AAP Endocrinology Newsletter Summer/Fall 2002


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AAP Endocrinology Newsletter Summer/Fall 2002

  1. 1. The Section on ENDOCRINOLOGY Newsletter Volume 10 Summer/Fall 2002 Chairperson’s Column Inside this Issue Janet Silverstein, MD Growth Hormone in The last newsletter was devoted to the and work force issues are the major concerns of Peripubertal Children: Is it manpower issues currently resulting in long section membership. This resulted in the distribu- Really Worth the Cost? workdays for pediatric endocrinologists, long tion to both AAP SOEn members and members of Paul Kaplowitz, MD waits for patients to be seen, and inadequate LWPES of the questionaire regarding billing/ time for academic pursuits. We dicussed some coding practices. The survey asked for specific Clinical Controversies: of the ways in which the AAP education and information about strategies that have been Growth Hormone Treatment advocacy programs were addressing these successful, especially in areas such as diabetes in Children wtih Short issues. Since that time, we have prevailed on education, nutrition psychology/social work Stature many of you to participate in some of the AAP services and reimbursement for obesity. Only one Allen W. Root, MD activities for which you had indicated interest (1) survey per practice was requested; the Robert Rapaport, MD on the membership survery. response was good, with 72 responses received from a total of 925 surveys sent to individuals. Insulin Resistance Among these are: The results are currently being tabulated and Consensus Conference Technical Reviews analyzed by AAP staff. The results will be Summary available soon and should be helpful in develop- Merrily Poth, MD - The AAP Nutrition Handbook is being ing a coordinated approach to these issues in revised and Section members were asked conjunction with the LWPES, the AAP Committee LWPES Update to review the chapters on diabetes, on Coding and Nomenclature, and the ADA. Patricia Donohue, MD obesity, and the ketogenic diet. The input Again, we will be calling on those of you who was extremely valuable with most sugges- expressed interest in this issue to participate. Reimbursement Issues tions incorporated into the final version. in Diabetes Care - The policy statement “Screening for Education Georgeanna Retinopathy in the Pediatric Patient with Klingensmith, MD Type 1 Diabetes Mellitus” is in the Endocrinology will be well represented at the process of being updated and revised. Transitioning the October 2002 meeting of the AAP National Inger Hansen, MD will spearhead the Pediatric Endocrine Patient Conference and Exhibition (NCE). Several revision on behalf of the SOEn in conjunc- to the Adult Endocrinologist programs designed to keep the primary care tion with the Section on Ophthalmology. Mark Parker, MD pediatrician updated in endocrine issues will be Once the statement is complete, the draft presented including: will be distributed to members of the SOEn The Perspective of a New Executive Committee for comment, and • Breastfeeding and Vitamin D Pediatric Endocrine Nurse then to members interested in reviewing it. • New Advances in the Management of Type 1 Kirsten Kent, RN - Stephen LaFranchi, MD and Songya Pang, • Diabetes: Better Care Through Technology MD are assisting in the revision of the • Turner Syndrome – Clues to Early Diagnosis “Newborn Screening Fact Sheets.” and Therapies • Type 2 Diabetes: the New Epidemic of Reimbursement Issues Childhood • Controvorsies in the Management of Intersex The survey of membership conducted in • Common Office Endocrine Problems September 2001 indicated that reimbursement • Neonatal Endocrine Emergencies • Adolescent Endocrinology • The Thyroid: What you always wanted to know but were afraid to ask continued on page 5
  2. 2. Editor’s Column Growth hormone in peripubertal children: Is it really worth the cost? Paul Kaplowitz, MD T he use of growth hormone in GH testing, decided this was definite GH that children with idiopathic short stature children who are classically GH- deficiency and started GH using will achieve a modest benefit from GH deficient gives impressive results Genentech’s recommended pubertal therapy in terms of final height. Although and is one of the most satisfying things we dosing of 0.7 mg/kg/week. Over the next no one to my knowledge has designed a do as pediatric endocrinologists. In 15 months, he grew 13 cm (to 159.3 cm) and study in which GH therapy for ISS is addition, the judicious use of GH in the parents were delighted. By the time I stopped at the onset of puberty, the data children who are very short and growing saw him, at age 16 4/12, his GH dose had as a whole suggest that nearly all of the slowly but may not be classically deficient been increased to 4.8 mg 6 times a week, benefit in terms of height prediction occurs by provocative testing is also often very which at a cost of $480 per 10 mg, came to before the take-off of the pubertal growth worthwhile. However, I am concerned roughly $1400/week or $70,000/year (with spurt. So why do some physicians want to about what I see as the increasing use of more standard GH dosing, it would have treat these peripubertal children with GH GH, often at very high doses, in 12-15 year been a mere $35,000/year). His exam was and get very upset if the insurance old children who are somewhat short, but late pubertal and his bone age was 14 1/2, companies do not agree with their deci- will likely grow quite well with their own which gave a height prediction of 168 cm, sion? Perhaps they fear that if they wait endogenous GH once they get into their similar to the original one. The parents for the growth spurt will start and it pubertal growth spurt. I am specifically were most upset when I pointed out that doesn’t happen right away, the bone age excluding from this discussion children his endogenous pubertal growth spurt will advance to the point where GH with definite GH deficiency (e.g. post CNS- may have been more responsible for his therapy could not be justified. Perhaps tumor and/or documented multiple excellent growth than all of the GH he was they enjoy seeing kids grow and don’t pituitary deficiencies), since it is well taking, and that it was unlikely that have a problem with taking credit for the known that these patients will have a additional GH would be of benefit. pubertal growth spurt which will occur blunted or absent growth spurt should during treatment. And after all, is there they have spontaneous puberty and not I have seen or reviewed the files on quite a any harm in using GH in a child who might receive GH replacement. However, I have few other healthy but somewhat short grow well even without it? had the opportunity to review a fair children in whom GH therapy was being number of cases in the past few years in requested in a peripubertal or early I would argue that given the high cost of which the proposed use of GH in a pubertal child who had not yet had a clear long-term growth hormone therapy, the peripubertal child was more difficult to and convincing growth spurt. Typically inability of our health care system to justify, since the chances were excellent the IGF-1 levels are low-normal or border- provide even basic coverage for large that the pubertal growth spurt was about line for a 12-18 year old, and GH test numbers of children and adults, and the to kick in.. results are anywhere from low as in the rapidly rising cost of health insurance for case above to borderline to clearly normal. those lucky enough to have it, we have an To give an example of this dilemma, The pitfalls of relying on GH testing alone obligation to be cost-effective in the use of consider the following case. A boy old to diagnose GH deficiency are well- GH. The cost of your own health insur- was seen by a pediatric endocrinologist at documented. If you have any doubts on ance is doubtless rising, and one of the age 14 10/12 with a height of 146.2 cm (-2.7 this subject, you should read Mauras et al main reasons is increasing use of newer SD), pubic hair Tanner 3 and testicular (Pediatr Res 48:614-618,2000). This study costlier drugs and existing but expensive volume 8 cc. His parents are short (mom showed, using a new immunofunctional ones including GH. We all want insurance 5’0", dad 5’4 ½ “). Bone age was 12-6, and GH assay vs the Hybridtech assay, that companies to be flexible on agreeing to the height prediction was 170 cm by 30% of normal subjects have peak GH cover GH for children with normal pro- Bayley-Pinneau, but the parents were told levels after arginine plus L-dopa or insulin vocative testing but significant short that without treatment he might not do of < 5 ng/ml, including 2 pubertal subjects stature, poor growth, and low or borderline better than 5’3". Because he had not yet who peaked at only 2 ng/ml on both IGF-1 levels. As part of the process, we shown clear evidence of a pubertal growth assays. It seems very likely that most of should be very cautious about prescribing spurt, the physician ordered an IGF-1 (222 these kids will ultimately grow quite well GH for children with moderate short ng/ml), an IGF-BP3 (6 mg/ml), and a with their own sex steroids and GH if we stature and normal IGF-1 for maturational combined arginine L-dopa test in which will give them a little time, and reach adult age, particularly for those in whom we can the peak GH was only 3 ng/ml. Although heights which may be shorter than they anticipate the onset of the pubertal growth one could have made a strong case for this would like, but consistent with their spurt within 6-12 months. Also, for short child having a combination of genetic genetic potential. Several studies includ- boys who are over 14 and are prepubertal, short stature and constitutional delay, the ing the one sponsored by Genentech treating physician, solely on the basis of (Hintz et al, NEJM 1999:340:502-507) show continued on page 8 Section on Endocrinology Page 2
  3. 3. Clinical Controversies: Growth Hormone for Short Children born SGA Growth Hormone Should Not be Administered Routinely to Growth Hormone Treatment in Short Children Born SGA - Children with Short Stature due to Intrauterine Growth FDA Approved and Recommended Retardation who are not Classifically Growth Hormone Robert Rapaport, MD Deficient Emma Elizabeth Sullivan Professor and Chief AllenW. Root, MD Division of Pediatric Endocrinology and Diabetes Professor of Pediatrics Mount Sinai School of Medicine All Children’s Hospital New York, NY St. Petersburg, FL By definition, the designation intrauterine growth retardation I agree with my colleague Dr. Root that there is no universally (IUGR) refers to the neonate whose birth length is more than two accepted definition of SGA. One current definition is a birth standard deviations (SD) below the mean length for gestational weight and/or length at least 2 SD below the mean for gestational age (Chatelain et al 2001). The term “small for gestational age” age which is approximately the 2.3 percentile for gestational age (SGA) applies to newborns with birth weight and/or birth length [Alkalay, 1998]. Other definitions have included a birth weight, more than two SDs below their respective means for gestational length, and/or head circumference below the 10th percentile for age. Nevertheless, the terms SGA and IUGR have been used gestational age [Lapillonne, 1997]. interchangeably, and a number of investigators have applied these terms to include also neonates with birth weights below the Growth in children born SGA 10th percentile for gestational age or those whose birth lengths The vast majority of children born SGA exhibit catch-up growth are less than -1.88 SDs below mean for gestational age. Thus, during their first 2 years. About 10% of children born SGA will comparison of data between investigators is often difficult remain below –2 SD for height into adulthood [Albertsson- because the subjects studied are dissimilar. Wikland, 1997]. Of the children whose growth does not catch up by age 2 years, those born light (below –2 SD for weight) have a Within these constraints, the majority of published data suggest relative risk of 5.2 for being short at age 18 compared with that while short- and long-term treatment with recombinant human children born appropriate for gestational age (AGA). For those growth hormone (rhGH) increases linear growth rates, it may not born short (below –2 SD for height), the relative risk is 7.1 substantially increase the adult stature of short SGA children [Albertsson-Wikland, 1997]. Most short children born SGA (Table 1). Very recent data, however, suggest that early treatment exhibit normal GH secretion, as measured by overnight sampling of non-GH deficient, short, IUGR children for prolonged periods and also normal IGF-I and IGFBP3 levels. On rare occasions, with usual doses of rhGH (treatment beginning at 3-5 years of age resistance to IGF-1 has been described [Wood, 1996] and averaging 0.23 mg/kg week continuously for perhaps 15 The consequences of SGA birth are not limited to the effects on growth. In a long-term follow-up study, Strauss observed that continued on page 4 children born SGA had small but significant deficits in academic achievement at ages 10 and 16 years [Strauss, 2000]. Larroque and colleagues noted that being born SGA at term was associated Table 1. Effect of growth hormone on adult stature of subjects with poorer school performance at 12 and 18 years [Larroque, born small for gestational age (SGA). 2001]. In a study of Swedish conscripts, Lundgren and colleagues Reference SGA Criteria Data at onset rhGH regimen Adult found that low birth weight and short birth length were both Height Height N CA SDS (mg/kg/week) (SDS) associated with subnormal intellectual and psychological performance [Lundgren, 2001]. Thus psychologically, short Ranke & BW ≤-2 SD 16 12.7 -2.7 0.24 x 4.7 yrs -1.7 children born SGA may not be as normal as children with idio- Lindberg, 1996 (2) pathic short stature, based on the studies cited by Dr. Root. Coutant et al BL ≤-2 SD Though multiple factors may be involved, the possibility exists 1998 (3) Untreated 40 10.0 -2.8 -2.2 Treated 70 10.7 -2.9 0.13 x 4.6 yrs -2.0 that improving their growth may alleviate some of their academic deficits and psychological problems. Zucchini et al BW <10th percentile 2001 (4) Untreated 20 10.7 -1.97 -1.78 Treated 29 10.9 -2.28 0.27x 4.5 yr s -2.2 GH therapy in children born SGA The objectives of GH therapy in SGA children with persistent Wit et al BW <-2 SD 2002 (5) Untreated 9 -2.5 short stature are to induce and maintain catch-up growth during Treated 12 0.17-0.33 -2.4 childhood and to normalize adult height. Multiple clinical trials x 4-5 yrs performed predominantly in Europe suggest that these objectives CA - Chronologic age at beginning of treatment BL - Birth length BW - Birth weight can be safely and effectively be met by GH therapy. de Zegher and colleagues (2000) performed an epi-analysis of the 6-year growth responses obtained with GH treatment in short (height <– 2 SDS) prepubertal children born SGA . Four randomized multicenter studies explored the effects of continuous and continued on page 4 Section on Endocrinology Page 3
  4. 4. Root short children with behavioral problems therapy given for 3 to 6 years normalizes continued from page 3 and learning disabilities are referred more the stature of short SGA children, includ- frequently for endocrine evaluation than ing those who are not GH deficient, at least years) or with high doses of rhGH intermit- are their normally achieving age and height during childhood and early puberty [de tently (0.47 to 0.7 mg/kg/week for intervals peers (Kranzler et al 2000). Furthermore, it Zegher, 2000; Czernichow, 1997; of 2-3 years over the same span of years) is quite possible that the extensive testing, Chernausek, 1996]. Adult stature had been have an estimated increase in adult stature daily injections, and frequent medical reported to improve with GH treatment. of 11 cm (de Zegher, 2002). visits needed during rhGH administration Ranke et al (1996) reported 1 S.D. gain in may imprint upon the child (and reinforce adult height even in those treated late Even should this increase in adult stature to the parent) a negative concept of his/ (mean age at onset of treatment 12.7 years) be achieved, there are several consider- her self worth. It is estimated that the cost and even with a relatively dose of GH not ations that mitigate against the routine use of rhGH treatment in normal short children much above that used of GH deficiency of rhGH in IUGR subjects. IUGR subjects is approximately $35,000 per inch of height (0.4 mg/kg/week). Preliminary results are at greatly increased risk for the gained (Finkelstein et al 2002), a high cost presented by Dr. H. Kollega of the Nether- development of insulin resistance and for an unknown benefit in a period of lands group in Barcelona (April 2002) hyperinsulinism, perhaps because fetal limited medical resources. confirm substantial improvements in adult malnutrition associated with impaired height in treated subjects. In contrast, the intrauterine growth leads to adaptive In conclusion, although rhGH may 2 negative articles quoted in a Lancet responses designed to decrease energy increase the linear growth rate of short editorial and by Dr. Root both have used expenditure for growth in order to favor children with IUGR with/without “GH much lower GH doses (0.13-0.24 mg/kg/ survival and organ development (Botero, deficiency,” its beneficial effect on adult week) in a mixed bag of children. Lifshitz 1999; Hattersley, Tooke 1999). stature has yet to be firmly established. Postnatally, these intrauterine adaptive Both IUGR and administration of rhGH are GH treatment in children born SGA has not responses result in peripheral insulin associated with insulin resistance and resulted in any long-term adverse events. resistance, hyperinsulinism, and hyperinsulinemia. We do not as yet know The concern about insulin resistance, a hypercortisolemia. Insulin resistance and whether administration of rhGH may known occurrence in individuals born SGA hyperinsulinemia are associated with the exaggerate the risk of type 2 diabetes regardless of stature and GH treatment, “metabolic syndrome” of impaired carbo- mellitus and the “metabolic syndrome” in has been shown to not result in abnormal hydrate tolerance progressing to type 2 IUGR subjects. Therefore, until the glucose levels or diabetes even after 6 diabetes mellitus, dyslipidemia, hyperten- efficacy and long-term safety of rhGH years of treatment. A recent study has sion, increased mortality due to coronary treatment of short IUGR children are shown that insulin sensitivity parameters artery disease, and in females - conclusively proven, the administration of adversely affected during 2 years of hyperandrogenism and the polycystic rhGH to these subjects must be considered treatment with high dose GH (0.7 mg/kg/ ovarian syndrome. Growth hormone experimental. It should be undertaken only week ) revert to normal within 3 months of administration is also associated with in facilities where randomized treatment the discontinuation of therapy. GH insulin resistance and hyperinsulinism in groups can provide very long term data on treatment for up to 6 years has been IUGR children and other subjects, al- growth response, and information con- shown to result in normalization of initially though these effects may be reversible. cerning post-therapy complications can be decreased BMI SD score with little change Interestingly, the development of type 2 accumulated and analyzed. in skinfold thickness (Sas, 2000). Lipid diabetes mellitus is not only related to levels did not increase, and systolic blood subnormal fetal growth but also to Rapaport pressure SD score which was initially increased rates of linear growth between 7 continued from page 3 slightly positive, decreased to normal. and 15 years of age (Forsen et al 2000). It In 2001, the US Food and Drug Administra- discontinuous regimens of GH treatment in is precisely at this age that rhGH is to be tion (FDA) approved GH for the treatment short, non-GH-deficient SGA children. A administered to subjects with IUGR to of children born small for gestational age total of 49 untreated and 139 treated increase their rate of linear growth, (SGA) who fail to manifest catch-up children mean age 5.2 years were followed potentially increasing still further their risk growth (CUG) by age 2 years at a dose of over 2 and 6 years, respectively. Their for development of type 2 diabetes 0.48 mg/kg/wk. While caution needs to mean height was –2.4 SD adjusted for mellitus. always be employed when embarking on a parental height. Continuous GH treatment new method of treatment in children, I for 6 years at a dose of 0.24 mg/kg/wk Assuming that administration of rhGH can believe that the judicious use of GH in increase the adult stature of children with resulted in height increments of 2.0 ± 0.2 children born SGA who have not ad- IUGR, there are as yet no data demonstrat- SD, while a dose of 0.48 mg/kg/wk resulted equately caught up in stature is reason- ing any beneficial effect of treatment on in height increments of 2.7 ± 0.2 SD. Bone able. The cumulative data worldwide their psychological well-being, educational maturation progressed similarly in all seems to support that it is both safe and advancement, or vocational attainment. treatment subgroups, and after 6 years effective. Many studies document the psychological bone age remained slightly delayed good health and normal educational compared with chronological age. Treat- FOR A LIST OF REFERENCES progress of healthy children with idio- ment with GH was well tolerated. PLEASE VISIT THE WEB SITE: pathic short stature (Voss 2000). In fact, These and other studies confirm that GH www.aap.org/sections/endocrinology Section on Endocrinology Page 4
  5. 5. Insulin Resistance Consensus Conference Chairperson’s Column Merrily Poth, MD in patients with IRS, the pro-thrombotic continued from page 1 Uniformed Services state associate with insulin and the IRS, University of Health Sciences the importance of inflammation and Bethesda, MD inflammation markers in patients with IRS. Furthermore, data was presented on the T Insulin Resistance he conference held August 25-27, PCO syndrome in adolescents, on children 2002, sponsored by the American and adolescents with characteristics of the College of Endocrinology, brought syndrome and importance of environmen- Merrily Poth, MD represented the SOEn in together national and international leaders tal issues in the increasing incidence of an Insulin Resistance (Dysmetabolic) in the field. The intention was to bring obesity and other components of the Syndrome Conference, sponsored by the attention to the syndrome, and to stimulate syndrome in children, on the importance of Amercian College of Endocrinology and research, practice and public policy to help IRS in patients with various aspects of the designed to bring attention to the syn- prevent the diseases caused by this PCO syndrome, data purporting to show drome and to stimulate research, practice syndrome, including atherosclerotic that treatment of the IRS syndrome with and public policy in attempts to prevent its cardiovascular disease and diabetes. drugs that sensitize to insulin resulted in comorbidities. A summary of the confer- improved gonadal function in his patients, ence is included in this edition of the Goals of the conference included: including resumption of menses and newsletter. This conference is the first • To recognize that the Insulin Resistance fertility, and data on gestational diabetes, multidisciplinary approach to tackling the (Dysmetabolic) Syndrome is an epidemic showing that this is an important precursor formidible task of defining what we do affecting 1 in 4 Americans, is rising in in many individuals of the full blown know and what still needs to be learned of incidence and underlies much of the syndrome. Also discussed was the the Dysmetabolic Syndrome; it is an illnesses from obesity and sedentary increase in the incidence of the IRS in important first step in raising awareness lifestyles such as heart disease and Hispanic, African-American populations as for the public and for funding agencies diabetes; well as those from southern Asia. In and for developing a coordinated ap- summary, the syndrome of insulin resis- • Call to action by endocrinologists for proach to identify the pathophysiology, tance in clearly increasing in this and in the public and for fellow clinicians to risk factors, and best treatment modalities other developed countries. Although there recognize and treat this disorder; of this huge public health problem. are genetic propensities to develop the • Define the Insulin Resistance syndrome that are important to families (Dysmetabolic) Syndrome; Advocacy and to ethnic groups, environmental and • Explore the pathophysiology of the behavioral factors remain important areas syndrome; for attention and targets of intervention. As the “prevalence” of childhood obesity and Type 2 diabetes mellitus has in- • Differentiate between the syndrome and Interventions should be targeted at creased, the AAP has attempted to Type 2 Diabetes; populations, public health initiatives, as educate the public on means of preventing • Define the disease-related well as at individual affected patients. excess weight gain. The SOEn has consequences of the syndrome; participated in this effort by serving as a • Identify individuals at risk for the The syndrome carries with it huge patho- technical reviewer on the Committtee on syndrome; logic implications and it is important for School Health Tehcnical Report, “Soft clinicians to recognize the syndrome in the • Review obesity and its relationship to Drink Contracts and Schools” and the absence of frank diabetes and to approach the syndrome; it aggressively in order to maximally care Committee on Nutrition statement “Preven- • Develop criteria for predicting the for the patients affected. In particular, tion of Pediatric Obesity” syndrome; under-appreciated aspects of the syn- • Explore the clinical utility of the drome and the interrelationship of different Workforce Issues recognizing the syndrome; systems affected should be publicized • Evaluate the treatment of the syndrome. within the medical profession. In an effort involve pediatric residents in the AAP SOEn, a bylaw referendum It was noted that research in every aspects Speakers presented information on the creating a “Resident” category of member- of the syndrome is under-funded, particu- characteristics and genetic aspects of IRS, ship was mailed to section members. This larly relative to the numbers of affected the use of in situ NMR studies of muscle gives the Resident Fellows all but voting individuals and the societal costs. All glycogen kinetics to examine insulin privileges of the Section for a reduced efforts to increase funding for such sensitivity and resistance, links between dues fee of $10. By involving young research and for wider recognition of the insulin resistance and measures of physicians in the advocacy and educa- all aspects of the syndrome should be endothelial dysfunction, the importance of tional tasks of the Section, we may instill in aggressively pursued. elevated insulin in the pathogenesis of them a spark of interest to continue the hypertension, occurrence of liver disease work that we have just begun. Section on Endocrinology Page 5
  6. 6. Summary of Sessions at the 2002 LWPES Annual Meeting Patricia Donohue, MD The next event was the LWPES Esoterix presentations by LWPES fellowship award University of Iowa Hospitals and Clinics Lecture, which was combined with two winners: The first was Dr. Andrea Haqq, Iowa City, IA other talks to create a minisymposium on Oregon Health Sciences University, winner genetics. The first speaker was Dr. Norman of the Pharmacia Fellowship: “Character- The 2002 annual meeting of the LWPES Fost, University of Wisconsin, whose title ization of a novel binding partner of the was a trailblazer. For the first time, The was “Genetic Testing in Endocrinology: melanocortin-4 receptor (MC-4R): LWPES and PAS meetings were com- Ethical Considerations.” This talk pro- Attractin-likeprotein (ALP).” The second pletely integrated. Rather than attending vided a comprehensive overview of the was Dr. Diva Ng, Children’s Hospital of the 2-day LWPES meeting and then latest trends in and interpretation of Philadelphia, winner of the Lilly Fellow- staying another 3 days for the endocrine- regulations concerning research involving ship: “GLP-1 regulation of endocrine related programming of the PAS, the human subjects. The burden of review pancreas growth.” The third was Dr. attendees had three (very full) days of and documentation has increased signifi- Michael Agus, Children’s Hospital of Pediatric Endocrinology Programming. cantly in light of several high profile cases Boston, winner of the Astrazeneca The program committee of the LWPES involving deaths of research subjects. Fellowship: “Effect of hyperinsulinemic (myself, Joseph Majzoub, and Marsha Next, Dr. Barton Childs of Johns Hopkins clamp on protein catabolism in critically ill Davenport) worked closely with the University gave a talk entitled “Overview neonates.” The remaining 5 presentations LWPES liaisons to the PAS program of Human Genetics/Genomics: Relevance covered molecular studies of IGFBP3 in committee (myself, Charlotte Boney, and to Pediatric Endocrinology.” Dr. Childs, cancer, IGF-1 acid-labile subunit mutations Ray Hintz) to construct the complex and who was a personal friend of Lawson in disease, GNAS mutations in fibrous exciting program. All sessions were very Wilkins, presented his theories on a newer dysplasia, INSL6 insulin-like gene muta- well attended, as the combined program- way to look at medicine, that is to view tions in infertility, and TNF alpha influence ming made access to the LWPES plenary individuals’ genetic backgrounds, environ- on GH action in inflammation. This was sessions open to all PAS meeting regis- ments, and their interactions, to produce followed by an excellent poster session trants. We grouped the platform presenta- variations of health and disease. These which occurred simultaneously with the tions into themes, and titled the sessions principles are developed in more detail in PAS opening reception. accordingly so that attendees could better his recent book, Genetic Medicine: A construct their own personal program. Logic of Disease. The final speaker in the Sunday, May 5, started with the second There was a large amount of diabetes- symposium, Dr. Keith Parker from Univer- LWPES plenary, which featured two related programming. The huge success of sity of Texas Southwestern Medical lectures. The Presidential Lecture, given this year’s meeting was attributable in School, gave the Esoterix Lecture entitled by Dr. Barbara Lippe (Pharmacia & great part to the administrative and “Single gene defects and what they have Upjohn), focused on Turner Syndrome, logistical assistance of the PAS staff. As taught us about developmental and clinical especially growth in the first years of life. we look ahead to future meetings, this endocrinology.” He talked about the roles She pointed out that we may need to collaboration will greatly enhance the of the orphan nuclear receptor ste- revisit our approach to growth promoting success of the next combined PAS/AAP roidogenic factor 1 (SF-1) and DAX1 in therapy, and there may be benefit to meeting in 2005. endocrine development. SF-1 regulates starting it earlier than we have been doing. the expression of multiple genes that Her lecture was followed by the first The meeting started with the first LWPES mediate steroidogenesis and reproduction, annual Robert Blizzard lecture, given by Dr. plenary session on Saturday morning, whereas mutations in DAX1 cause adrenal Nelly Mauras, Nemours Children’s Clinic May 4. The Genentech Clinical Scholar hypoplasia congenita, an X-linked disorder of Jacksonville, Florida. She discussed the Award lecture was given by Dr. Adda that includes adrenal hypoplasia and dynamic interaction of GH, IGF-I and sex Grimberg from Children’s Hospital of hypogonadotropic hypogonadism. Dr. steroidal hormones that play a major role in Philadelphia. She presented her data Parker reviewed the ways in which pubertal growth and body composition describing the role of IGFBP3 in mediating knockout mouse studies and careful changes. The GH neuroendocrine rhythms p53-induced cellular apoptosis. These phenotypic characterization of human are both affected by testosterone and data introduced to us a possible new subjects with mutations in SF-1 and DAX1 estrogen and GH in turn potentiate many antineoplastic role for IGFBP3. This was have provided novel insights into mecha- of the metabolic actions of the sex ste- followed by the annual “Lawson Wilkins nisms of endocrine development. roids. Leptin also plays what appears to be Lecture,” given by Dr. Stephen Shalet of a key regulatory role in the process of Manchester, UK, who presented his Later that afternoon was the first PAS sexual development in the child, yet the findings on the late (adult) endocrine endocrinology platform session. The specific nature of these interactions is not effects of childhood cancer. The plenary session was entitled Molecular Studies: fully unraveled. The targeted replacement was followed by the Annual business Endocrinology I. There were eight ab- of hormonal deficiencies in puberty and meeting. stracts presented. The first three were the continued on page 9 Section on Endocrinology Page 6
  7. 7. Reimbursement Issues in Diabetes Care: Summary of Sessions at the 2002 LWPES Annual Meeting Georgeanna Klingensmith, MD services. Currently, the difference is made ments, as residual beta cell function Barbara Davis Center of up primarily through philanthropic support improves. In addition to physician and Childhood Diabetes and cost shifting from other services, nursing management, dietary management Denver, CO including inpatient diabetes and endocri- is also important. The family needs to nology services. As cost shifting options learn the carbohydrate content of foods in T here are many important issues decrease, finding other ways to support their diet and how to maintain a consistent facing pediatric endocrinology endocrinology and diabetes services carbohydrate intake or ideally to adjust today. These issues include a becomes imperative. Options presented at the amount of insulin given, depending on severe manpower shortage and lack of previous meetings have been improvement the number of grams or servings of adequate reimbursement for the team care in reimbursement for fee for service carbohydrates eaten. Psychosocial required for current diabetes management. through more appropriate coding for support is important in dealing with While there are multiple causes for the services and improved reimbursement for families and patients at the time of manpower shortage in pediatric endocri- non-physician services. Some advance- diagnosis. This is a time of grief and guilt nology, lack of adequate reimbursement is ments have been made in this area with for families, and the social worker may a significant contributing factor. In Medicaid now recognizing and reimbursing help them to deal with these feelings in a recognition of this, the Lawson Wilkins some diabetes education costs. Another positive and constructive way. Psychoso- Pediatric Endocrinology Society Annual approach is to look at the way chronic care cial services may also help siblings and Meeting addressed this issue in a is reimbursed and suggests that fee for other relatives to deal with their feelings symposium, exploring reimbursement reimbursement is more appropriate for about diabetes and help families to issues in endocrinology and diabetes. episodic acute illnesses and that care of appropriately share diabetes tasks. chronic diseases is better managed Gail Richards, M.D., Director of Pediatric through a global rate plan similar to Both Dr. Rubin and Dr. Tamborlane Endocrinology at The Children’s Hospital reimbursement for most services provided stressed that hospitalization at the time of and Regional Medical Center, Seattle, to the pregnant patient. diagnosis would be used for required Washington, presented information on medical stabilization, but that the majority cost analysis of providing both endocri- William Tamborlane, M.D., Director of of diabetes education and management is nology and diabetes services. Their Diabetes Services at Yale University and done as an outpatient, thus shifting center evaluated activity-based costing, Karen Rubin, M.D., from Connecticut inpatient costs to outpatient costs. This using relative value units describing Children’s Medical Center, presented will allow third party payers to reallocate physician work. They separated physi- information on contracting for global rate funds from the initial week of care cian costs and facility costs. Their facility services for diabetes care. Dr. Tamborlane traditionally provided in the hospital, to costs included nursing costs, dietary outlined three levels of service provided to the entire 3-4 months of initial care and costs and social work costs in providing children with diabetes. The initial level of more appropriately allocate those re- both diabetes and endocrine care. The service is for the 3-4 months following sources to outpatient services. Endocrinology Service at Washington diagnosis, when families and patients are provides almost 5,000 visits per year, with taught the essentials of diabetes manage- The second phase of diabetes manage- approximately 30% those visits for ment, including pathophysiology, genetics, ment is the modern or intensified manage- diabetes care. and the importance of metabolic control in ment of patients who have had diabetes preventing diabetes complications, in for more than 4 months. There should be Their cost analysis determined that an addition to the practical essentials of an annual rate covering all outpaient endocrinology visit cost The Children’s insulin administration and home blood diabetes services including telephone Hospital between $115-$130 to provide glucose monitoring. A solid basis in the consultations. The standard of care for and under their current billing structure, principles of diabetes management is diabetes patients is a visit and hemoglobin revenue from these visits averaged $50- necessary to avoid emergency room visits A1c at least every three months; however, $55 per visit. and hospitalization during sick days and multiple studies have shown that close episodes of mild or moderate hypoglyce- interaction with a diabetes provider Cost analysis of diabetes visits, which mia. This period of time is also essential between visits for insulin dose adjust- require more non-physician time, was for comprehensive medical assessment and ments and management during sick days, determined to be $238 per visit, with a adjustment in treatment regimen, both can decrease costs of diabetes care and revenue that was not substantially during frequent outpatient visits and improve hemoglobin A1c levels. different from endocrinology revenue. frequent phone contacts. Close contact Anticipated services would include This leads to a significant institutional during this time is also required because of regular scheduled outpatient visits, with loss for endocrinology and diabetes the dramatic changes in insulin require- continued on page 8 Section on Endocrinology Page 7
  8. 8. Reimbursement Issues diabetes. This team care has been shown likelihood of hospital readmission for any continued from page 7 to improve diabetes control and, therefore, cause. Furthermore, economic analyses would be expected to save healthcare suggest that ambulatory care may cut the physician, nursing, dietary, and social dollars in the long run. It additionally will costs of initial management by as much as work consult as necessary, as well as provide phone management services to 80%. Although there is exceedingly limited interaction with schools and school nurses children and families for intercurrent data on psychosocial outcomes, most or daycare providers. management illness, as well as between reports do not provide evidence of any visit diabetes insulin dose adjustments. disadvantage to ambulatory care for these The final area of care is intensified These services have been shown to children. In summary, the experience to management with pump therapy. This part decrease the annual cost of healthcare in date suggest that the benefits of outpa- of the program would include all evalua- the managed care environment. Finally, tient management for new onset type 1 tions and assessments required for the adequate reimbursement will allow diabetes are well-established, and that education around pump management and diabetes services to include the introduc- randomized controlled trials comparing the initial follow up and stabilization on tion of new technology in the diabetes different ambulatory versus in-patient insulin pump therapy. care provided to patients such as continu- initial management of children with new ous glucose monitoring and intensified onset type 1 diabetes are not warranted. Dr. Rubin presented contracting informa- diabetes management. These technolo- tion derived from working with several gies, likewise, are expected to, or have nationwide third party payers. Third party been shown to, improve diabetes manage- payers concerns about global rates for ment and decrease diabetes costs. prolonged services have to do with patients transferring from one insurance Editor’s Column Many of the services provided in the continued from page 2 program to another and therefore, a global plans described above have been monthly “point of service capitated provided by pediatric endocrinologists for giving a few monthly injections of test- arrangement” for global rates appear to be many years. However, as hospitals and osterone to induce a pubertal growth spurt the most effective way to deal with this medical institutions become increasingly and hasten the onset of spontaneous type of service. Under this contract unable to cost shift monies to provide puberty is both extremely effective and arrangement, higher levels of service these services, comprehensive diabetes very inexpensive. In the cost-benefit provided during the initial four months of care for children is at risk, unless other equation, a year of GH for a 40 kg care, or during the 1-3 months required for ways of reimbursement can be identified. peripubertal short child using standard insulin pump therapy would be contracted weight-based dosing is typically at least at a higher level than the monthly rate for In the final talk of the session, Denis $30,000, whereas a year of GH for a short established patients. Dr. Rubin suggested Daneman, MD from the Hospital for Sick 15 kg six year old who is far more likely to that there are current HCPCS codes, which Children in Toronto addressed the issue of benefit costs closer to $10,000. We also adapt well to the global rate model and outpatient management of new onset need to be realistic in what we tell parents these are listed in the table below. diabetes. Both philosophical standpoints about the likely outcome of GH therapy. and fiscal demands have led many centers Based on letters written by parents to Level II HCPCS codes best fit for “global to introduce ambulatory care programs for support appeals of GH denial, they not rate” model such children. Although there is a paucity only believe that GH will make the differ- • New onset care: G-9001 of controlled trials in this area, numerous ence between their child growing a lot vs (Coordinated care fee, initial rate) experiences show that ambulatory care is growing little or not at all, but that the at least as safe, in terms of avoiding child will only have a normal life or reach • Established care: G-9002 metabolic deterioration or precipitating their full potential if they are allowed to (Coordinated care fee, maintenance rate) hypoglycemia, and effective, in terms of receive GH therapy. hospital readmissions and HbA1c out- • Insulin pump initiation: G-9003 comes, as more traditional in-patient In summary, I propose that we in the (Coordinated care fee, risk adjusted programs. Dr Daneman presented data pediatric endocrine community exercise high, initial) from his institution showing that since restraint in our use of GH for older non-GH 1995, they have avoided admitting more deficient children, in hopes of preventing The advantage to providers for global rate than 70% of children with new onset type the situation in which more and more contracting is the reimbursement for non 1 diabetes, and that the HbA1c levels at 6, insurers decide that they are spending so face-to-face time that is so important in 12 and 24 months after diagnosis have much on GH that they need to restrict its maintaining good diabetes care and avoids steadily decreased from their earlier period use more so than they have already done. hospitalizations during sick days, as well of week long admissions to a period with as more appropriately reimbursing non- short inpatient stays to their current physician face-to-face care provided at the outpatient program. In fact, a number of time of a physician visit. The advantage to reports document not only lower HbA1c third party payers is the availability of the levels the two years following diagnosis in team care to children and families with those never admitted, but also a lower Section on Endocrinology Page 8
  9. 9. covering the several aspects of diabetes LWPES Update therapy and etiology, as will as other Endocrinology continued from page 6 studies of glucose homeostasis in non- Upcoming Meetings the manipulation of the timing of pubertal diabetic individuals. The diabetes theme maturation has resulted in better strategies continued that morning with the second 2002 to treat profoundly short children during LWPES minisymposium of the meeting. AAP National Conference and this period, several of which are still under This was entitled “Breaking the obesity- Exhibition investigation. type 2 diabetes link.” After opening October 19-23, 2002 remarks by Dr. Des Schatz (University of Boston, MA Following the PAS/LWPES poster session Florida, Gainesville), Dr. Michael Freemark https://www.a2zshow.com/ssl/aap/ II was the second LWPES career develop- presented the first talk (DukeUniversity), aap2002/enter.html ment seminar for fellows and junior faculty. “Metformin Therapy in Obesity.” He I organized this session to provide a way described his studies that demonstrated a Asia Pacific Pediatric Endocrine for fellows to be exposed to various career beneficial effect of this treatment on BMI, Society (APPES) path opportunities. This year’s speakers leptin, and fasting blood glucose in obese November 11-13, 2002 were Joe Majzoub (academic center, adolescents with a family history of Type 2 Cairns, Australia laboratory research), Silva Arslanian diabetes. The second talk was by Dr. http://www.appes2002.com.au (academic center, patient-oriented re- David Ludwig (Children’s Hospital of search), Jeff Baron (NIH), Deborah Edidin Boston), “Dietary Glycemic Index in the (private practice), and Charmian Quigley Treatment of Obesity and Related Compli- 2003 2nd International Workshop on (industry). I hope to make this an annual cations.” In summary, dietary carbohy- the Genetics of Bone Metabolism event, and to expand the time for the drate is traditionally characterized as & Disease session to encourage more discussion and “simple” or “complex,” though the Feb 15-18, 2003 mentoring of our associate members. biological significance of this distinction Davos, Switzerland has been questioned in recent years. An http://www.ectsoc.org Later that afternoon was the PAS State of alternative system of carbohydrate the Art Symposium on Insulin Resistance classification is the glycemic index, which 30th European Symposium on Syndromes. This symposium was cospon- reflects the rate of rise of blood glucose Calcified Tissues sored by the LWPES and the AAP, and after a meal. A large number of studies May 8-12, 2003 was organized and moderated by Dr. Alan have found beneficial effects of a low Rome, Italy Rogol (Insmed Pharmaceuticals) and Dr. glycemic index diet in various disease http://www.ectsoc.org Charlotte Boney (Rhode Island Hospital). states associated with hyperinsulinemia. The purpose was to educate the attendees The final talk of the symposium was by Dr. LWPES Annual Meeting about the underlying factor in conditions Philipp Scherer (Albert Einstein College of May 2-5, 2003 associated with widespread morbidity and Medicine), “New Advances: Adiponectin Seattle, Washington mortality, and as a result is a major public in Diabetes and Obesity”. Acrp30 (also www.lwpes.org health issue. There were three talks. Dr. called adiponectin) has recently provided Silva Arslanian (University of Pittsburgh) some exciting insights into how fat cells AACE 12th Annual Meeting spoke on the topic “Insulin resistance: It’s communicate with other tissues. Serum May 14-18, 2003 not for adults only.” Dr. David Freedman levels are lower in obese and diabetic San Diego Marriott Hotel & Marina (CDC, Atlanta) gave a talk entitled “Clus- patients. The gene has been implicated in San Diego, CA tering of coronary heart disease risk various aspects of “syndrome X.” Dr. www.aace.com factors in obese children”. The third talk Scherer and others have shown that was given by Dr. James Roemmich Acrp30 / adiponectin can act as a sensitiz- (University of Buffalo), and was entitled ing agent for the action of insulin in liver. “The insulin-leptin axis in puberty.” In healthy individuals, insulin will lead to a In summary, there was a wealth of pro- reduction of hepatic gluconeogenesis. In gramming, something for everyone, at the The last event of the day was the PAS diabetic individuals, this insulin-mediated 2002 LWPES/PAS meeting. The program platform session Endocrinology II: Clinical repression is strongly impaired, leading to was enriched further by the scheduling of Investigation. For this session we grouped elevated blood sugar levels even in other PAS symposia, etc. that were of 6 presentations that represented work on between meals. Acrp30 increases the endocrine interest, during the days of the clinical studies. The topics included GnRH sensitivity of the liver to the action of LWPES meeting. We look forward to our analog trials, Tamoxifen in McCune insulin, even in diabetic tissue. Similar continued relationship with the PAS as an Albright Syndrome, PCOS, Idiopathic positive effects on insulin sensitivity have “Alliance Society.” The chair of the Short Stature, and placental growth been demonstrated for Acrp30 in muscle. LWPES program committee for the 2003 hormone in SGA. Therefore Acrp30/adiponectin or synthetic meeting (May 2-6, Seattle) is Joe Majzoub, analogs hold promise as a therapeutic Children’s Hospital of Boston. Please send Sunday, May 6, started with the PAS agent and might be useful in the treatment your programming suggestions to him Endocrinology III Platform session: of type 2 diabetes and perhaps other soon! Diabetes. Eight abstracts were presented states characterized by insulin resistance. Section on Endocrinology Page 9
  10. 10. Transitioning the Pediatric Endocrine Patient to the Adult Endocrinologist Mark Parker, MD Further, no doctor can send a patient’s is very helpful. To keep the different plans Pediatric Endocrinology and records to anyone without a signed release straight in our office, we have a checklist Diabetes Specialties from the patient. Once a child turns 18, he in the back section of each child’s medical Charlotte, NC or she must sign this release. The primary record identifying their particular plan that care physician making the referral therefore lists specific requirements of that plan: H aving been in practice since 1983, will not be able to send the pediatric a. Is a referral required and if so, what I have had the opportunity to see endocrinologist’s records to the referring kind? many of my patients grow up. physician. We have a standard form letter Saying goodbye to them as they transition for our patient to sign requesting records b. Which is the preferred hospital? to “adult physicians” is in many ways very transfer. similar to the way I felt sending my own c. Which is the preferred laboratory? two children off to college. Seeing many When I am referred a new patient who of them four times a year for scheduled moves to North Carolina from another d. Can we do labs in the office? appointments, and helping them deal with state, I truly appreciate a one or two page problems in between, in our specialty we summary of laboratory, x-ray, medications e. Is preauthorization required for have a wonderful opportunity to come to and a growth chart from the previous further tests like MRI? know them very well. Like our own endocrinologist. Some of these patients children, when it’s time for them to leave when they leave have a medical record an We can aid our patients by giving them a the nest, there are things we can and inch or two thick. The adult endocrinolo- copy of this “cheat sheet” should do to make the transition as gist who assumes care of our patients will smooth as possible. Before sending our appreciate the same courtesy. The Health Insurance Portability and patient to the new physician, we can be Accountability Act of 1996 began to take extremely helpful by insuring that insur- INSURANCE effect in 1997 and is now almost fully ance issues, records transfer, and our My office participates in over 30 insurance implemented. We must be familiar with it. patient’s psychological preparation for the plans for which we have unique contrac- Included in this law are provisions transition are addressed before he or she tual obligations. Several of these plans protecting information in patient medical leaves our nest. require preauthorization before the records as alluded to above as well as appointment. The requirements for this provisions for continued coverage after a WHO MAKES THE REFERRAL? preauthorization are varied. Some require a child is no longer on their parent’s In principal, the referral to an adult piece of paper from the primary care insurance. Provided that a child has had endocrinologist should come from the physician, some require a number, and for 12 months of continuous coverage for a pediatric endocrinologist. In practice, others voice authorization is sufficient. condition, he or she cannot be refused because of our present insurance climate, Failure on our part to identify the required coverage for a “preexisting condition” for the receiving adult endocrinologist to hoop and jump through it before we see within 30 days. It is important that a be paid for the child’s appointment in the patient will result in a denied claim that child’s policy not lapse and that new many cases the referral has to come from is very expensive to appeal. Some of insurance be in force within 30 days of the primary care physician. It is therefore these plans specifically disallow retroac- terminated coverage. It may be necessary necessary that all the physicians involved tive authorization, so that if a patient is for a child to get a COBRA or bridge in the child’s care also be involved in the seen without prior authorization, payment policy if they start a new job whose transition. The primary care physician is denied and we cannot even appeal. We insurance coverage does not go in force needs to be informed of the pediatric tell our patients that they need to know the until a waiting period after employment. endocrinologist’s plan to transition care. requirements of their own particular For children in college, many plans require insurance policy. Our patients whose a letter from the registrar verifying that the RECORDS plans require preauthorization need to patient is a full time student for coverage. When our patient is referred to an adult make sure that this happens before the Some plans require this annually, others endocrinologist, the receiving physician’s appointment. more frequently. If this is a requirement of office will need the correct referral from the the child’s plan, failure to have this letter correct doctor (in many plans this will have Most children at 17 or 18 years of age are will result in a denial of payment that will to be the primary care physician). The not very knowledgeable about their health require time and effort to appeal. adult endocrinologist also needs the insurance. Insurance is not as easy as it pediatric endocrinologist’s records . Law used to be. Discussion with the family, prohibits one doctor sending another including the patient who is transitioning continued on page 12 doctor’s records to a third physician. Section on Endocrinology Page10
  11. 11. The Pediatric Endocrinology Nursing Society (PENS) The Perspective of a New Pediatric Endocrine Nurse Kirsten Kent, RN containing the program procedures and that I developed through the program. Permian Endocrine and Diabetes pediatric endocrine nursing information. In April, PENS holds an annual confer- Midland, TX Arrangements are made for the preceptee ence. New and experienced endocrine to make a visit to an experienced nurse nurses are welcome to attend and learn I stood nervously as the parents and (preceptor) to observe patient manage- about recent developments in endocrinol- child walked in the examination room to ment, assessment, testing and teaching. ogy, the management of endocrine be educated about growth hormone I went through the Preceptor Program at disorders as well as practical pointers from administration. It was my first time Cook Children’s Clinic in Fort Worth, more experienced endocrine nurses. It is a teaching on the topic. The night before, I Texas, in March 2001. Although it was great way to network and establish a had gone over all the teaching materials approximately a five hour drive, I had a rapport with nurses from all over the and reviewed the video. As I started to wonderful experience. The preceptor that country. The conference is arranged so speak, my voice was high pitched and trained me has been a nurse and diabetes nurses may select issues that benefit their shaky, and I forgot important points that educator for several years and was nursing career. The goals of the PENS needed to be taught. The mother asked, knowledgable in several areas of endocri- conference include enhancing the “Is this your first time teaching about nology, including: interpreting laboratory education of nurses and sharing informa- growth hormone?” Thoughts raced results, diabetes tion among healthcare through my mind on what to say, and in education, and formulas professionals. It my calmest voice I said, “I have reviewed to determine dosages helps nurses become the material, especially the video, several times, and I have personally given the on mediation and growth rates on E ndocrinology nursing is a broad specialty that deals with many different familiar with new developments in the injections to some of our patients.” patients. She was a field of endocrinol- diseases including thyroid patient and wonderful ogy. The topics at the disorders, diabetes, hypopi- From that moment on, I decided that I teacher who knew 2001 conference tuitarism, and congenital needed to learn more about pediatric exactly what to teach a included Type I and II adrenal hyperplasia. As a endocrinology. My new goal became new endocrine nurse. diabetes management, specialty nurse it is impor- “expand my knowledge and learn as much an overview of tant to be aware of the as possible about the management of In order to assess what endocrine disorders, proper assessment, evalua- endocrine disorders.” areas of learning I and a review of the tion and treatment plan for needed, I discussed my endocrine system. the various diseases. Endocrinology nursing is a broad specialty potential learning that deals with many different diseases experience with my What’s my message including thyroid disorders, diabetes, colleagues. Also, I to the pediatric hypopituitarism, and congenital adrenal found it helpful to have endocrinologist’s hyperplasia. As a specialty nurse it is a list of questions prepared. Before my reading this column? A new pediatric important to be aware of the proper visit with my preceptor I had many endocrine nurse should learn as much as assessment, evaluation and treatment plan questions. “Why is this test being possible and it is worth the time to make for the various diseases. The vast performed?” “Why did the doctor change an investment in his or her training. One information and nursing procedures the insulin dose only at breakfast to two of the best ways is to have him or her get can be overwhelming and frightening. units more and not the supper dose?” My involoved in an organization like PENS. To overcome these fears and become a participation in the PENS Preceptor Knowledge makes us more competent and more competent nurse, I have found the Program helped to clarify my understand- enables us to teach our patients and peers Pediatric Endocrinology Nursing Society ing of diabetes, especially sick day with confidence. (PENS) to be a great resource. management and changing insulin doses. I also learned much about the evaluation For more information about the PENS I joined the organization and enrolled into and management of the endocrine patient. organization see our web site at the Preceptor Program. This program is It helped increase my competency and www.pens.org. For specific questions designed to help new nurses become more reinforce the nursing skills that I devel- about the Preceptor Program please competent by learning the skills and oped from other job experiences. By contact Colleen Weber at 314/577-5600 ext. resources available to the pediatric enhancing my knowledge and skills as a 3103 or colleen_weber@ssmhc.com. endocrine nurse. The new nurse pediatric endocrine nurse, I feel I am much (preceptee) is sent the Program Manual more confident. I still enjoy the friendships Section on Endocrinology Page 11
  12. 12. Transitioning and reimbursement for endocrinologists. continued from page 10 As our profit margins become thinner and Executive Commitee billing and reimbursement become more Roster complex, the value of this organization has SPECIFIC DIAGNOSES proven itself to me. I have been warmly 2001-2002 There is considerable variation in diabetes welcomed into our local chapter, which is control among the patients we graduate. I comprised of endocrinologists from both Chairperson have mixed feelings about referring the Carolinas, and presently serve on our Janet Silverstein, MD mature, tightly controlled teen whose chapter board of directors. Through this hemoglobin a1c levels are in the mid 6 organization, I have developed a collegial Members range. On one hand, when they go to the relationship with the physicians who will new practice, they make me look good. ultimately be taking care of all my patients. Kenneth Copeland, MD On the other hand, it is harder to say It is much easier to send these children to goodbye to someone who follows a friend. Inger Hansen, MD directions consistently. Truthfully, though, I also have mixed feelings about In summary: Francine Kaufman, MD sending the patient with the double-digit a1c level. I want just a little bit more time • All doctors need to be included in to make them see the light, and am not too transition: primary care MD, Susan Rose, MD happy about my colleagues seeing that pediatric endocrinologist, adult level of control coming out of my office. I endocrinologist, and new primary Surendra Varma, MD do however definitely believe that both care MD if this is to happen groups, a1c 6 or a1c 13, deserve to be around the same time and correct followed by an endocrinologist. At a referral made according to Membership Chairperson recent AACE meeting, one of my adult patient’s insurance guidelines. Kenneth Copeland, MD endocrine colleagues to whom I send lots of patients told me that he rather enjoys • A summary sheet of medications, Newsletter Committee seeing some of these double digit kids lab and radiology tests, and Paul Kaplowitz, MD grow up in the first couple years and is growth is helpful to the receiving gratified to make such a difference for physician. Lilliam Gonzalez de Pijem, MD them. He told me that in his experience, when they fall in love (and start caring • Records releases must be signed Nominations Committee about what another adult thinks—other in accordance with HIPAA rules. Stephen LaFranchi, MD than their parents or doctor!) is when the Edward Reiter, MD changes really start. Our patients with • Insurance issues need to be diabetes know that we do a hemoglobin discussed including change of A1C every three months, that they need insurance if there is one, patient Program Chairperson to see the eye doctor every year, and that responsibilities concerning Surendra Varma, MD we check thyroid levels, cholesterol, and referrals. urine for microalbumin annually. They are Pediatric Endocrine told to expect the same level of attention. • Patient should have a handle on treatment protocol prior to Nursing Society Liaison Our young ladies with Turner syndrome transfer to new doctor. Deb Welch, RN, MS know that they need an echocardiogram every five years. Sending our patients • A personal and professional with this knowledge, as well as our flow relationship between the sheet with our long-term protocols will pediatric and adult endocrinolo- help ensure that these parameters will gist will facilitate the transition. Section on Endocrinology Newsletter continue to be followed once they leave AACE is an excellent avenue. Copyright © 2002 American our practice. Academy of Pediatrics Statements and opinions AACE expressed in this publication I am a charter member of the American are those of the authors and Academy of Clinical Endocrinologists. In not necessarily those of the 10 years, this organization has made a big American Academy of Pediatrics. impact on endocrinology. AACE has taken the lead when it comes to coding Section on Endocrinology Page 12