According to the Centers for Disease Control, in 2017 Kentucky remained high among states in three leading causes of death, ranking first in deaths from cancer and chronic lower respiratory disease and ninth in deaths from heart disease. These diseases have long had a detrimental effect on public health in commonwealth, resulting from poor lifestyle habits among Kentucky citizens, lack of citizens’ access to health care, and scarce financial resources to pay for care, among other factors.
In September, KET conducted its latest health forum at the annual meeting of the Kentucky Medical Association in Louisville. Produced with KMA and hosted by Renee Shaw, the Prescription for Health Forum examined three major public health issues in Kentucky – smoking, Type 2 diabetes, and substance abuse – and touched on other current topics in health care.
The forum featured a four-person panel as well as several comments from physicians and public health professionals in the audience. The panel consisted of: Dr. Bruce Scott, MD, an ear, nose and throat physician and president of KMA; Dr. Monalisa Tailor, MD, an internal medicine physician; Allison Adams, director of the Buffalo Trace Department of Public Health and president of the Kentucky Health Department Association; and State Rep. Kim Moser (R-Taylor Mill), chair of the House Health and Family Services Committee.
Scott opened the discussion by reviewing the poor health indicators for Kentucky mentioned above, and he also mentioned the high smoking rates in the commonwealth – almost double the national average – and the ongoing opioid crisis. “As a result, Kentuckians live sicker and die younger,” he said. “These aren’t just statistics for us, these are our patients.”
According to the Centers for Disease Control, 46.1 percent of the U.S. population has diabetes (either Type 1 or, more commonly, Type 2) or prediabetes.
Dr. Fred Williams, MD, an endocrinologist, diabetes and metabolism specialist, spoke from the audience and said that when he began practicing in 1983, only 4 percent of Kentuckians were diagnosed with diabetes and about 20 percent with prediabetes (where blood sugar levels are elevated but not high enough to be diagnosed as Type 2 diabetes). Now, he said 14 percent of patients in Kentucky are diagnosed with diabetes, and over 1 out of 3 with prediabetes. Williams said that along with the higher rates of diagnosis, costs for drugs to treat diabetes have increased substantially, creating a pressing public health crisis in Kentucky and elsewhere in the U.S.
“The solution for this is not simple, otherwise we would have implemented something by now,” Williams said. “I think that the final solution is going to come from a variety of different areas, probably simultaneously.”
According to Williams, reducing diabetes in Kentucky will require the following steps:
- More access and better affordability to nutritious, whole foods, and eliminating sugared beverages.
- More physical activity for the entire lifespan, from childhood to the senior years.
- Reduce health care disparities in certain racial, ethnic, and socioeconomic groups.
- Improve access and reduce cost of diabetes medication.
“I think that solving the access issue and solving the affordability issue, in my opinion, is going to require a fairly major change in the whole health care system in this country,” Williams said.
Adams, of the Kentucky Health Department Association, discussed the value of Diabetes Prevention Programs run by some local public health departments in Kentucky. These year-long programs developed by Centers for Disease Control target the lifestyle habits Williams identified and educate patients to make permanent changes, resulting in long-term health benefits.
“It’s programs like the DPP that can really move a patient from thinking about changing to actually doing,” Adams said. “It’s the comprehensive package, because if you have a friend that wants to walk to and you meet them at the DPP and other evidence-based programs at the health department, you start to understand that you’re not in this alone.”
According to data from the Campaign for Tobacco-Free Kids, 24 percent of Kentuckians smoke, compared to 14 percent nationally. That’s the second-highest rate in the U.S. Dr. Tailor said that many of her patients that smoke have never really thought about why they took up, and maintain, the habit.
“Eventually they’ll come up with an answer,” Tailor said. “‘I’ve always done it.’ ‘It’s a stress reliever.’ ‘It’s how I get a break at work.’ But they’ve never thought about whether they could do something else to relieve their stress rather than pick up a cigarette.”
Options for smokers looking to quit are plentiful in Kentucky, and increased efforts are being made by public health organizations, physicians, and the state Health and Family Services Department to promote them and educate the public. Adams mentioned the Freedom From Smoking classes offered at some health departments, developed by the American Lung Association, that offers group support led by a trained facilitator.
“And then, the Quit Line is a pretty awesome program, with a counselor on the other line 24 hours a day,” she added. “So if you can’t find the time to go somewhere to actually participate in the group, you have a counselor.”
Ben Chandler, chief executive officer for Foundation for a Healthy Kentucky, and Dr. Patricia Purcell, a pediatrician, commented from the audience about addressing the significant rise in e-cigarette use among young people. E-cigarettes entered the U.S. market in 2007-08, Purcell said, which means that long-term research into their health effects is still lacking – and a recent spate of illnesses related to vaping, including pulmonary disease, has made national headlines.
“What I can tell you is that anyone who Juuls, who vapes, who uses an electronic nicotine delivery system device, is inhaling chemicals that have not been sufficiently studied,” Purcell said. “And we’re seeing the ramifications of that.”
Chandler said that Foundation for a Healthy Kentucky and other health organizations will be lobbying the 2020 Kentucky General Assembly to tax e-cigarettes at the rate of traditional tobacco cigarettes, and noted that Rep. Moser has already co-sponsored a bill adding this tax which will be introduced during the upcoming session. He also called for a ban on e-cigarette flavorings in Kentucky and, on the national level, for legislation that will raise the age to purchase tobacco to 21.
“It’s the use of these products by young people that we’re particularly concerned about,” Chandler said. “In fact, almost 80 percent of all usage of electronic cigarettes is by young people under the age of 18.”
The opioid crisis in Kentucky has continued to ravage families and communities since the late 1990s, but 2018 brought some positive, yet still sobering, news: according to the Kentucky Office of Drug Control Policy, overdose deaths declined in the commonwealth by 15 percent, from 1,566 the year before to 1,333.
Scott says that efforts to educate physicians about the proper prescription protocol for opioids are having an effect – opioid prescriptions are down, and the number of physicians using drug monitoring programs that were introduced in 2013 as part of state legislation are up. And community awareness is much more widespread. “The patients who come into my office now have a totally different attitude about the request for pain medication for after their tonsillectomy or their nasal surgery,” he said. “So the message is getting out. But we still have a major problem in our state, because we don’t have enough treatment opportunities for the patients who need it.”
Russell Coleman, U.S. Attorney for the Western District of Kentucky, and Dr. Philip Chang, chief medical officer for UK Healthcare, offered perspectives from the audience in the areas of law enforcement and pain treatment, respectively. Coleman said that his department’s mission is to pursue physicians who excessively, and criminally, over-prescribe opioids to patients rather than the overwhelming number of doctors who are responsible and ethical.
“We’re seeking the outlier,” he said. “We’re seeking the practice of a physician signing a stack of prescription pads and then leaving the country – an actual case in the western district of Kentucky. We’re seeking that conduct where a physician sees over 100 patients a day, three minutes or so per visit with a patient, and then writes scrips for opioids for cash.”
Chang discussed programs introduced at UK HealthCare that have transformed how pain management is administered by physicians, nurses, and staff. Chang and his team began by educating medical providers, and then moved to inform patients. They let patients know that pain can be treated by many other ways – pharmacologic and non-pharmacologic – apart from opioids. The overall effect has been to implement a new process for treating pain that ends with opioids rather than begins with them.
“We’ve leveraged the order sets in our electronic health records so that, for instance, we prompt you to order aromatherapy, we prompt you to order Tylenol or ibuprofen as appropriate, we have to go through things that are readily available – heating pads, cold pads, simple stuff – before you can get to the opioids,” he said.
Chang explained that his staff is upfront with patients, letting them know that pain is a part of their specific illness or injury and is to be expected. “Our goal together is to design a tailored, just for you, pain regimen so that you can participate in physical activities and rehabilitation,” he said. “Patient engagement, believe it or not, has actually gone up. They want to talk to us about their pain.”
- Several panelists and audience members touched on how they are re-focusing their health care systems to account for the social determinants of health. “One of the big things I see even in my patient population is that if you don’t have good access to housing, to food, to a good job, it’s going to be harder to do those proactive things to help with your health because you can’t get those basic needs met,” Tailor said.
- Addressing Kentuckians’ social determinants of health requires coordination among various providers, social service organizations, and schools. “I don’t think we’re working consistently in a collective, actionable way to improve the determinants of health at the county level,” Adams said. “I think that’s where public health comes into play – to convene the partners so that we’re working together in an organized fashion to improve the opportunities for health.” According to Adams, public health departments are currently expanding their services with assistance from legislators such as Rep. Moser to become leaders in formulating comprehensive health policy, while also maintaining their role as a safety net provider.
- Scott discussed a current KMA initiative that is designed to reduce barriers between patients and doctors in order to improve communication and care. AIM (Administrative Improvements in Medicine) for Better Care is designed to bring patients and providers together to share experiences about having delays in care and work toward solutions. “This is trying to attack those legislative, those administrative issues, those regulations from the health plans, those payer issues, and the public perception to a certain degree, that impact that valuable and precious relationship between the patient and the physician,” he said. According to Scott, two barriers to health care in Kentucky that are particularly harmful are pharmacy benefit managers (third party administrators for insurance plans) who in many cases disrupt drug prescriptions for patients, and insurance companies that require prior authorization for accessing substance use treatment in their policies.
- The popularity of “Dr. Google” as a resource for patients was discussed as it relates to the patient-physician relationship. Dr. Erica Sutton, MD, formerly an assistant dean at the University of Louisville School of Medicine and now the associate dean of academic programs at the Morehouse College’s School of Medicine in Atlanta, spoke from the audience about this relationship as it exists in the era of electronic media. According to Sutton, the Internet can be a useful self-learning tool for patients – but it’s no substitute for having an honest conversation with your doctor.
“If I were to write a prescription for health for patients, it would have two parts,” Sutton said. “First, find a doctor who listens to you and answers your questions. Being heard and having your questions answered is an important part of educating yourself about your own health. The second portion of your prescription would be to come to your doctor visits open and willing to share.”
A question-and-answer session between panelists and members of the audience followed KET’s forum – available below.