dren” and never has that been

more important. As a nation we

recognize that there are many

challenges and choices that will

be made in the months and years

ahead and those that speak for

children will need to keep their

voices steady and strong.

We recognize that to be effec-

tive, we as pediatricians need to

be strong ourselves, and address-

ing the needs of our members is

essential.

Some of the ways nationally and

in our district that we are meeting

the needs of members are by sup-

porting young physicians and pe-

diatric subspecialists. We also are

meeting members’ needs by en-

hancing resources for Maintena-

nce of Certification.

Each of these areas has been ad-

dressed specifically in the district

and your chapter leaders have

provided support as well. Nation-

ally, the Office of Federal Affairs

has added a full-time staff mem-

ber to focus on specialty pedia-

trics. Additional examples of pro-

motion of young and specialty

physicians include the Section on

Perinatal Pediatrics that has en-

gaged their trainees in an initiative

called TECaN (Trainees and Early

Career Neonatologists) to foster

career development and en-

hancement of leadership in Neo-

natal-Perinatal Medicine.

The Section on Surgery is working

with the Section on Residents and

the Association of Pediatric Pro-

gram Directors to develop a cur-

riculum for pediatric surgery for

pediatric residents and practicing

pediatricians.

The Ohio Chapter continues to ad-

vance the opportunities for Main-

tenance of Certification, and na-

tionally more programs are being

developed. Your chapter leaders

are ensuring that your needs are

met. We seek your input and sug-

gestions for specific areas where

we can support your interests and

encourage direct communication

to focus on your needs.

Marilyn J. Bull, MD

District V Chair

Marilyn Bull, MD

We need to be strong tobe effective for children


MOBI scoreshigh marks inCDC report

The Ohio Department of

Health (ODH) is asked by the

Centers for Disease Control

(CDC) to evaluate one of

their grant programs every

two years. This year, ODH

chose to examine the Max-

imizing Office Based Immu-

nization (MOBI) program,

which is funded through a

grant from CDC and ODH

and implemented by the

Ohio AAP.

The overall goal of the MOBI

program is to increase immu-

nization rates to 90% among

children 2 years of age living

in Ohio.

The object of the evaluation

was to get a clearer picture

of the strengths and weak-

nesses of the program. The

recommendations from the

evaluation will aid in ensur-

ing appropriate goals are

set, as well as identifying

areas in which the MOBI pro-

gram can be developed so

that it can more effectively

meet these goals.

The evaluation showed that

the MOBI program has been

successful in aiding the

adoption of immunization

best practices by pediatric

and family practice primary

care offices throughout

Ohio.

Measurements taken during

the MOBI presentation and

See MOBI...on page 19

Work smarter, not harderCoding Corner

16

The bread and butter codes

for most pediatricians, both

generalists and specialists, is

the established patient

99212-99215 series. These

codes are to be used for

problem-oriented estab-

lished patient office visits,

and are selected based on

criteria defined in the CPT

book. Traditionally it has

been assumed by payers

and providers alike, that the

use distribution of these codes is in a bell-shaped

curve or bar graph as represented (figure 1), with

the 50% peak number of visits provided at 99213.

Multiple studies have now shown that for general

pediatricians, seeing a typical patient population,

this graph should be shifted to the right (figure 2),

with a significant

number of 99214

visits provided.

To make the

opportunity

even greater, it

has also been

determined that

most pediatri-

cians code with

a coding curve shifted to the left, with few 99214,

and rare 99215 visits (figure 3). Specialists will often

have a graphic coding representation shifted to the

right with a significant number of 99215 visits. This

results in a huge

opportunity to

increase a pedi-

atrician’s bot-

tom line, with-

out additional

work or prac-

tice overhead,

by appropriate-

ly coding 99213

and 99214

established patient office visits.

The 99213 or 99214 level is selected based on meet-

ing two of the

three key criteria

of history, exami-

nation, and

medical deci-

sion. The code

can also be

selected based

on time, when

more than 50%

of the face-to-face encounter time is spent coun-

seling and/or coordinating care in the outpatient

setting.

It is helpful to consider reasons for visits when you

ask yourself if a particular office visit should be a

99214 instead of the typical 99213 established office

visit. A partial list of problems with examples, which

should raise the question of coding 99214 vs. 99213

include:

A Child with Special Health Care Needs

Ex : Cerebral palsy, ADHD, premature infant

An Established Patient with a New Diagnosis

Ex : newly diagnosed bronchiolitis, urticaria

Multiple active diagnoses

Ex: patient with pneumonia and otitis media

A repeat visit for a patient problem – patient worseEx: Patient returning with persisting sore throat andfever, strep negative at earlier visit

Co-morbities - not inherent in the problem being

seen

Ex: Pharyngitis with fever and lethargy

A patient requiring Lab or X-ray to diagnose and

manage the problem

Ex: CXR to diagnose pneumonia, CBC to r/o leuko-

cytosis

A patient problem requiring consultation with anoth-

er physician or facility (telephone or face-to-face

consultation)

Ex: Patient with infectious disease prompting call to

local ID specialist

Richard Tuck, MD

EM ESTABLISHED OFFICE- Expected

0055

110011552200225533003355440044555500

EEMM EESSTT OOFFFFIICCEE

99992211119999221122999922113399992211449999221155

EM ESTABLISHED OFFICE- Real Pediatrics

00

55

1100

1155

2200

2255

3300

3355

4400


99992211119999221122999922113399992211449999221155

EM ESTABLISHED OFFICE- Actual

00

1100

2200

3300

4400

5500

6600


99992211119999221122999922113399992211449999221155

Figure 1

Figure 3

Figure 2


See Coding...on page 17


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A prescription written for the problem(s)

Ex: Antibiotics prescribed for recurrent otitis media

(straightforward otitis media would typically be a

99213 visit)

The problem requires office procedures (aerosol,

pulse ox)

Ex: Patient with exacerbation of asthma requiring

office aerosols, pulse ox

A patient with chronic problem requiring change in

treatment

Ex: Patient with asthma and frequent exacerbations,

requiring treatment adjustment in controller/rescue

meds

A patient with a time-based office visit or “consulta-

tion” not truly meeting the requirements of a consul-

tation visit

Ex: Patient with behavior or toilet training problems

requiring extensive time-based counseling

A follow-up visit requiring extensive discussion

Ex: F/U visit for ADHD with significant home and

school behavior problems

Although, the problems in this list generally support a

99214 visit level, they are not in and of themselves the

defining element in code selection. They should, how-

ever, prompt you asking yourself if this visit could be a

99214, instead of the too frequently used 99213.

In addition to appropriate documentation to support

these visit levels, ICD diagnosis coding should also

support the CPT level selected, consistent with the

considerations outlined above. This includes coding

multiple diagnoses, co-morbidities, and all problems

addressed at the visit.

Remember: Code and work smarter; not many of us

can work harder!

Richard Tuck, MD, Zanesville

Ohio AAP Coding Expert

Coding...from page 16

Ohio AAP welcomes new members


Ilona Brener Albrecht, Dayton

Alicia Marie Alcamo, Cincinnati

Amber Ellis Anastasi, Cincinnati

Katherine Scott Auger, Ann Arbor,

Raymond C. Baker, Cincinnati

Lauren Cantor Bar-lev, Columbus

Elizabeth Barnes, Dayton

Paul S. Bellet, Glendale

Melissa K. Benvow, Dayton

Thomas F. Boat, Cincinnati

Aparna Bole, Cleveland

Ada Booth, Corpus Christi, TX

Eric Scott Bowman, Grove City

Miles J. Burke, Cincinnati

Mary Carol Burkhardt, Cincinnati

Lindsay C. Burrage, Houston

Rolly Chaudhary Chawla, Avon

Sophia W. Chen, Broadview Hts.

Mary Lorentz Clough, Gates Mills

Victoriano T. Co, Fairfield

Leandro Cordero Jr., Columbus

Corin Cozzi, Columbus

Dannika Cross, Gwynn Oak, MD

Joel Davidson, Akron

Sarah Anne Denny, Worthington

Katie Ellgass, APO

Rachel M. Engen, Brookline, MA

Benedicta G. Enrile, Worthington

Emily Tancous Ferguson, Colum-

bus

Adam Garlock, Columbus

Kristin Leigh Garton, Columbus

Rakhi Gupta, Cleveland

Scott E. Hickey, Hilliard

Susan E. Ingraham, Columbus

Irwin B. Jacobs, Chagrin Falls

Stephen A. Koff, Columbus

Venkatesan Krishnan, Sylvania

Eileen Murtagh Kurowski, Cincin-

nati

Lisa M. Light, Twinsburg

Jamie R. Macklin, Grove City

John C. Markovich, Cincinnati

Mindy Deason Marlowe, Sanford

John David Martino, Columbus

Margaret McBride, Akron

Bruce P. Meyer, Columbus

Cameron Miller, New Albany

Jillian Miller, Stow

Laurie Mitan, Cincinnati

Teresa Moon, Barberton

Andrew Newburn, New

Philadelphia

Andrew Garrett Norris, Columbus

Gregory J. Omior, Akron

Tiffany Jan Owens, Dayton

Douglas P. Powell, Cleveland

Regina E. Ramirez, Strongville

Charles R. Redman, II, Columbus

JoAnn Clare Rohyans, Columbus

Sarah Ronis, Rochester, NY

Allison L. Rund, Shaker Hts.

Melissa Lynn Skaug, Columbus

Mary Kathleen Skoch, Lakewood

Michael Slogic, Witchita, KS

Denise Anne Somsak, Cincinnati

Libbie Stansifer, Cleveland Hts.

Hurikadale P. Sundaresh, Solon

Sherri Ann Thomas, Bowling Green

Jonathan Lee Tolentino,

Cincinnati

James Tschudy, Mountain Home

Carrie Tuten, Columbus

Kleuhoa Tran Vo, Columbus

Kirstin Weerdenburg, Toronto, ON

Valerie T. Whitcomb, Royal Oak,

MI

Pamela Hood Williams-Arya, Cin-

cinnati

Matthew J. Wyneski, Medina

Rachael Zanotti-Morocco, New

Albany

Campaign raises awareness ondelays in developmentThanks to a grant provided by the Ohio Department

of Health, Bureau of Early Intervention Services, the

Ohio AAP’s Autism Diagnosis Education Pilot Program

(ADEPP), and the coordinating Concerned About

Development Learning Collaborative (CADLC), was

able to hire a communications firm to raise public

awareness about developmental delays.

The campaign focuses on three common develop-

mental milestones – smiling, crawling and talking –

which show parents holding their child asking if he/

she should be smiling/crawling/talking yet? Mobile

billboards, print ads, and radio spots are already

popping up around the state.

A campaign to raise public awareness aboutdevelopmental delays are using mobile bill-boards to get the message out to parents.

Ounce makes office callsThe Ohio AAP wants to help you. After much success with the Ounce of Prevention regional trainingsand webinars, the Ohio AAP has decided to bring the Ounce of Prevention program to your office!

With a grant from the Ohio Department of Health, Robert Murray, MD, or Amy Sternstein, MD, willtravel to your office and provide a one-hour FREE CME training on a date and time that works bestfor YOU!

Along with training for pediatricians and office staff, you will receive an Ounce of Prevention toolkit thatincludes: · Parent handouts on nutrition, physical activity, calcium, snacks and serving sizes · Anticipatory guidance tip sheets for the patient's chart, office posters, BMI growth charts, and BMI wheels

· CD with all educational materials in English and Spanish

To register, please visit: http://www.theounceofprevention.org/parentsurvey/ounce-of-

prevention-training-information/office-based-training


one month following showed that

the MOBI program was successful

in helping offices change in seven

of the eight recommended immu-

nization practices.

Prior to their MOBI presentation,

more than two-thirds of the offices

had scheduled or had AFIX mea-

surements. An additional 26 offices

scheduled or had AFIX measure-

ments done at the time of the

one-month follow up. The practice

of checking patient’s immunization

status at every visit was improved

upon most with 66.0% of offices

engaging in the practice before

the MOBI and 85.9% of offices

practicing it after. Sixty-eight per-

cent of the offices gave immuniza-

tions even if a mild illness was pre-

sent before the MOBI. This im-

proved to 75.9% one month after.

Three hundred and ten offices

(69.2%) gave all vaccines that pa-

tients are due previous to the

MOBI and 350 or 78.1% did at fol-

low up. The percent of offices that

updated their policies to reduce

barriers to immmunization im-

proved from 53.1% to 65.0%. The

use of reminder recall system im-

proved from 50.9% to 65.0% of of-

fices. Finally, 68.3% of offices were

using the IMPACT SIIS immunization

registry, which increased from

59.4% at the baseline.

The only practice that did not

show significant improvement was

VFC enrollment. Three hundred

forty-five offices were enrolled in

the VFC program prior to the MOBI

and four offices became providers

or started the process between

the times of the MOBI to the one-

month follow up.

Key recommendations from the

report include adding behavioral

change objectives to the logic

model in order to build more ef-

fective strategies to address and

target barriers practices may have

to adopting the recommended

MOBI practices.

As a result of the report, the MOBI

program will refine its current sur-

vey tool for improved validity and

reliability which are key steps to

enhance measurement accuracy.

MOBI...from page 15

The Ohio AAP announces the following meetings and events.

Aug. 25-27 Ohio AAP Annual Meeting

Thursday, Aug. 25 - FREE day for members and their staff.

9 a.m. Developmental Screening

11:15 a.m. Ounce of Prevention is Worth a Pound of Cure

1:30 p.m. Maximizing Office-Based Immunization (MOBI)

2:45 p.m. Bike Helmets: Anticipatory Guidance and Free Helmets

Friday, Aug. 26

12:30 p.m. Quality Improvement

1:45 p.m. Quality Improvement Roundtable Discussion

2:45 p.m. Medical Home Panel: Reimbursement, Resources & Benefits

4:30 p.m. Opening Reception

7 p.m. Casino Night for Adults; Pajama Party for Kids

Saturday, Aug. 27

7 a.m. Ohio AAP Annual Breakfast

9 a.m. Maintenance of Certification

10:45 a.m. Case-based Studies of Common Pediatric Problems

12:30 p.m. Annual Awards Luncheon

2 p.m. Ohio AAP Executive Committee Meeting

Sept. 21 Wear Your Helmet to School/Work Day

Calendar of Events

Dues remitted to the Ohio

Chapter are not deductible

as a charitable contribution,

but may be deducted as an

ordinary and necessary busi-

ness expense. However, $40

of the dues is not deductible

as a business expense be-

cause of the Chapter’s lob-

bying activity. Please consult

your tax adviser for specific

information.

This statement is in reference

to fellows, associate fellows

and subspecialty fellows.

No portion of the candidate

fellows nor post residency

fellows dues is used for lob-

bying activity.

Ohio ChapterAmerican Academy of Pediatrics450 W. Wilson Bridge Rd. Suite 215Worthington, OH 43085

PRESORTEDSTANDARD

Permit No. 156

U.S. Postage

PAID

DUBLIN, OH

Dues disclosure

statement

standing behind ohiows children summer … fully funded the prevnar vac - cine program. another...

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