Centers for Disease Control and Prevention

Working Together for Better Public Health

Q&A with Dr. Raul Pino, commissioner of the Connecticut Department of Public Health and a UConn Health board member

Q

What are some of the major public health issues facing Connecticut?

There are many public health issues facing both Connecticut and the nation as a whole. At the Department of Public Health, our emphasis is on the Centers for Disease Control and Prevention’s 6|18 initiative, which targets six major health conditions — asthma, high blood pressure, tobacco use, hospital-acquired infections, teen pregnancy, and diabetes — with 18 evidence-based public health interventions.

Each of these conditions is common, preventable, and costly, but importantly, all have proven interventions that can be effectively employed across the health care spectrum to improve both individual and community health, saving lives and dollars. Other areas where I believe we can see good results in Connecticut by employing evidence-based interventions include addressing HIV and the rising number of syphilis cases.


Q

How can physicians assist the DPH daily to address and reduce these issues?

Doctors, particularly primary care physicians, are the main point of contact with the public for health education. We need to engage practitioners in addressing the six major health conditions with their patients — screening for the conditions; educating in advance to enhance prevention of disease; and providing effective, evidence-based treatments when needed. Physicians play a critical role on the front lines of health care to shift our focus from treatment to prevention through lifestyle changes and other healthy choices. They are an indispensable part of the continuum of care between DPH, health care practitioners, and public health.


Q

As DPH commissioner, what drives your daily public health passion and mission?

I am convinced that we — as a nation, a state, and as public health professionals — can do more than we are currently doing to impact public and population health. Addressing the health disparities that continue to plague our population, costing millions of lives and countless health care dollars, is what drives me. We are so fortunate to live in one of the richest countries, and states, in the world, yet we spend so little on public health. My mission is to spread the message that modest investments of money, time, and effort in proven education and prevention methods can lessen these disparities, which will save millions of dollars in health care costs and, more importantly, save lives.


Q

Tell us about your connection to UConn Health and what you hope to accomplish as a member of the board of directors.

I am a 2009 graduate of the UConn Master of Public Health program and receive my own health care at UConn Health. Spending time there for my education and health care has really crystallized for me that UConn Health is the epicenter of clinical care and education in Connecticut. UConn Health is where advances in science and medicine happen, which allows patients to get the best in cutting-edge care. As a member of the board of directors, I am looking to learn and understand better the role that this large institution plays in public health work. I hope my passion for public health and the elimination of health disparities will allow me to give a voice to the importance of integrating education, prevention, public health, and clinical care in order to strengthen our health care system, curb rising health care costs, and foster healthy communities and individuals.

Ventilator-Associated Pneumonia Still a Concern, Study Says

mask holds oxygen mask to face


Contrary to data published by the Centers for Disease Control and Prevention, ventilator-associated pneumonia rates in hospital intensive care units have not declined significantly since 2005, according to a new study out of the UConn School of Medicine.

The study, published in the Journal of the American Medical Association, found that about 10 percent of critically ill patients placed on a ventilator develop ventilator-associated pneumonia (VAP). The finding is based on reviews of charts from hospitals across the country from 2005-2013.

“VAP is not going away; it still affects approximately one in 10 ventilated patients,” says the study’s lead author, Dr. Mark L. Metersky of UConn Health’s Division of Pulmonary and Critical Care Medicine. “Our findings are in stark contrast to the CDC’s report of a marked decline in VAP rates that had some believing it may no longer be an important problem.”

Researchers reviewed data compiled by the Medicare Patient Safety Monitoring System from a representative sampling of 1,856 critically ill Medicare patients, ages 65 and older, who needed two or more days of mechanical ventilation.

While the VAP rates were stable throughout that time, the rates did not correlate with the CDC’s National Healthcare Safety Network reported rates, which suggest declining rates between 2006 and 2012 in both medical and surgical ICUs. The rate of VAP is one of the metrics for patient safety and health care delivery quality that many hospitals are scored on nationally.

VAP is not going away … Our findings are in stark contrast to the CDC’s report of a marked decline in VAP rates that had some believing it may no longer be an important problem.

Patients in need of mechanical ventilation are often the most critically ill in a medical or surgical ICU hospital setting. Research has shown that up to 15 percent of patients who get it may die from VAP.
The study authors examined the prevalence of VAP in patients on a ventilator following a heart attack,
heart failure, pneumonia, or major surgery. These types of patients are at higher risk for developing pneumonia, a bacterial infection, due to the need for a tube extending down their throat and into their lungs to help them breathe.

“We have not beaten this,” says Metersky. “Current hospital interventions that are used in an attempt to prevent VAP are not working. VAP is still a significant issue, and needs more examination into how we survey its occurrence and report it, along with more research into how best to prevent this type of pneumonia in vulnerable patient populations.”

The higher-than-expected VAP rates may be leading patients to experience complications or death from their lung infection or spend more time on a ventilator or in the ICU, slowing recovery. It may also increase use of antibiotics, leading to potential resistance, and increase health care costs due to longer hospital stays.

Metersky collaborated on the study with colleagues at Qualidigm, Harvard Medical School, and Harvard School of Public Health. It was supported by the Agency for Healthcare Research and Quality of the U.S. Department of Health and Human Services.

America’s Opioid Epidemic: What Doctors Need to Know

Q&A with Dr. Surita Rao, UConn Health assistant professor of psychiatry

Q

Can you characterize the U.S. opioid epidemic?

Our country’s opioid epidemic has been going on for several years. The U.S. is the biggest global consumer of prescription opioids. In 1997, 76 million prescriptions were written, more than doubling by 2013 to 207 million. Americans consume nearly 100 percent of the world’s hydrocodone (Vicodin) and 81 percent of its oxycodone. The majority of those physically addicted or overdosing are getting opioid prescriptions from their doctors’ offices.


Q

What are the dangers of opioids?

These strong pain pills are very physically addictive and it’s often hard for patients to live without them, even after their pain subsides. The biggest dangers of opioids are overdose and death. After doctors stop prescribing them, some patients turn to the street to illegally get their pills, while some may even switch to heroin. When mixed with heroin, anxiety medications, or alcohol, opioids are even more likely to lead to overdose.


Q

What do the new Centers for Disease Control and Prevention guidelines call for?

In March the CDC called on primary care doctors to more carefully assess each individual patient’s risk of taking an opioid and to take extreme caution when prescribing it for longer than seven days for acute pain, unless for terminal cancer or palliative care. The lowest-effective dose of non-slow-release pain pills should always be used, and patient use needs to be continuously reevaluated. Guidelines stress the critical need for increased education and communication about opioid risks including constipation, drowsiness, stopping breathing, drug and alcohol interaction, addiction, overdose, and death.


Q

What should medical providers keep top-of-mind?

For patients, physicians should always consider first NSAIDS (such as acetaminophen and ibuprofen), routine exercise, physical therapy, hot and cold compresses, and possibly steroidal injections. If opioids are necessary, beware that long-term opioid use can lead to physical dependence and intense withdrawal. Patients should be slowly weaned off. Patients who have developed an addiction to opioids that goes beyond a physical dependence will need to undergo medical detox, or take agonist maintenance medication to curb their brain-receptor cravings. Psychotherapy specifically targeted for substance abuse disorders, including individual counseling and group therapy, is always needed for successful recovery from an addictive illness. Patients should be encouraged to proactively lower their daily pain risk factors, not abuse or share opioids, and seek medical attention if they start to experience withdrawal symptoms or addiction.