UK research project will create strategies to improve respiratory health for those living in Appalachian Kentucky

Public health researchers at the University of Kentucky will undertake a five-year long research project called "Community-Engaged Research and Action to Reduce Respiratory Disease in Appalachia," Sarah Noble writes in a UK press release.

Funded by the National Institutes of Health's National Institute of Environmental Health Sciences, the project will involve creating strategies to improve respiratory and environmental public health. Kentuckians living in Appalachian counties have the state's highest rates of serious respiratory illness.

"Adults in Appalachian Kentucky are 50 percent more likely to develop asthma or chronic obstructive pulmonary disease than the overall U.S. population," Noble writes. "As many as one in five adults in the region have received a diagnosis of asthma, and rates of COPD are nearly two-and-a-half fold the incidence of the disease in other parts of the country.

Although studies show associations between respiratory health problems and environmental contaminants, data doesn't yet include individual-level assessments or behavioral risk factors common in the area—such as smoking, poor diet and insufficient physical activity. The "Community Response to Environmental Exposures in Eastern Kentucky" project will fill those gaps.

The CREEEK project will include three steps. A community-based assessment will "identify the relationships between indoor air pollutants, behavioral and social determinants and the effects these factors have on risk of respiratory disease," Noble writes. That information "will be shared with local stakeholders in an effort to increase understanding of the environmental exposures present in the region," then the project will put in place "an environmental public health action strategy and will evaluate that strategy's ability to impact short-and long-term outcomes for respiratory health."

Newspapers' data analysis finds that Kentucky's seniors on Medicare are among the sickest in U.S.; local data available

Red counties are over 21%. For map with data, click here.

The top 10 Kentucky counties with the highest percentage of seniors on Medicare who have six or more chronic conditions are also in the nation's top 50 for sick seniors, according to government data analyzed by USA Today and The Courier-Journal. Nine of the top 10 counties are in Appalachia.

"That's not surprising," Fran Feltner, director of the University of Kentucky Center of Excellence in Rural Health, told The C-J's Laura Ungar. "And when you're having breathing problems, high blood pressure problems and other problems, to me it seems like you're waging a daily battle against the chronic diseases. It's hard to fight the battle ... and as you get older, it's harder."

The top 10 Kentucky counties ranked by percentage of the 65-and-older Medicare population with six or more chronic conditions are Clay, 27.1 percent; Breathitt, 26.3 percent; Johnson, 26.2 percent; Knott, 25.1 percent; Perry, 24.6 percent; Letcher, 24.2 percent; Bell, 24 percent; Floyd, 23.8 percent; Wolfe, 23.7 percent; and Taylor, 23.6 percent. Taylor County (Campbellsville) is not in Appalachia but borders three non-coal Appalachian counties.

Beve Cotton (C-J photo by Mark Mahan)

Beve Cotton, 81 and with a long list of chronic diseases, is one of those seniors. He lives in Manchester, the seat of Clay County, which ranks 12th among more than 3,100 counties nationally for the percentage of seniors on Medicare with six or more chronic conditions, Ungar reports.

"I'm a mess," said Cotton, who gets around in a power chair and wears a full set of dentures after losing all his teeth. "I'm not able to do things. I'm an accomplished cook, but I can't do that anymore ... I can't drive. My legs don't cooperate. ... It's very hard."

Ungar reports that Clay County, population 21,147, has many of the factors that combine to cause poor health.: "Nearly 38 percent of residents live below the poverty level, compared with a state average of 19 percent, according to the Census Bureau. Median household income is about $22,000 a year, about half the state average.Access to health care, especially specialists, is limited, and there are few well-stocked grocery stores or safe places to exercise. Smoking and obesity rates are sky-high."

Carmen Webb, who directs the senior center in Manchester, told Ungar that many seniors struggle with being able to afford staples, let alone healthy food and also the high cost of transportation, making it difficult to get to doctors appointments to manage their illnesses.

Cotton, who grew up in Manchester, told Ungar that he depends on others for rides, frequently to doctors' appointments, including many at the Veterans Affairs Medical Center in Lexington, about 100 miles away. Webb noted that public transportation in the area costs $1.50 per mile.

Feltner added that many seniors in the area don't know how to prevent chronic disease, some have fatalistic attitudes and because many of them are on multiple medications, they face the dangers of drug interactions and side effects, Ungar reports.

Experts say that such high levels of illness hurts communities, "hastening a downward economic spiral locally and requiring huge portions of Medicare budgets," Ungar writes. It also overtaxes the medical communities in rural counties even thinner.

"These patients need to be seen frequently by doctors, and they need much longer visits. ... These folks need intense care," Dr. Michael Karpf, executive vice president for health affairs at UK, told Ungar. "Given the shortage of primary care in Appalachia, this kind of patient just exacerbates that shortage."

"The real issue is prevention — weight control, exercise, food habits," Karpf said. "But it's hard. Fast food is cheaper than wholesome, healthy food, and (the way people eat) is partly cultural. Those things are hard to change. It's a generational process."

Hepatitis C is on the rise in Appalachian Kentucky, and dirty needles are to blame; officials predict surge of HIV to follow

Kentucky has the highest rate of acute hepatitis C in the nation and public officials predict it could get much worse, Claire Galofaro and Dylan Lovan report for the Kentucky bureau of The Associated Press.

Dirty needles shared by drug users is the primary cause of this upsurge in hepatitis C, a contagious liver disease that destroys the liver, often leads to cancer or cirrhosis, and is the leading cause of liver transplants. It is spread primarily through contact with the blood of an infected person.

Patton Couch talks about his troubles.
(AP photo by David Stephenson)

Patton Couch, 25 and one month sober, is one of thousands of young Appalachian drug users recently diagnosed with hepatitis C. Galofaro tells the story of how one night four years ago, Couch said “he plucked a dirty needle from a pile at a flophouse and jabbed it into his scarred arm” even though he knew most of the addicts in the room probably had hepatitis C.

"All I cared about was how soon and how fast I could get it in," he says. "I hated myself, it was misery. But when you're in the grips of it, the only way I thought I could escape it was one more time."

Public-health officials are also concerned that Kentucky or part of it will become the next Scott County, Indiana, which is dealing with one of the worst American HIV outbreaks among injection drug users in decades, Galofaro notes. She says Scottsburg is much like many Appalachian towns – which have poor and/or few treatment options, and have long been seized by an epidemic of prescription drug abuse.

"One person could be Typhoid Mary of HIV," said Dr. Jennifer Havens, an epidemiologist at the University of Kentucky's Center on Drug and Alcohol Research, who has studied Perry County drug users for years as the hepatitis rate spiraled through small-town drug circles there. Of the 503 drug users she has tracked since 2008, 70 percent have hepatitis C.

“An explosion of hepatitis C, transmitted through injection drug use and unprotected sex, can foreshadow a wave of HIV cases,” Galofaro writes.

In Scott County, 160 people have tested positive for HIV in five months, compared to just 49 drug users testing positive in New York City in all of 2013, Greg Millett, director of public policy for the Foundation for AIDS Research, told Golofaro. “This is a canary in the coal mine for other places with high rates of hepatitis C,” he said.

In a study released last month, the federal Centers for Disease Control and Prevention found that hepatitis C cases across four Appalachian states — Kentucky, Tennessee, West Virginia and Virginia — more than tripled between 2006 and 2012.

Kentucky leads the nation in the rate of acute hepatitis C, with 4.1 cases for every 100,000 residents, more than six times the national average, according to the CDC.

Officials in Appalachian are “scrambling to figure out how to stop it, whether through needle exchange programs, drug treatment or jail,” Galofaro writes.

Kentucky passed a law in March allowing local health departments to create needle-exchange programs. The guidelines have been set, but it is up to the counties to decide whether they want one.

Louisville and Lexington plan to launch needle exchange programs this summer, but “few rural communities have expressed interest,” possibly letting the larger cities work out the details first, Van Ingram, executive director for the Kentucky Office of Drug Control Policy, told Galofaro.

Even with the law in place, the debate about the needle-exchange programs persist. Proponents maintain that “we have to change the way we think” about treatment and that doing nothing is not an option, others told her that in small communities, the “fear of being exposed as a drug user may keep users away,” and others objected on a moral ground, “claiming they facilitate drug use rather than prevent it,” Galofaro reports.

CDC says SOAR should focus on substance abuse, obesity and diabetes; idea of mountaintop mining study is largely ignored

By Melissa Patrick
Kentucky Health News

Shaping Our Appalachian Region, the bipartisan effort to revitalize and diversify Eastern Kentucky's economy, will focus its health efforts on substance abuse, obesity and diabetes, SOAR Executive Director Jared Arnett told Kentucky Health News.

"We believe they have the greatest impact on our ability to create jobs and build a world class workforce," Arnett said in an email. He said David Roberts of the federal Centers for Disease Control and Prevention, determined the priorities after spending three months at the SOAR office in Pikeville.

The priorities differ from those put forth by SOAR's Health Working Group, which made two major recommendations after a series of public forums: a coordinated health program in schools, and a study of the health effects of large-scale surface mining. However, when SOAR published the working groups' ideas a few weeks later, it listed only the "shortest-term recommendations" and did not include the mining study. No recommendations appear on the health group's webpage.

At the health session of SOAR's "Strategy Summit" May 11, Dee Davis of the Whitesburg-based Center for Rural Strategies asked the moderator/presenter, Jennifer "Jenna" Seymour of the CDC, what if anything was being done about the recommendation. Seymour replied that she wasn't aware of it, Al Cross reported for the Appalachian Kentucky page of The Rural Blog.  

"That dismayed me," Cross writes. Later, upon raising his hand and being recognized by Seymour, he told her and the audience that it was "disconcerting and almost unbelievable" that she was unaware of the recommendation about mountaintop mining. Seymour replied that she had, in fact, heard about it.

Cross wrote, "Noting that the Pike County Fiscal Court Room was nearly full, I told Seymour that a lot of people had attended meetings and made their concerns known, and that even though this issue was "a hot potato," because of the coal industry's role, she needed to "go back to the powers that be, and tell them there's a room full of people who want answers."

Cross wrote that he was not for or against a study on the health effects of mountaintop mining, and " Unless they're writing opinion pieces, journalists aren't supposed to take sides," he wrote. "But they do need to speak up when issues of broad community concern aren't being addressed, especially when those concerns have been solicited."

The SOAR working groups concluded their meetings last summer and submitted their final reports. Since then, the SOAR executive board has decided to launch a SOAR Advisory Council and hold annual roundtables, or more as needed. They have made a request for a community health representative to be appointed to serve on this council, and Arnett said he expects this person to be appointed by June 1 or so. 

In addition, a follow-up CDC representative will be assigned to the SOAR office for one year beginning in late summer to help put together a strategic plan to address the three areas of focus recommended by the CDC at the summit. This person will also lead a Community Health Action Team for SOAR to work on building a blueprint for improved public health in the region, Arnett said.

"We are focused on working with our corporate partners and the Community Health roundtable to address these issues identified by the CDC on what can have the broadest reach and the greatest impact," Arnett said. A full report of all of the CDCs recommendations is expected in the near future, he said.

Kentucky led the nation in hepatitis C cases in 2013; state's rate rose 357 percent from 2007 to 2011

By Tim Mandell
Kentucky Health News

Kentucky had the nation's highest rate of hepatitis C in 2013, with 5.1 cases per every 100,000 people, says a report by the federal Centers for Disease Control and Prevention. As many as 3.5 million people in the U.S. have hepatitis C and more than 56,000 Kentucky resident may have chronic hepatitis C infection, according to the state Cabinet for Health and Family Services. The main cause of hepatitis C is shared needles among intravenous drug users.

Hepatitis C cases rose 364 percent in Kentucky, Tennessee, Virginia and West Virginia from 2006 to 2012. The big increase was in 2007-11, when the rate rose 357 percent, a CDC state health profile says.

"Of the cases that have been reported and researchers gathered data about potential risk factors, 73.1 percent reported injecting drugs," Brian Wu reports for Science Times. Among new cases, 44.8 percent were people under 30.

While officials said HIV rates are low in the four Appalachian states, they said they fear that the increase in hepatitis C cases could lead to a rise in HIV cases, Wu writes. Officials said needle-exchange programs are key to reduce the number of potential HIV cases. Kentucky recently authorized such programs if local officials agree to them.

"About 4.5 million Americans older than 12 abused prescription painkillers in 2013 and 289,000 used heroin, according to the Substance Abuse and Mental Health Services Administration," Liz Szabo reports for USA Today. "About 75 percent of new heroin users previously abused opioid painkillers. The number of first-time heroin users grew from 90,000 people in 2006 to 156,000 in 2012, according to the CDC."

Kentucky has the third highest drug overdose mortality rate in the U.S., with 23.6 deaths per 100,000 people, says the 2013 report "Prescription Drug Abuse: Strategies to Stop the Epidemic," reports Trust for America's Health. "The number of drug overdose deaths—a majority of which are from prescription drugs—in Kentucky quadrupled since 1999 when the rate was 4.9 per 100,000."

Baptist Health is first stand-alone health provider to become founding partner of Shaping our Appalachian Region effort

Baptist Health has become the first stand-alone health-care provider to sign on as a founding partner in Shaping Our Appalachian Region, an initiative to improve the economy of Eastern Kentucky.

Baptist will work with SOAR to develop and implement health and education initiatives for residents of Appalachian Kentucky and has committed $150,000 to the initiative over the next three years, the organizations said in a press release.

“Baptist Health understands Eastern Kentucky because we have a proven and time-honored commitment to the health and well-being of our people,” Stephen C. Hanson, chief executive officer of Baptist Health, said in the press release. “Our participation in SOAR reflects this pledge. Besides Richmond, we’ve also got hospitals in Corbin and Lexington, along with outpatient facilities, doctors’ offices and other services all over Eastern Kentucky, the rest of the commonwealth and indeed throughout the region."

The University of Kentucky was the first founding sponsor of SOAR, pledging $300,000 over the next three years and winning the right to use the UK HealthCare brand on SOAR materials as well as the university's general logo.

Gov. Steve Beshear and Congressman Hal Rogers formed SOAR in the fall of 2013 to create strategic plans to improve Eastern Kentucky's economy and quality of life.

“Our primary objective is creating and maintaining jobs across eastern Kentucky, and in order to do that, we need a healthy and well-educated workforce,” Beshear said in the release. “I’m pleased that Baptist Health understands the key connections among our efforts and the critical role that health will play in the future of this region."

Proposals sought for research of Appalachian 'bright spots' where health is better than socioeconomic factors would indicate

A three-year research project to determine factors that can support a culture of health in Appalachia and whether that knowledge can be translated into actions that address the region's health disparities has released its Request for Proposal to invite proposals from qualified research teams and consultants who would like to work on this project.

The project,“Creating a Culture of Health in Appalachia: Disparities and Bright Spots,” is sponsored by the Appalachian Regional Commission, the Robert Wood Johnson Foundation and the Foundation for a Healthy Kentucky and will run through the end of 2017.

The research for this project will identify Appalachian “bright spots,” where health outcomes are better than would be expected based on unemployment and poverty rates and other community factors, and try to figure out why. Researchesr will also try to determine why health outcomes in some communities are not as good as would be expected.

The request for proposals offers detailed guidelines for submissions, which are due June 8. Applicants are encouraged to register for a webinar, detailed on the RFP, to be held May 7 at 10 a.m. EDT. Click here for more information.

Study of poor but healthy Appalachian counties aims to find community-based approaches to improving the region's health

Though some people equate Appalachian areas with poverty, David Krol seeks to "shine a light" on a different picture—one that reflects "how health can flourish across Appalachia," despite data that confirms economic hardship, Krol writes for the Robert Wood Johnson Foundation.

While Krol was reviewing the Appalachian Regional Commission's county-based economic data, which compares economic indicators like poverty and unemployment rates with national averages and then ranks each county, it occurred to him to overlay this county index with the annual County Health Rankings.

For the most part, Krol said he found what he expected, "that the most economically distressed counties in Appalachia would also be in the lowest quartiles of health outcomes and factors for their state." But some counties that were economically distressed ranked in the top quarter of their state in health factors and outcomes.

"What was it about Wirt County, West Virginia; Pickett County, Tennessee; and Oktibbeha County, Mississippi, that helped them overcome significant economic challenges towards better health outcomes when similarly distressed counties in the same state did not?" he wrote.

The need to know why these "unexpected outliers" occurred has prompted Krol, with the help of the ARC and the Foundation for a Healthy Kentucky, to study how these counties have accomplished this and to look at whether this could be re-created in similar communities.

"This approach is rooted in the belief that communities have the best solutions to the problems they face—as opposed to solutions driven by outside experts," he wrote.

It’s an opportunity to “go beyond the data.. to community conversations about what’s important,” Susan Zepeda, CEO of the foundation, told Krol.

Krol wrote, "Quantitative data can get only get us so far—it’s up to us to ask those critical questions of “Why? How? What can be done? It’s up to us to turn data into action."

West Virginia to involve Kentucky in examination of studies that link health problems to mountaintop-removal coal mining

Kentucky Health News

The administration of Democratic Gov. Earl Ray Tomblin of West Virginia "said Tuesday that it would initiate an evaluation of the growing body of studies that have found residents living near mountaintop removal coal-mining operations face increases risks of serious illnesses and premature death," Ken Ward Jr. reports for The Charleston Gazette. Studies have found correlations between mountaintop removal and cancer, birth defects and the endangerment of freshwater species.

Dr. Rahul Gupta, commissioner of the state Bureau for Public Health, "said that his agency would work with the state Department of Environmental Protection to examine the issue and to seek help from various federal scientific and regulatory agencies to review existing research on the subject," Ward writes. “The analysis is something that is needed going forward,” Gupta said. “The bottom line here is to let science speak for itself. It’s time that we attempt to do that.”

"Gupta said that his plan would 'engage surrounding states' such as Kentucky and Virginia to 'evaluate the scientific research being conducted by academia, non-profit groups, and others with an emphasis on peer-reviewed research to better understand the issues,'" Ward writes. "Also, Gupta said, his agency would work with the DEP to ask 'federal partners'—such as the U.S. Environmental Protection Agency, the Centers for Disease Control, and National Institutes of Health, and the federal Office of Surface Mining—to 'seek relevant subject matter expertise allowing for the exploration of a federal-state, multi-agency partnership to conduct analysis of the existing research in the field.'" (Read more)

Johnson foundation, Appalachian commission, Foundation for a Healthy Ky. to examine bright and dark spots in Appalachia

The Appalachian Regional Commission, the Robert Wood Johnson Foundation, and the Foundation for a Healthy Kentucky are working on a three-year health-research project to determine factors that can support a culture of health in Appalachia and whether that knowledge can be translated into actions that address the region's health disparities.

“Creating a Culture of Health in Appalachia: Disparities and Bright Spots,” will run through the end of 2017. The project will identify “bright spots” where health outcomes are better than indicated by unemployment, poverty rates and other community factors. Experts will try to figure out why, and will likewise examine why health outcomes in some communities are not as good as would be expected. 

The Robert Wood Johnson Foundation is providing $750,000 for the project, and ARC will contribute $250,000. The Foundation for a Healthy Kentucky will administer the project.

“This groundbreaking effort will provide a deeper understanding of factors that contribute to or undermine community health,” said Susan Zepeda, president and CEO of the foundation.

The project will produce a database with county-level health and economic data; hold discussions with local leaders to help explain the findings; develop policy-based user tools, including a Web site featuring data sets and a GIS-based tool to help visualize research outcomes and community profiles; and examine policy implications and make recommendations.

Appalachians Together Restoring the Eating Environment to help Eastern Kentucky communities develop local, healthy foods

A new project searches for ways to increase access to healthy foods in Eastern Kentucky and looks to communities to find these solutions.

Appalachians Together Restoring the Eating Environment, or Appal-TREE, is a collaborative project between the Community Farm Alliance and the University of Kentucky. It is based in Whitesburg and funded by a grant from the National Institutes of Health. Other partners include Grow Appalachia, the Cowan Community Center and the Mountain Garden Initiative.

"This project is unique in that the community got to determine the pathway and the goal of the grant funding," Valerie Horn, director of the project, told the UKNow news service. "We wanted to talk to the people who have the most influence about food issues, as well as those people who are most affected by those decisions."

About one in six Kentuckians, or 16.4 percent, struggles with food insecurity in Kentucky, according to the U.S. Department of Agriculture. Food insecurity is defined as the lack of reliable access to a sufficient amount of affordable, nutritious food.

Horn has worked with several grass-roots efforts in Appalachia to combat food insecurity: Grow Appalachia, local farmer's markets, local food pantries, summer feeding programs for country children, weekend backpack programs and a free meal program at the weekend farmer's market for children. She told UKNow that these grassroots efforts represent a "growing awareness about local, healthy foods in Eastern Kentucky over the last several years."

The first year of the project was spent gathering community input about the topic. "The problems related to nutrition are ones that can be solved locally and they're not insurmountable, said Mark Swanson, associate professor in UK's College of Public Health and principal investigator on the grant. "We have solutions in the communities. It's neat when UK can help communities solve their own problems. We don’t know the solution — they do. It's the idea of pairing academic knowledge with local expertise."

The next two years of the grant will focus on several key projects, two of which focus on schools. The first is a "water first" campaign to encourage middle- and high-school students to choose water over sugary drinks, and the second will focus on increasing healthy options in school concession stands in Letcher County.

"We'd like to work with the schools to help them see that at a ball game, you can still make money selling snacks that are less harmful," Horn said.

Appal-TREE will organize free cooking classes throughout Letcher County. Each program will include six sessions that emphasize healthy food on a budget.

Nearby, the Clay County Cooperative Extension Service has also promoted food security through community cooking classes, teaching families how to can their own food and helping to start Clay County's first farmers market last summer, UKNow reports.

"Food is tied to so many things here -- when there's a funeral, dining room tables are covered with cakes and dumplings and just the best of food. We have wonderful cooks here," Horn said. "I say that it's like being a talented musician and learning another instrument — it's just learning another way to make food."

Appalachian women are more likely to get cervical cancer and die from it, but pass up vaccine partly because of fatalistic beliefs

By Melissa Patrick
Kentucky Health News

A fatalistic belief that getting or preventing cancer is beyond a person's control is one of many reasons young women in Appalachian Kentucky are likely to not get or complete the series of HPV vaccinations to prevent cervical cancer, according to a study by researchers at the University of Kentucky, published in The Journal of Rural Health.

"Our study found that fatalistic beliefs influenced immunization behaviors, which is concerning, given the high success rates of preventing HPV infection and cervical cancer through HPV vaccination and the elevated burden of cervical cancer in Appalachian Kentucky,” Robin Vanderpool, lead author of the study, said in an email.

The human papillomavirus, or HPV, is the most common sexually transmitted infection in the U.S., affecting an estimated 79 million individuals. Two types of HPV cause two-thirds of all cervical cancers, and unlike any other cancer, there is a three-dose HPV vaccine that can prevent it, according to the federal Centers for Disease Control and Prevention.

The UK researchers found that the women in the study who believed they had limited control over their health generally and limited control over cervical cancer specifically were significantly less likely to complete the HPV vaccine series than those who did not have this belief.

"This is an important finding because rural Appalachian residents often perceive cancer as pervasive, inevitable and mostly hereditary," the authors wrote.

The 344 rural Appalachian women who volunteered for the study were given the first dose of vaccine free of charge, and surveyed about their beliefs regarding cancer. They were followed for nine months after the first dose to determine completion rates.

Other studies had determined that many Appalachian women don't get or complete the HPV vaccine because of cost, lack of transportation, cultural views, lack of knowledge about cervical-cancer prevention and limited support from parents, peers and health-care providers. A belief in fatalism can now be added to this list.

Health advocates are working to get through these barriers because Appalachian Kentucky has the state's highest rates for cervical cancer and deaths from it, according to the Kentucky Cancer Registry. This, in a state that is among the top 14 for the most cases of HPV-related cervical cancers in the nation, according to the CDC.

Kentucky has a low HPV vaccination rate, with only one in four adolescent women initiating the vaccine and less than one in nine receiving the full series, according to The Kentucky Cancer Consortium. These rates are even lower in Appalachia, says the study.

The CDC recommends routine HPV vaccination for females ages 11-12 and catch-up vaccination for females ages 13-26. The second dose should be given one to two months after the first injection; the third dose should be administered six months after the first dose. Males are also encouraged to get the vaccine.

The study acknowledged that future such studies should compare women who have received the first dose of the vaccine, as in this study, against women who had not. It also suggests that these findings indicate a need for future research in how to educate and intervene with Appalachian women in a way that is culturally sensitive to improve HPV vaccination rates and to impact cancer disparities that affect the women in the region.

Collaboration, telemedicine save lives in rural Kentucky

Many rural women in Appalachia can now have their babies closer to home thanks to a partnership between Appalachian Regional HealthCare and UK HealthCare.

UK HealthCare women's health providers are now based at permanent community clinics in Morehead, Georgetown and Hazard, says a University of Kentucky news release. Prenatal emergencies are still transferred by air ambulance to the UK Chandler Hospital, but full-time obstetricians, telehealth and a partnership with ARH is allowing most women to deliver closer to home.

A Breathitt County mom, Elma Thorpe, shared her story about how Dr. James Dawson, one of two doctors based at the UK HealthCare Women's Clinic in Hazard saved her life and her newborn son's life in November 2012.

At 36 weeks pregnant, Thorpe had stomach pains and thought she was going into labor. She went immediately to the hospital and was admitted to the emergency department at Appalachian Regional HealthCare Medical Center in Hazard. Her regular doctor was on vacation, so the on-call obstetrician Dr. James Dawson, one of two doctors based at the women's clinic, stepped in to deliver Thorpe's baby.

While waiting to be taken to the labor and delivery department, Thorpe developed a placental abruption, which occurs when the placenta prematurely breaks away from the wall of the uterus and was causing bleeding from the womb. That cut off the baby's oxygen supply, and Dawson feared that the baby would die inside the womb before he was able to deliver. He also knew Thorpe was in danger from losing a high volume of blood.

"With some emergencies, you have several minutes or an hour, but this was one where we had only a few minutes," Dawson said. He and the ARH medical team performed an emergency Cesarean section to deliver baby Nicholas and then successfully worked to stop Thorpe's bleeding.

UK HealthCare's Women's Health in Hazard employs two full-time obstetricians with the intent to keep women closer to their home for prenatal care and delivery, even when emergencies arise, UKNow reports.

Dawson and colleague Dr. Misty Thompson live and work in the Appalachian community they serve. A partnership between UK and ARH allows them to be on-call for deliveries and emergencies, and provide women's health services at health departments in surrounding counties.

Obstetricians in Hazard also have access to the latest ultrasound technology and consultations with UK specialists in Lexington through telemedicine if they partner with UKHealthCare.

Dr. Wendy Hansen, chair of UK's Department of Obstetrics and Gynecology, said these collaborative resources and support "will improve the level of care for women in every part of Kentucky" and will also "help recruit doctors to an historically underserved area that struggles to attract providers."

Nine hospitals in Kentucky get maximum Medicare penalty for readmissions; they blame socioeconomic factors

Article updated 10/20/2014
Nine hospitals in Kentucky, eight of them in Appalachia, have been hit with the highest penalty possible by Medicare for high rates of patient readmission.

This is the third year the program has fined hospitals, under the federal health-reform law, for having too many patients return within 30 days for additional treatment.

This year, the maximum penalty is a 3 percent reduction in Medicare payments for all patient stays in the fiscal year beginning Oct. 1. Last year, the cut was 2 percent. The fines are based on readmissions from July 2010 through June 2013.

Kentucky hospitals fined the maximum amount this year are the Appalachian Regional Healthcare hospitals in Harlan, Whitesburg and Hazard; Memorial Hospital in Manchester; Methodist Hospital in Henderson; Pineville Community Hospital in Bell County; Three Rivers Medical Center in Louisa; Monroe County Medical Center in Tompkinsville; and Westlake Regional Hospital in Columbia. All except Henderson are in Appalachia, and most are in Eastern Kentucky.

“Some of the specific challenges that have faced hospitals in Eastern Kentucky is that they see a greater proportion of patients who have suffered from heart attacks, heart failure and pneumonia,” Elizabeth Cobb, vice president for health policy at the Kentucky Health Association, told Kevin Halpern of the Middlesboro Daily News.

Cobb also said the region has "higher numbers of chronically ill patients, who require a greater amount of hospitalization," and that high rates of obesity and smoking, which affect how well a patient does after discharge, as well as a lack of oupatient services in rural areas, also contribute to readmissions. The formula for calculating readmission penalties does not take such problems into account.

Nationwide, 2,610 hospitals received a readmissions penalty, but only 39 were hit with the full 3 percent. In Kentucky, 63 hospitals, about two-thirds of the state's total, were penalized, with the average penalty being a 1.21 percent reduction in payment, according to an analysis of federal records from Kaiser Health News.

Halpern, citing KHA, reported that Kentucky represented a "disproportionate share of (the) hospitals receiving the maximum penalty, with nine hospitals, representing 23 percent of the total."

KHA supports pending legislation that will require the Centers for Medicare and Medicaid Services to adjust its program to account for socioeconomic conditions that "are beyond a hospital's control," Halpern reports. Opponents say "hospitals that have many readmissions are providing substandard care and should not be let off the hook," Kaiser's Jordan Rau reports.

The penalties have forced hospitals to provide better follow-up care for their patients after discharge in efforts to avoid readmission. The days of handing a patient a written discharge plan and expecting the patient to follow them without follow-up are quickly becoming a thing of the past, Rau reports.

Instead, hospitals are finding ways to ensure patients are not readmitted like ensuring outside doctors monitor discharged patient's recoveries; providing free medication for those who can't afford them; or sending a nurse to a patients home to make sure they are taking care of themselves.

But some hospitals are still struggling with these new guidelines, resisting many such efforts because they aren't paid for these services, Rau reports, and some continue to readmit patients because it has been financially beneficial to the hospital in the past.

Medicare officials estimate that $17 billion of the $26 billion Medicare pays for readmissions is a result of "potentially avoidable readmissions," Rau reports.

CDC sending full-time senior staffer to E. Ky. to help health departments tackle the region's chronic, serious health problems

The federal Centers for Disease Control and Prevention will place a full-time employee in Eastern Kentucky to help public health departments battle the region's serious, chronic health problems, the area's congressman said Tuesday.

Republican Rep. Harold "Hal" Rogers of Somerset, chair of the House Appropriations Committee, said CDC Director Dr. Thomas Frieden, who spent three days with him in his Fifth Congressional District last month, told him he would assign a senior staffer to the job.

Beshear, Rogers (Melissa Newman photo)

Rogers made the announcement at a meeting of the executive committee of Shaping Our Appalachian Region, the economic-development effort he started with Democratic Gov. Steve Beshear. In a meeting at Natural Bridge State Resort Park, the panel heard reports from chairs of SOAR's working groups, which held "listening sessions" around the region this summer.

The Health Working Group "recommended pushing a statewide ban on smoking indoors in public; asking the Centers for Disease Control and Prevention to study poor health in the region and the emerging research on a correlation between mountaintop mining and health problems," Bill Estep reports for the Lexington Herald-Leader.

The working group's PowerPoint slide said, "Invite the CDC to form a task force to accurately map the current state of health in Eastern Kentucky and to create a strategic health plan for the region; start the 'Healthy 5 for the 5th' campaign for individual health in an effort to promote wellness in the region; explore Coordinated School Health programs for our entire region; ramp up oral-health efforts to encourage school-based oral health services are underway in every school district in the region."

UK-EKU center gets $5 million to address occupational health and safety issues in Central Appalachia and Kentucky

A center based in the University of Kentucky College of Public Health has received a five-year, $5 million grant to advance occupational health and safety in Central Appalachia and Kentucky, the university reports.

The grant was funded by the National Institute for Occupational Safety and Health at the federal Centers for Disease Control and Prevention. It will support the Central Appalachian Regional Education and Research Center as a "cohesive, fully equipped and recognized resource for occupational safety and health research and training in Central Appalachia," a UK release says.

It says Central Appalachia has "high proportions of fatal occupational injuries related to transportation and highway incidents; injuries in agriculture, forestry, fishing and hunting, and mining." However, "Systematic attention to the safety and health concerns of its work force has been limited," CARERC Director Wayne Sanderson said.

CARERC was formed in 2012 by the colleges nursing, public health and engineering at UK as well as the College of Justice and Safety at Eastern Kentucky University. It is one of only 18 such centers in the nation and provides interdisciplinary graduate education for students and health professionals in five programs: agricultural safety and health, occupational epidemiology, mining engineering safety and health, occupational health nursing, and occupational safety.

Seventy percent of the funding will support students in the CARERC program. The center also serves as a resource for industry, labor, government agencies, and other stakeholders and is partnering with stakeholders in the mining industry to develop new methods to reduce miners' coal-dust exposure.

"There aren’t many courses or programs where you're out in the field working with nurses, epidemiologists, and safety experts," Sanderson said in the release. "Everything we do is very interdisciplinary, which is how the real world works — people working together to solve problems."

Appalachian Kentucky has much of what it needs to improve its poor health status, key federal officials agree

By Al Cross
Kentucky Health News

Appalachian Kentucky has the enthusiasm, creativity, people and facilities needed to greatly improve its dismal health status, two high-ranking federal officials said after looking at the problem on a recent tour.

Dr. Thomas Frieden, Rep. Hal Rogers

"I want to stir up our people to get involved in a grass-roots effort," U.S. Rep. Harold "Hal" Rogers, R-Somerset, who hosted Dr. Thomas Frieden, director of the federal Centers for Disease Control and Prevention, on a four-stop tour of his Fifth Congressional District in early August.

Rogers and Frieden were guests on KET's "One to One" Sunday afternoon, in a program recorded right after they returned from their trip, where Frieden said he saw much creativity and enthusiasm.

Using one of Rogers's favorite sayings, Frieden said, "If you plan your work and work your plan, you may very well have tremendous success."

Rogers said what struck him most about the trip was "the infrastructure we already have in place," including hospitals, health departments, doctors and other health providers, and he wants to "talk about enhancing them.

Rogers is in a position to do that with federal money, because he is chairman of the House Appropriations Committee. He is also co-founder, with Democratic Gov. Steve Beshear, of Shaping Our Appalachian Region, an initiative to improve the economy of Eastern Kentucky.

Asked by "One to One" moderator Bill Goodman where the role of government begins and personal responsibility for health begins, Frieden said, in an apparent reference to smoking bans, "You don't want to go to your job and get cancer as a result."

"We don't tell people what to do" at the CDC, he said, but offer communities choices from a list of proven programs. Earlier, he said smoke-free laws not only reduce smoking, but heart attacks among non-smokers.

Rogers said he asked Frieden what one thing he would recommend for improving personal health in the region, and the doctor replied, "Walk."

Frieden said walking is an especially good option for Kentuckians because they have such a beautiful state. However, many rural areas in the state lack sidewalks or other easily accessible places to walk.

"Physical activity is the closest thing we have to a wonder drug" for all sorts of ailments, Frieden said, "but you have to do something you love to do" in order to stick with it. He said it also helps children be good students: "The more physical activity they get, the better their minds will work."

That point was made a few days before the two men's trip, at the Kentucky Summit on Childhood Obesity and Physical Activity at the University of Kentucky.
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UK president sees the need for 'irrational optimism' and working as a community to improve Kentucky's health

The health and economic issues facing Appalachian Kentucky are daunting, but still worthy of "irrational optimism," as espoused by the head of the federal Centers for Disease Control and Prevention, University of Kentucky President Eli Capilouto says in his most recent short essay.

Dr. Thomas Frieden of the CDC, who toured Eastern Kentucky with Capilouto and U.S. Rep. Hal Rogers last week, had a daily motto for his staff while working in India, a place with even greater challenges: "Irrational optimism is a pre-requisite for sucess," Capilouto writes. He says he saw the power of that in a day-long symposium on health issues sponsored by the Shaping Our Appalachian Region initiative started by Rogers and Gov. Steve Beshear.

"Where so many see problems, Kentuckians see potential," Capilouto writes. "Where others place limits and barriers, Kentuckians see the promise of a brighter tomorrow," especially when they can work together. To illustrate that, he tells the story of a Denver minister he heard on a radio show.

"She was discussing the idea of what it means to be human; what it means to be part of a community," Capilouto writes. "The minister said she disagreed with the notion that God will never give you more than you can handle. 'God,' she said, 'will never give you more than your community can bear or you as a member of a community.' The idea, of course, is that we all need each other. And we all have responsibilities to each other. That’s what it means to be part of — and partners with — community." (Read more)

Health issues facing Appalachia, focus of CDC director's tour, could be a forewarning of where the country is heading

The chronic health issues of Appalachia, the focus of a recent tour by the head of the federal Centers for Disease Control and Prevention, are really no different than the chronic health issues the entire country faces; they are simply more concentrated in one area, Laura Ungar writes for The Courier-Journal and USA Today.

"It's about proportion and intensity rather than something unique that's happening there," Jesse Roman, chairman of the Department of Medicine at the University of Louisville, told Ungar. "The problem is larger and more visible there, but they're not alone."

Ungar describes the health challenges of one couple in Appalachia, 48-year-old Alisha Blankenbeckler and her husband, Tony. Alisha has diabetes, bowel and bladder problems and is on oxygen. Her condition makes it hard to take care of her husband who has heart disease and hip problems since being struck by lightening in 2010. He takes 11 pills a day; she takes 30.

"Dying is something I think about every day," Alisha told Ungar.

This story, Ungar reports, is common in the Appalachian region, which is considered one of the nation's unhealthiest regions.

Heart disease prevalence is 84 percent higher in the region than the national average, diabetes is 47 percent higher, and lung cancer kills at a rate 83 percent higher. The region has the highest-in-the-nation smoking rates, with nearly a third of adults smoking cigarettes, and Kentucky has the highest number of deaths caused by cancer.

"We're in the stroke belt, the diabetes belt, the coronary valley. We get all those labels," Fran Feltner, director of the University of Kentucky Center of Excellence in Rural Health at Hazard, told Ungar. "We're in a sad state here."

Some experts say Appalachia "may be a harbinger of where the country is headed if we don't rein in epidemics like obesity," Ungar writes. Obesity spawns "diabetes, heart disease and many cancers and spanning all socioeconomic levels/."

CDC Director Tom Frieden recently toured Eastern Kentucky to "find out more about the underlying causes of the region's ills and how to treat them -- and in the process gain traction against the rising burden of chronic disease that ails the nation," Ungar reports.

"The Appalachian region is just like the rest of the U.S. — only more," Frieden said on the tour. "We want to help an entire community and a whole nation."

Ungar writes, "Appalachia, like some blighted urban areas and Native American reservations, mixes several ingredients of poor health: doctor shortages and access-to-care problems; stressful, unhealthy lifestyles; low education levels; and insidious poverty."

Alisha Blankenbeckler told Ungar that at times she has had to stretch her insulin by taking less than the prescribed amount and once needed to go to the hospital but didn't because she had no insurance or money to pay the bill. She recently got insurance through the state's Medicaid expansion, and her husband is on Medicare, but that doesn't guarantee access to all the care they need because of required Medicare co-payments, medical equipment that is not covered, and gas to get to the doctor. The couple gets disability benefits of $1,427 a month.

Though more than half a million Kentuckians have enrolled in health insurance through the Affordable Care Act, "access to health care is difficult in Appalachia," Roman told Ungar.  "And there seems to be something about culture — a sense of fatalism, that whatever happens, happens."

Ungar writes that Friden and Benjamin Sommers, assistant professor of health policy and economics at the Harvard School of Public Health "say improving the health of Appalachia and like communities will not be easy, because it depends on changing seemingly intractable socioeconomic disparities and personal health habits."

Frieden said that while outreach and health education is crucial, he will "listen and take cues from local communities about how best to attack their particular health problems. If he finds an effective program, he said, he will replicate it and fit it to other communities."

UK, CDC announce two new health initiatives for Appalachia

University of Kentucky President Eli Capilouto, joined by U.S. Rep. Hal Rogers and Dr. Thomas Frieden, director of the U.S. Centers for Disease Control and Prevention, announced during Frieden's visit to the region Tuesday two new UK initiatives toward improving the health of Appalachian Kentucky.

The Appalachian Cancer Patient Navigation Project will allow UK and its partners to establish an infrastructure to train patient navigators over the next five years in five Appalachian states, a UK press release said. The navigators will serve as advocates for patients and help them connect with the services they need.

This $1.5 million project, funded by the CDC and the Appalachian Regional Commission, will also address cancer and other chronic diseases by promoting screening and prevention in the region. The program is part of a new multi-year partnership with the CDC's Division of Cancer Prevention and Control.

“Patient navigators can help Kentuckians get screened for cancer—finding it early can save your life,” Frieden said in the release. “By training more patient navigators where they are most needed, this CDC grant can help people in Appalachian areas live longer, healthier, cancer-free lives.”

The second initiative announced was the launch of the Community Leadership Institute of Kentucky, "a three-week intensive leadership development program designed to enhance research and capacity-building competencies in community leaders who play a key role in using data and decision-making related to health and health care," Powell writes.

Training for this program is competitive and will begin in October and November. Selected participant organizations will receive a $1,500 grant for completion of their proposed project over a 12-month period. Applications are currently being accepted through Aug. 29 for the first class of eight to 10.

"Our commonwealth is only strong if every community is strong," Capilouto said in the UK release. "And every community will only be strong when every community is healthy."

“We owe a great debt of gratitude to the University of Kentucky,” Rogers said in the release. “UK has helped transform the availability of health care in the mountains—improving access to specialists, spending thousands of dollars on cancer research and screening projects, and training students who want to come home to practice medicine.”

The announcements came during a symposium at Hazard Community and Technical College, the second Shaping Our Appalachian Region "Health Impact Series" event with Frieden. “I am thrilled to have such an impressive group of experts in health care here this week to focus on our health issues,” Rogers said. “We’re laying out our problems on the table.”

Tuesday’s symposium, sponsored by Appalachian Regional Healthcare, also featured presentations by Stephanie Mayfield, commissioner of the Kentucky Cabinet for Public Health, CDC Deputy Director Dr. Judith Monroe and a panel discussion of health care experts moderated by Dr. Nikki Stone, associate professor of the UK College of Dentistry/Medicine and chair of the SOAR Health Work Group.

Common themes in the discussions included "wellness, healthy foods, the smoke-free initiative, a focus on children and coordinated school health, oral health, diabetes/obesity, seniors, the need for mental health assessments and services beginning in early childhood and the drug epidemic," the UK release says.

Compared to the national averages, the prevalence of heart disease is 84 percent higher in the region. Diabetes is 47 percent higher, obesity is 26 percent higher and the state's lung cancer mortality rates are among the highest—at 67 percent above average—according to the Kentucky Department for Public Health. Kentucky as a whole has the nation's third highest rate of deaths from drug overdoses.

Rogers presented "Health Impact Awards" at the meeting to celebrate the "great work" of these organizations in awareness and prevention efforts, Powell writes. The awards went to Appalachian Regional Healthcare, the UK Gill Heart Institute-Appalachian Heart Center, the Hazard Police Department, the Knott County Drug Abuse Council and Kentucky Homeplace.