CHESAPEAKE
Physician YOUR PRACTICE. YOUR LIFE.
FIGHTING CANCERS TODAY AND TOMORROW UNDER VACCINATING SHINGLES AND HPV KEEPING POPULATIONS HEALTHIER
chesphysician.com VOLUME 5: ISSUE 5 SEPTEMBER/OCTOBER 2015
Maryland/DC/Virginia
Contents 10
VOLUME 5: ISSUE 5 SEPTEMBER/OCTOBER 2015
18
F E AT U R E S
10 Fighting Cancers Today and Tomorrow 18 Under Vaccinated! Teens & Seniors at Risk
D E PA R T M E N T S
Cases
| 7 | Genetic Testing Gives New Hope for Lynch Syndrome
Solutions HIT
| 9 | Why Physicians Should Make the Shift to Value-Based Care
| 22 | Keeping Populations Healthier
Compliance Our Bay
| 41 | Working With Older Patients: What Physicians Need to Know About Legal Capacity
| 42 | Celebration of the Chesapeake Bay
On the Cover: Kashif Ali, MD, oncologist/hematologist at Maryland Oncology Hematology
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CHESAPEAKE
Physician YOUR PRACTICE. YOUR LIFE.
Maryland/DC/Virginia www.chesphysician.com
JACQUIE COHEN ROTH FOUNDER/PUBLISHER/EXECUTIVE EDITOR jroth@chesphysician.com LINDA HARDER, MANAGING EDITOR lharder@chesphysician.com PRODUCTION MANAGER Stefanie L. Jenkins sjenkins@mojomedia.biz
Cancer is center stage for many many of us – professionally and personally. Every year, the September/October issue spotlights advances in cancer diagnostic tools and treatments. Each of these issues is a personal one for me. Over the last four years of publishing, I’ve shared with our readers that I lost my mom to AML and then my sister to breast cancer two years later. With the advances in diagnostic tools and treatments since their deaths (some of them described in the following pages), it’s very likely their life spans would have been longer and possibly, they might even be alive today. This issue’s Cases on Lynch syndrome (see page 7), Fighting Cancers Today and Tomorrow (see page 10) and Under Vaccinated! (see page 18) underscore the Chesapeake Physician mission, which includes a print and digital platform of original content focused on clinical, business and policy aspects of healthcare in the Chesapeake Bay region. Our goal is to inspire you and inform you so that you’re able to do what you love: care for patients and their families with the highest quality of medical care. A ground swell of change is mostly definitely under way (maybe a tsunami?) that is impacting the way you may have to and would like to practice medicine. Healthcare regulations impacting CMS and other payers are pushing physicians and providers to move from a fee-for-service model to more population health management and value-based models. We describe some of the innovative approaches that are underway in our region (see Solutions page 9 and HIT page 22). Throughout the year, Managing Editor Linda Harder and I consult with the Chesapeake Physician Advisory Board for editorial counsel, recommendations, submissions and review across our print and digital platforms. I’m delighted to announce three new board members: Randy M. Becker, MD, with Advanced Radiology; Harry Brandt, MD, with Sheppard Pratt Health Systems and Michael Freedman, MD, with Evolve Medical Clinics. Welcome, Doctors! These two months, September and October, offer some of the most specular weather and images of the year in the Chesapeake Bay. In Our Bay (see page 42) every issue, we showcase a seasonal image and spirit. Days are shorter and crisper along the shores of our beautiful and dynamic Chesapeake. For many of us it’s a time for spiritual renewal. To that…
To life!
Jacquie Cohen Roth Founder/Publisher/Executive Editor jroth@chesphysician.com @chesphysician
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Chesapeake Physician — Your Practice. Your Life.™ is published bimonthly by Mojo Media, LLC, a certified Minority Business Enterprise (MBE). Mojo Media, LLC PO Box 949 Annapolis, MD 21404 443.837.6948 mojomedia.biz Subscription information: Chesapeake Physician is mailed free to licensed and practicing physicians and a select group of healthcare executives and stakeholders throughout Maryland, Northern Virginia and Washington, DC. Subscriptions are available for the annual cost of $52. To be added to the circulation list, call 443.837.6948. Reprints: Reproduction of any content is strictly prohibited and protected by copyright laws. To order reprints of articles or back issues, please call 443.837.6948 or email sjenkins@ mojomedia.biz Chesapeake Physician — Your practice. Your life. Advisory Board: An advisory board comprised of medical practitioners and business leaders in diverse practice, business and geographic scopes provides editorial counsel to Chesapeake Physician. Advisory Board members include: RANDY M. BECKER, MD Advanced Radiology HARRY BRANDT, MD Sheppard Pratt Health Systems PATRICIA CZAPP, MD Anne Arundel Medical Center HOLLY DAHLMAN, MD Green Spring Internal Medicine, LLC MICHAEL EPSTEIN, MD Digestive Disorders Associates STACY D. FISHER, MD University of Maryland Medical Center MICHAEL FREEDMAN, MD Evolve Medical Clinics GENE RANSOM, JD, CEO Maryland Medical Society (MedChi) CHRISTOPHER L. RUNZ, DO Shore Health Comprehensive Urology VINAY SATWAH, DO, FACOI Center for Vascular Medicine THU TRAN, MD, FACOG Capital Women’s Care Although every precaution is taken to ensure accuracy of published materials, Chesapeake Physician and Mojo Media, LLC cannot be held responsible for opinions expressed or facts supplied by authors and resources. Printed on FSC certified, 100% PCW, chlorine-free paper
CASES
Genetic Testing Gives New Hope For Lynch Syndrome By Christy Haakonsen, ScM, CGC
CASE: Sarah is a 49-year-old woman with an extensive family history of gastrointestinal cancer. Her brother was diagnosed with colon cancer at 34. Her father was diagnosed with an adenocarcinoma of the cecum at age 45 and died from metastases at 47. Her paternal uncle developed colon cancer in his 30s and then stomach cancer in his 60s. A paternal aunt died from colon cancer in her 40s. Another paternal aunt had colon and uterine cancer in her 40s. Five of her paternal cousins had colon cancer, one notably at age 27. Another cousin died from brain cancer in his 30s. Sarah’s paternal grandmother died from colon cancer at age 31 and her paternal great-grandfather died from colon cancer at 55. Because of her family history, Sarah met with a genetic counselor and underwent genetic testing. She was subsequently identified to have a mutation within the MLH1 gene, meaning that Sarah has Lynch syndrome. After receiving this result, Sarah was strongly encouraged to have her uterus, ovaries and fallopian tubes removed because of the increased risk for uterine and ovarian cancer, and lack of reliable screening. She underwent this prophylactic surgery and was incidentally identified to have a grade 3 adenocarcinoma of the endometrium with 6/10 positive lymph nodes. After this surgery, she received adjuvant chemotherapy and radiation therapy. Both of her children underwent genetic testing at a later time, and her 22-year-old daughter also tested positive for the MLH1 mutation.
DISCUSSION: Lynch syndrome, also known as hereditary nonpolyposis colorectal cancer (HNPCC), accounts for about two to three percent of all cases of colon cancer and about two to four percent of endometrial cancer in the United States. Approximately one in 300 to 500 people carry a mutation in one of the five genes associated with Lynch syndrome, which include MLH1, MSH2, MSH6, PMS2, and EPCAM. Individuals with Lynch syndrome have a 50 percent chance of passing on this condition to each of his/her children. This is known as autosomal dominant inheritance. People with Lynch syndrome have the greatest risk to develop colorectal cancer (up to a 40 to 80 percent risk by age 70). They also have an increased risk for stomach (one to 13 percent), and small bowel cancer (three to six percent). Women have an increased risk for developing endometrial (25 to 60 percent) and ovarian cancer (four to 24 percent). These individuals also can develop cancer of the renal pelvis and ureter, pancreas, brain (glioblastoma), and skin (sebaceous adenomas), although less commonly. Recent work has focused on the risks for breast and prostate cancers in those with Lynch syndrome, although this association remains unclear. In light of these increased cancer risks, the National Comprehensive Cancer Network (NCCN) recommends beginning colonoscopy screening by age 20 to 25, with repeat colonoscopies every one to two years. Screening for gastric and duodenal cancer may include an EGD with extended duodenoscopy every three to five years beginning at
age 30 to 35. Annual urine cytology can be done to screen for urothelial cancers. In addition, women with Lynch syndrome may want to consider removal of the uterus, ovaries, and fallopian tubes after child-bearing to reduce risk. Multiple guidelines, criteria and models have been created to assist providers in selecting patients for whom diagnostic studies for Lynch syndrome are indicated. The Amsterdam criteria are helpful, but only about half of families fulfilling these pedigree criteria actually have Lynch syndrome. The Bethesda guidelines were designed to target patients in whom tumor testing for DNA mismatch repair deficiency should be conducted, but these criteria are fairly non-specific and lack high sensitivity. Personal and family history is critical in assessing the likelihood of Lynch syndrome. Genetic counselors perform a thorough family history evaluation, provide a risk assessment, discuss options for screening and prevention, and facilitate genetic testing, which has become increasingly complex. Additionally, many institutions have implemented Universal Screening Programs in which all colorectal tumors (and sometimes endometrial tumors) are screened for microsatellite instability (MSI) and immunohistochemistry (IHC) of the four mismatch repair proteins associated with Lynch syndrome. Following testing, primary care providers can facilitate referral to the appropriate specialists. Christy Haakonsen, ScM, CGC, is a genetic counselor with The Harvey Institute of Human Genetics at The Greater Baltimore Medical Center. She can be reached at chaakonsen@gbmc.org.
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2016 CLINICAL EDITORIAL CALENDAR JANUARY/FEBRUARY n Cover Story: Advances in Cardiovascular Care n Feature: Diabetes & Co-morbidities n HIT: Health Enterprise Zones — Are They Working?
MAY/JUNE n Cover Story: Chesapeake Female Healthcare Innovators n Feature: Women’s Health & Pediatric Care n HIT: Independent Practice Models That Work
SEPTEMBER/OCTOBER n Cover Story: Progress in Cancer Care n Feature: Advances in Imaging n HIT: Telehealth — A New Standard of Care
MARCH/APRIL n Cover Story: Digestive Disease Update n Feature: 3D Printing & Prosthetics n HIT: Connected Health
JULY/AUGUST n Cover Story: Progress in Orthopaedics n Feature: Podiatrists — Partners & Referrers n HIT: Reputation Management in Social & Digital Media
NOVEMBER/DECEMBER n Cover Story: Brain Medicine n Feature: The Biology of Depression n HIT: Integrated Care Delivery Platforms
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SOLUTIONS
Why Physicians Should Make the Shift to Value-Based Care
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By Stephanie Kovalick and Melissa Pitchford
HYSICIAN GROUPS HAVE HEARD the same message for years — the shift away from fee-for-service (FFS) models to value-based care (VBC) models is coming and will disrupt the way you manage your practice. Yet, change has been slow to materialize, causing providers to doubt the shift will ever happen. In light of recent Centers for Medicare and Medicaid (CMS) policy adjustments at the state level, it’s time to take VBC seriously. CMS is driving the move away from FFS models. By 2018, 50 percent of all Medicare funding will be reserved for alternative payment models. Opposed to an approach that fully embraced capitation, CMS is paving the way with methods that manage cost of care against a set target. CMS is encouraging providers to apply VBC methodologies to reduce costs of care while improving quality and outcomes. In one scenario, if a provider is able to reduce that cost by two percent for a target population while meeting quality metrics, the provider gets a check from CMS for half of that. If providers meet additional quality metrics on top of that, they stand to receive even more reimbursements and incentives. Physician groups in Maryland, Delaware, DC, and Virginia are feeling varying degrees of pressure from their private payers, contributing to the belief that the FFS model isn’t going away. While the Delmarva Medicare population is moving to the VBC payment model, many private payers are still embracing a FFS structure. Looking at the current state of the private payer mix, however, is not an accurate predictor of future changes.
Historically, other payers follow CMS’ lead, whether that change takes six months or three years. In the Delmarva region, Maryland is unique: the largest private plans currently affecting the change don’t have a large presence in the state. Payers such as Aetna and Cigna are emphasizing quality-based and FFS+ models, while looking for ways to maximize shared savings with providers — and offering bonuses for meeting quality metrics. More and more, these companies are trending away from traditional FFS models.
By 2018, 50 percent of all Medicare funding will be reserved for alternative payment models. Even so, providers in the region have more to gain from shifting to a VBC model than they stand to lose. One emerging approach is the formation of collaborative Accountable Care and Managed Services organizations. Providers joining these organizations are receiving higher patient margins, benefitting from Medicare shared savings, and improving their clinicalfinancial alignments. Value-based organizations encourage physicians to do what they do best to diagnose and guide the treatment process. Teaming up with the ACO and MSO facilitates and leverages the entire medical office staff to deliver the treatment required and record the outcomes most efficiently,
increasing revenue while delivering better outcomes. Consider the recent announcement made by the US Department of Health and Human Services (HHS): providers in 75 major metropolitan markets will be required to bundle all Medicare payments for hip and knee surgery from admission until 90 days after discharge. This announcement comes as a wake-up call to many, who are holding fast to the belief that participation in alternative payment models would remain voluntary. To succeed, providers will need to engage in better communication and care coordination with surgeons and post-acute providers. Aligned with incentives in other CMS programs, this mandate confirms that the shift to VBC is real, and it’s already well underway. Making the shift to a VBC model is worth the time, investment and implementation challenges. Dealing with those now puts providers ahead of the game, ready to receive additional incentives and avoid future penalties — while delivering better care at a lower cost to their patients. If you’re struggling with the decision, there are many resources that can help guide your transition in the most effective ways possible, including references to other practices that have already made the change. Don’t hesitate to reach out — your patients will thank you for it, and you’ll ensure the continued financial stability of your practice. Stephanie Kovalick is senior vice president and practice leader at Sage Growth Partners and Melissa Pitchford is vice president and managing director at Sage Growth Partners. They can be reached at skovalick@sage-growth.com or mpitchford@ sage-growth.com.
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FIGHTING CANCERS TODAY AND TOMORROW Progress in Lymphoma, Breast and Pancreatic Malignancies.
ISTOCK@ADVENTTR
BY LI N DA H A RD ER
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While a magic bullet to treat cancer has never materialized, better understanding of the etiology of various cancers, more advanced detection and more targeted treatments continue to emerge. Experts from the Chesapeake region discuss the progress in treating lymphoma, breast and deadly pancreatic cancers. DISPELLING NON-HODGKIN LYMPHOMA MYTHS Maryland Governor Larry Hogan’s announcement that he had an aggressive form of non-Hodgkin lymphoma (NHL) led to renewed attention to this common form of cancer. There are five types of Hodgkin Lymphoma (HL) that involve Reed-Sternberg cells, and over 60 types of NHL that do not. The most common type of NHL is B-cell lymphoma, which accounts for about 85 percent of all cases of NHL, including the governor’s. With nearly 72,000 Americans diagnosed each year, NHL is the sixth-most common cancer for both men and women. Kashif Ali, MD, an oncologist/ hematologist at Maryland Oncology Hematology in its Silver Spring, Md., office, explains, “Whereas HL tends to affect children, NHL tends to occur later in life, with age greater than 60 constituting the biggest risk factor. Men, whites and those in developed countries are also at higher risk. Other risk factors include exposure to chemicals, such as benzene, herbicides and insecticides; radiation (including that resulting from
treatment for other cancers); immune diseases such as rheumatoid arthritis or celiac disease; and certain infections such as HTLV1, Epstein Barr, HIV/AIDS, H. Pylori and hepatitis C. If you treat these viruses, you’re also treating the NHL. Some studies also claim that being obese/overweight and eating an unhealthy diet contribute.” Dr. Ali continues, “These cancers generally are NOT inherited; as far as we know today, they’re acquired.”
molecular structure of DNA change and rearrange the chromosomes.” To accurately diagnose NHL today, physicians no longer need to see the whole structure of the lymph node. Dr. Ali explains, “With newer tests, we can use even a needle biopsy to precisely identify the type of lymphoma, determine which types are more likely to spread, and help us select more targeted, effective treatment for that patient.” Lymphoma Prognosis
Dispelling Myths About Lymphoma
“The general public has many myths about NHL,” notes Dr. Ali. “Doctors can help educate their patients about the facts so that they can pursue appropriate treatment. One such myth is that performing a biopsy may spread lymphoma. While there is a slight risk of spreading cancer cells with kidney or hepatobiliary biopsies, you generally want to biopsy lymphoma.” A second myth is that NHL always should be treated urgently. “Low-grade, early-stage follicular lymphoma and lymphocytic lymphoma may never need treatment,” Dr. Ali stresses. “Physicians sometimes scare patients unnecessarily, telling them they need chemotherapy immediately, when they would benefit instead from watchful waiting.” Other myths include: z Chemotherapy is not as beneficial as ‘natural products’ z Consuming sugar ‘feeds’ the lymphoma z Any cancer that spreads through the lymph system, such as breast cancer with lymph node involvement, should be treated as lymphoma z Swollen lymph nodes indicate lymphoma, when the most common cause is actually infection Molecular Diagnosis Improves Precision
“Newer treatment approaches for NHL are all based on molecular tests,” states Dr. Ali. “Whereas a decade ago, the disease would be diagnosed by a pathologist with a microscope, today’s pathologists are checking the DNA. We’re learning that changes in the
According to the National Cancer Institute’s Surveillance, Epidemiology and End Results (SEER) database, based on those diagnosed between 2002 and 2008, the overall five-year relative survival rate for all NHL cases is 69 percent, and the 10-year relative survival rate is 59 percent. However, the prognosis in NHL varies with the type of lymphoma. Ironically, indolent (slow-growing) lymphomas, including follicular lymphoma, are more challenging to treat and more likely to recur. In contrast, aggressive (fastgrowing) lymphomas, of which the most common is diffuse large B-cell lymphoma (DLBLC), are often curable with aggressive treatment. A European study found a 66-percent five-year survival rate at Stage 1 and a 50 percent survival rate at Stage 4. For the past two decades, the International Prognostic Index (IPI) has been used to determine the prognosis for those with aggressive NHL, although its risk scale has evolved during that time period. This index classifies NHL as low, intermediate or high risk. A classification of 3, or high risk, would involve three or more of the following: z z z z z
Age greater than 60 Stage 3 or 4 More than one site outside the lymph system An elevated serum lactose dehydrogenase level (LDH) Poor performance status
“I personally like the Eastern Oncology Performance Group (ECOG) performance status index,” says Dr. Ali,
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“which uses function as a prognostic factor. If you’re in bed less than half the day, you’re more likely to do better than those who are less active.” Less-aggressive lymphomas, such as follicular lymphoma, have a 90-percent five-year survival rate for Stage 1 diagnosis and an 80-percent survival rate when diagnosed at Stage 4. However, survival rates for all patients with NHL are significantly improving with newer treatment regimens, and these data are based on patients diagnosed and treated with older approaches.
Some cancers are curable even at Stage 4. That includes lymphomas. —Kashif Ali, MD
meeting, the two trials have had favorable results to date.” Early Detection Key
Primary care physicians can help patients by seeking early detection, which increases the likelihood of curing NHL. Symptoms for doctors to take note of include enlarging glands, or lymph nodes that remain large or increase, combined with older age. NHL also can cause generalized B symptoms — fevers, chills, soaking night sweats and/or unexplained weight loss, although patients may not exhibit these symptoms. Physicians should perform regular clinical exams of lymph nodes that are palpable, although, as was true for Governor Hogan, the cancer may start in the abdomen or other locations where it cannot be palpated. “Some cancers are curable even at Stage 4,” concludes Dr. Ali. “That includes lymphomas.”
Advances in Treating Lymphomas
“Because the lymphomas are so different, the treatment responses are broad. We know now that the same stage and same type of lymphoma will not necessarily have the same response to therapy,” Dr. Ali acknowledges. He adds, “Perhaps ironically, lowgrade lymphomas respond more slowly to treatment because any time the cell divides, chemotherapy is toxic to that cell. The disease is less likely to kill you, but chemotherapy is less effective. Conversely, with high-grade lymphoma, there’s a greater response to the chemotherapy but also a higher relapse rate. Patients who relapse don’t do as well, but the treatments are far better today than they were.” The standard treatment regimen has involved rituximab plus cyclophosphamide, doxorubicin, vincristine and prednisone (R-CHOP) — but new Phase 3 clinical trials are assessing the value of additional drugs. The SELENE study uses ibrutinib + R-CHOP to treat follicular or marginalzone lymphoma. The AUGMENT trial adds lenalidomide to rituximab in patients with relapsed or non-responsive lymphoma. While final results won’t be available for several years, Dr. Ali notes, “Early results suggest that the new drugs help patients. At a recent American Society of Clinical Oncology
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IORT: TARGETED RADIATION DURING LUMPECTOMY Intraoperative Radiation Therapy (IORT), which was first developed as an alternative to traditional radiotherapy for a select population undergoing lumpectomy in 1998, has had more widespread use only more recently. Kristen Fernandez, MD, Breast Center director at MedStar Franklin Square Medical Center in Baltimore, explains, “With IORT, women get their surgery and radiation therapy completed in one session. The radiation oncologist comes into the procedure room immediately following the lumpectomy, and gives a single dose of radiation therapy to tissue adjacent to the resection margins before I close the small incision. The woman avoids having to wait several weeks after her lumpectomy to receive radiation therapy treatments, and has everything taken care of in a single procedure, rather than having radiation therapy administered over five to six weeks.” Compared to conventional radiation approaches, IORT uses higher effective doses of radiation. Appropriate Candidates
Generally speaking, women who are good candidates for IORT are postmenopausal and have early-stage breast cancer with tumors two centimeters or less that have not spread. Women
undergoing a lumpectomy who are believed to be possible candidates meet with both a radiation oncologist and the surgeon to discuss the most appropriate treatment options. Advantages of IORT
“We’ve performed the procedure on about 20 carefully selected women in the past 18 months,” notes Dr. Fernandez. “IORT allows us to deliver more targeted radiation directly to the spot where the tumor was. It only takes about 30 minutes longer, and women go home the same day. The side effects are typically limited to some soreness and scar tissue. With traditional radiation therapy, the entire breast receives radiation, which can affect surrounding areas, such as the heart.” IORT may allow women to miss little or no work, compared to having to undergo radiation therapy twice a week for six weeks. And if the cancer recurs, women may still have the option to undergo another lumpectomy and/or traditional radiation therapy. It also reduces non-compliance, whether due to time or travel issues for patients, and decreases healthcare costs associated with multiple patient visits. Further, radiating tissue at the time of the procedure avoids treatment delays and eliminates the possibility of residual cancer cells proliferating in the period before radiation is begun. Clinical Trial Results
The TARGIT-A trial compared IORT with external beam radiotherapy (EBRT); over 1,400 women aged 45 years and older with invasive ductal carcinoma were randomly assigned to receive IORT or whole-breast EBRT. Results published in February 2014 in The Lancet showed that, after five years post-op, IORT was nearly as effective as EBRT in preventing recurrence. Following the TARGIT-A and TARGIT-E studies, a TARGIT-C (Consolidation) “Prospective Phase IV Study of IORT in Patients With Small Breast Cancer” launched in late 2014 to confirm IORT’s efficacy, with the addition of post-op whole-breast radiation therapy in those with risk factors. An in vitro study showed that wound fluid that had not been radiated stimulated the growth of
SEAN SCHEIDT
Kashif Ali, MD, an oncologist/ hematologist at Maryland Oncology Hematology, Silver Spring, Md.
Low-grade, early-stage follicular lymphoma and lymphocytic lymphoma may never need treatment. —Kashif Ali, MD
breast cancer cells, while irradiated wound fluid did not. Studies also have shown that the recurrence rate of breast cancer increases with each month of delay in radiation therapy. Huang et al. found that patients who received whole-breast radiation therapy within two months of surgery had a 5.8 percent recurrence rate, compared to 9.1 percent when patients undertook radiotherapy nine to 16 weeks post-procedure.
MAPPING THE GENETIC RISK OF PANCREATIC CANCER Pancreatic cancer, which kills some 40,000 Americans each year and carries
a lifetime risk of 1.5 percent through age 85, remains one of the deadliest cancers. Alison Klein, PhD, MHS, associate professor of Oncology in the Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, and director of the National Familial Pancreas Tumor Registry, is one of the researchers doing the painstaking work to modify that prognosis. She explains, “The five-year survival rate is still only four percent, and most people die within one year of diagnosis. Approximately 80 percent of patients have metastatic or locally advanced cancer upon diagnosis. For those with resectable disease who are able to undergo surgery, the five-year survival rates climb to 25 to 30 percent, still miserable when compared with the prognosis of other cancers.” Genetic Risk Factors
In an effort to map the genetic risk factors for the disease, Dr. Klein was the lead author in a study of nearly
10,000 people with pancreatic cancer and a control group of nearly 12,000 healthy individuals, published online June 2015 in Nature Genetics. The study found four regions in the human genome where changes may increase the risk of pancreatic cancer: z z z z
Position 17q25.1, which may increase cancer risk by 38 percent for each copy present in the genome Position 7p13, which may increase risk 12 percent Position 3q29, which may increase risk 16 percent Position 2p13.3, pinpointed in this and previous studies, may increase pancreatic cancer risk 14 percent
“These variants are common in the population, most of whom will never develop pancreatic cancer in their lifetime,” cautions Dr. Klein. “However, identifying and understanding these changes and combining this data with other risk factors may allow us to
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Kristen Fernandez, MD, Breast Center director at MedStar Franklin Square Medical Center in Baltimore
The mortality rate with surgery is high at one to two percent, but it may prevent development of a cancer that’s usually fatal. —Alison Klein, PhD, MHS
identify, and one day screen, high-risk groups.” Dr. Klein notes that the study also confirms the connection between pancreatic cancer risk and several genetic variants linked to other cancers. For example, variation in the TP63 gene is related to an increased risk for pancreatic, lung, bladder and other cancers. P16 is responsible for increasing the risk of familial melanoma and pancreatic cancer. Colon cancer genes also increase pancreatic cancer risk. “Some gene changes confer a high risk of the disease,” she states, “while others confer a slight risk.
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Since 1996, I’ve worked with the pancreatic cancer group, running their familial cancer registry. My goal is to understand why the disease clusters in some families. It also increases the risk of other cancers, including breast and ovarian cancers. There are some shared susceptibility genes among these cancers, including BRCA1 and BRCA2.” Environmental Risk Factors
Pancreatic cancer tends to affect people late in life — typically in their 60s, 70s and 80s. With a longer life expectancy and a growing obese and diabetic population, the cancer incidence is on the rise. “Smoking, an increased BMI, heavy drinking and diabetes are the key environmental risk factors for pancreatic cancer, with a complex relationship between diabetes and this cancer,” Dr. Klein explains. “Heavy drinking may increase risk in part because it increases pancreatitis. Long-standing diabetes is associated with an increased risk of
pancreatic cancer, whereas about one percent of new-onset diabetics may have developed diabetes as a consequence of an underlying pancreatic cancer. There is lots of interest in better understanding these relationships.” She continues, “MD Anderson recently reported that exosome DNA secreted in the blood may help detect pancreatic cancer without taking a tumor sample. It’s an exciting preliminary finding, but it needs to be validated in larger clinical studies, and is not available in the near term for a wider population. We want to take these exciting biomarkers and use them in large populations to create a screening test. There is a tremendous need to develop biobanks of samples from large group of at-risk individuals to serve as a validation sets to move promising new biomarkers forward to the clinic.” Pancreatic Cancer Screening Recommendations
In 2011, the International Cancer of the
z
z z
Individuals with three or more blood relatives with pancreatic cancer, with at least one affected first-degree relative (FDR) Those with at least two affected FDRs Individuals with two affected blood relatives with pancreatic cancer, with at least one FDR
TRACEY BROWN
Pancreas Screening (CAPS) Consortium summit on the management of patients with increased risk for familial pancreatic cancer recommended that the following be considered for screening:
Alison Klein, PhD, MHS, associate professor of Oncology in the Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, and director of the National Familial Pancreas Tumor Registry
Some one percent of those with recent-onset diabetes will get pancreatic cancer within three years,” Dr. Klein notes. “It’s not clear yet if it’s worth screening these patients. One question is whether or not it’s already too late by then.” “I encourage physicians to urge patients with a family history of pancreatic cancer to get regular screenings at a center with lot of expertise in screening for pancreatic cancer,” says Dr. Klein. “Endoscopic ultrasound has the best sensitivity and specificity for screening in high-risk families. At some point, we hope to be able to partner the use of biomarkers in the blood with endoscopic ultrasound for these screenings instead of, or in conjunction with, endoscopic ultrasound.” Physicians should be aware of the strong relationship between pancreatic and other cancers. Patients with a family history of multiple pancreatic cancers should be considered for referral to a screening center starting at age 50. Treatment Decisions are Difficult
One of the challenges of screening for pancreatic cancer is determining when surgical intervention is necessary. “The decision about whether or not to have surgery based upon the results of a screening test is really challenging,” Dr. Klein acknowledges. “It’s not like removing a polyp to prevent colon cancer. The mortality rate with surgery is high, at one to two percent, but it may prevent development of a cancer that’s usually fatal.” In addition, treatment decisions for newly diagnosed pancreatic cancer patients can be complex as well. Dr. Klein explains, “A percentage of
patients will undergo chemotherapy prior to surgery. Treatment with chemotherapy is suitable for widespread or metastatic disease, while radiation may be of benefit when treating localized disease or local recurrence. In many cases, treatment can improve quality of life, but in rare cases patients can have exceptional response to treatment. Immune-based therapies have great potential to improve survival for pancreatic cancer, and several clinical trials are currently underway.”
Kashif Ali, MD, oncologist/hematologist at Maryland Oncology Hematology, Silver Spring, Md. Kristen Fernandez, MD, Breast Center director at MedStar Franklin Square Medical Center Alison Klein, PhD, MHS, associate professor of Oncology in the Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, and director of the National Familial Pancreas Tumor Registry
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Breast Center navigator, who is on the front line, and gets the patient in quickly, usually within 24 to 48 hours. “Many physicians call us directly after their patients receive an abnormal mammogram because they know we work swiftly and make sure to keep our referring physicians in the loop throughout the process,” says Dr. Griffiths. “If a patient is diagnosed with breast cancer, that coordination continues through our Cancer Institute’s nurse navigator, who guides each breast cancer patient through treatment, scheduling diagnostics and answering questions. In addition, each patient and their family gain access to a full complement of support services through our social work team and an on-site American Cancer Society patient resource navigator.”
The Comprehensive Breast Center at Saint Agnes Hospital Delivering Unique Multidisciplinary Breast Care
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IANA GRIFFITHS, MD, medical director of the Comprehensive Breast Center at Saint Agnes Hospital in Baltimore, is not only passionate about fighting breast cancer, but in 1994 she began a mission to create a comprehensive breast center that would stay on the forefront of breast cancer treatment. She has directed that unique breast center at Saint Agnes since then, making a dramatic difference in women’s health. The Breast Center at Saint Agnes became one of the first in the U.S. to be recognized for excellence through accreditation by the National Accreditation Program for Breast Centers (NAPBC). It is also one of the only centers in Baltimore offering a true multidisciplinary model of care, where before treatment even starts, the entire Breast Center team comes together to create a coordinated approach for each patient. “I don’t know any other breast center in the area that does it this way,” says Dr. Griffiths. Evolution of Advanced Breast Care
“Historically,” she points out, “surgery
was the only option for breast cancer treatment.” As the science evolved, many other disciplines, once considered revolutionary, became a standard part of care. “At Saint Agnes, our team of six specialty physicians — a surgeon, radiation oncologist, radiologist, pathologist, plastic surgeon, and medical oncologist — meet to thoroughly study each patient’s case. We answer such detailed questions as, ‘What’s the best way to make the patient’s mastectomy incision to prepare her for the next step of reconstructive breast surgery?’ We quickly coordinate the patient’s fullcare plan and then provide thorough education to the patient, which is very encouraging and relieving to her.” On the same day, a summary of treatment recommendations is sent to her referring physician. Coordinated Care Benefits Patients and their Physicians
This level of detailed, coordinated care occurs at every step along the patient’s journey. It begins with one call to the
Clinical Trials, Exciting Therapies
Patients receive state-of-the-art care, including minimally invasive biopsies with ultrasound guidance, sentinel lymph node biopsy and lumpectomies. Saint Agnes was the first community hospital in Maryland to routinely do sentinel lymph node biopsies, which is now a standard of breast cancer care. “In addition, we’ve stayed on the forefront of advanced technologies like Tomosynthesis and Accuboost to enhance radiation therapy for our patients. We are involved in clinical trials, and offer new, exciting drug therapies that dramatically improve the curability of cancer,” says Dr. Griffiths. “We can identify the genetics of a patient’s cancer, screen patients more aggressively, and use targeted therapies.” Dr. Griffiths completed her fellowship training at Johns Hopkins, her residency at Baltimore City hospitals, and graduated from Boston University Medical School. She has nothing but praise for the caregivers at the Breast Center at Saint Agnes, explaining, “We are a close-knit team. I have great colleagues who make our work very rewarding. When physicians send patients to us, they can be assured they’re in the best hands that I trust myself.” For more information on Diana Griffiths, MD, or to refer a patient to the Breast Center at Saint Agnes, please visit TeamSaintAgnes.com or call 410.368.3434.
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More Teens, Seniors Need to Get HPV, Shingles Vaccines BY LI N DA HA RD ER
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ISTOCK@MAXUSER
UNDER VACCINATED!
SEAN SCHEIDT
Susan Peeler, MD, MBA, co-founder of the Comprehensive Gynecology Center in Gambrills, Md.
ven as some parents endanger the wider U.S. population by refusing to vaccinate their children, many more teens and seniors should take advantage of newer vaccines to combat HPV and shingles. Our experts explain.
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STOPPING THE SPREAD OF HPV Human papilloma virus (HPV) is the most common sexually transmitted infection in the country, affecting almost every sexually active individual. Most people never exhibit symptoms, but the virus can cause everything from genital warts to a host of cancers, including cervical, vulvar, vaginal, penile, anal and even oropharyngeal malignancies. It is estimated that some 79 million Americans are currently infected, and that HPV results in 360,000 cases of
genital warts, 12,000 cases of cervical cancer and 24,000 other cancer cases each year. Yet no effective treatment for the HPV virus exists. With FDA approval of the first HPV vaccine in 2006, this rampant disease is finally coming under attack. The original vaccines were bivalent or quadrivalent (addressing two to four of the HPV types). Today, Gardasil 9, introduced in the spring of 2015, offers protection against the nine most common HPV types, including 6 and 11, which cause genital warts, and 16 and 18, which are responsible for most HPV-related cervical cancer. The remaining five types also are linked to several cancer types. As the vaccines do not prevent all cervical cancers, women should continue being tested for cervical cancer even after getting HPV vaccines. Susan Peeler, MD, MBA, co-founder of the Comprehensive Gynecology Center in Gambrills, Md., says, “The
HPV vaccine is recommended for all girls and boys ages 9 to 26. The target age range for both sexes is 11 to 12 — hopefully, before they’re sexually active and become at risk.” This can be a challenge for some parents, she acknowledges. “It’s hard for them to discuss this with their child and to believe that the child is, or could be, sexually active and at risk. “The rationale for not offering vaccinations after the mid 20s is that as people age, their immune system is less able to respond effectively,” continues Dr. Peeler. “The vaccine does not treat any existing HPV. If an individual received the quadrivalent HPV vaccine, he or she should finish the series of three shots with that same vaccine.” The vaccines are not recommended for pregnant women until further research results are available, although studies have shown that babies born SEPTEMBER/OCTOBER 2015
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to women who were vaccinated during pregnancy did not experience problems. HPV Vaccine Rates Remain Low
While the vaccine is widely available and effective, only about half of girls who should get the vaccine actually receive it, and only about one-third of those complete the series of three vaccines. “We live in a time of vaccine fear and hysteria, and social media hasn’t done us any favors,” laments Dr. Peeler. “Parents should know that the risks of HPV are far higher than the risk of any adverse reaction from the vaccine. One of my patients once remarked that if this were a vaccine to prevent breast cancer, women would be all over it, and she’s right.”
I recommend that physicians present [the HPV vaccine] as a way to prevent several types of cancer, along with vaccines to prevent measles and whooping cough. —Susan Peeler, MD, MBA
Adverse Reactions to HPV Vaccine
The series of HPV injections is perhaps more painful than most vaccine shots. The most common adverse reaction from the vaccine is minor pain and swelling at the injection site, with fever, dizziness and nausea less-common reactions. “We always have our patients stay in the office for 15 minutes after administering the injection,” Dr. Peeler comments. “That way, we can ensure they don’t faint or experience unusual reactions. Also, patients who are allergic to yeast cannot get the vaccine. Adverse events are minimal, but should they occur, there is a registry to report them.” HPV Resources
The CDC offers some excellent resources for providers to give to patients at http://www.cdc.gov/cancer/cervical/basic 20 |
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_info/risk_factors.htm. Another great resource to spread the word about the prevalence and potential dangers of the HPV virus is a documentary film called “Someone You Love: The HPV Epidemic,” which follows five women who got cervical cancer (hpvepidemic.com). A second documentary film about cervical cancer called “Lady Ganga” is being funded through a Kickstarter campaign and hopes to raise sufficient funds for its release. The film follows 45-year-old Michelle Frazier Baldwin, a mother of three diagnosed with advanced cervical cancer, as she travels Captions here. to India — the country with the highest mortality rate from cervical cancer in the world — and paddleboards down the Ganges River to spread awareness about the disease. High-profile Hollywood stars may help to shine a brighter light on the dangers of HPV. Publicity surrounding actor Michael Douglas’ recent battle with oropharyngeal cancer helped to raise awareness of its link to HPV infection. In the United States, more than half of cancers diagnosed in the oropharynx are linked to HPV type 16, possibly contracted by oral sex, and exacerbated by smoking and chewing tobacco. Smoking plus HPV also presents a higher risk for cervical cancer. Pap Tests Still Necessary for Those Under 65
Even with HPV vaccines, Papanicolaou (pap) tests are still needed,” Dr. Peeler observes. “If the HPV is positive, we genotype it to see if it is type 16 or 18. An abnormal pap smear that is HPVnegative is something we monitor closely. If it is abnormal with a positive HPV, we typically will perform a colposcopy and consider a biopsy.” However, debates about the necessity of pap tests in older women have surfaced. “Good research suggests that women over 65 years old with routinely negative pap tests, and no history of cervical abnormalities or vaginal bleeding, don’t need to continue getting these tests, but women are reluctant, nonetheless, to discontinue them,” Dr. Peeler states. “I advise physicians to listen closely to their patients, really hear what they’re saying about their bodies and concerns, then determine how the protocol applies to them. An individual
approach, rather than blindly performing it on every patient, is ideal.” “We don’t routinely test women under 30 for HPV with the pap test because their immune system usually clears it,” notes Dr. Peeler. “We only order HPV co-testing if the pap results are abnormal. We start performing pap tests at age 21 and I usually do them yearly, though some recommend that women ages 21 to 29 get the test every three years as long as results are normal. In women ages 30 to 65, however, we order HPV co-testing routinely.” Advice for Other Physicians
Dr. Peeler has this advice for other physicians: “While the target age for HPV vaccine administration is 11 to 12, I think it’s better to discuss it with your patients earlier, and set it as an expectation that it will be part of their routine screenings so it doesn’t become stigmatized. I recommend that physicians present it as a way to prevent several types of cancer, along with vaccines to prevent measles and whooping cough. I also recommend ensuring that girls finish their HPV series before they go to college, as many of them get lost in the health system there and don’t complete the three injections.” Data to date indicates that the HPV vaccine appears to be protective for at least a decade, and longer-term data is believed likely to validate its effectiveness for far longer.
PREVENTING THE PAIN OF SHINGLES One more item to add to the medical check-up list for those reaching their 60th birthday is the shingles vaccine. This vaccine, appropriate for those in their 60s (and older), prevents the pain and sometimes more serious medical complications of the long-dormant wild-type varicella zoster virus (V2V), the virus that causes chickenpox. This virus lurks for years in the dorsal root ganglia and is re-activated in one million Americans each year in the form of shingles, most typically creating a rash along the thoracic dermatome. About half of those in the U.S. who live to age 85 will get shingles. Women, Caucasians and those over 60 are at higher risk for shingles. Aimee Seidman, MD, FACP, an internist at, and founder of, Rockville Concierge
Rapid Treatment with Antivirals
Pain medications such as ibuprofen can help address lower-level pain, while more serious nerve pain may require gabapentin, and sometimes narcotics. Dr. Seidman comments, “Three to four antivirals have proven to have few side effects and low risk in treating shingles. These include acyclovir, which has been studied the most but is required to be taken multiple times per day, valacyclovir and famciclovir, which has the advantage of fewer daily doses.”
Aimee Seidman, MD, FACP, an internist at, and founder of, Rockville Concierge Doctors
Non-Indications for the Vaccine
Doctors in Rockville, Md., notes, “Shingles is the same virus as the chickenpox virus but has different manifestations. It sits on the nerve and waits. As your antibody titers decrease with age, your risk of contracting shingles, as well as the risk of complications such as prolonged rash, pain and post-herpetic neuralgia, increase.” The existing vaccine, Zostavax, recommended for people age 60 and older, prevents shingles only 64 percent of the time, and becomes less effective over time, diminishing to only 38 percent effectiveness by age 70. Dr. Seidman says, “We only administer one shot. It acts like a booster to the immune response, but currently it’s not recommended to get more than one in a lifetime.” By 2017, a more effective vaccine, developed by GlaxoSmithKline, may be on the market. A study of over 16,000 patients aged 50 and older found this vaccine to be efficacious more than 97 percent of the time, thanks to an adjuvant that heightens the immune response. The company plans to present data to the FDA sometime in 2016. With only 25 percent of Americans receiving this vaccine today, however, the impact on combatting this disease is far less than ideal. According to Dr. Seidman, adults tend to be undervaccinated both because they don’t have a vaccination schedule as children do,
and also because not all insurers pay the roughly $250 cost of the injection. Medicare does typically cover the vaccine’s cost after age 60. Be Alert to Early Warning Signs
Dr. Seidman encourages physicians to be alert for potential symptoms of shingles in older patients, even when those symptoms don’t fit the classic presentation of a rash and blisters along one side of the back or trunk. “Patients don’t always get a rash, but anyone with unexplained sensitivity along a nerve root should be assessed quickly because this is the best time to start antiviral medications,” she explains. “Treating the virus within 72 hours is the only way to achieve efficacy.” Prior to developing a rash, many patients experience an area of burning, itching, tingling or sensitivity on one side of the body for one to three days. The rash most typically spreads along one side of the back and/or abdomen (T-10 or upper lumbar nerves), although the trigeminal and other nerves can instead be affected. Occasionally, patients may experience fever, light sensitivity or headache. Dr. Seidman notes, “The vaccine decreases the duration of the rash and the likelihood of post-herpetic neuralgia, which can be very disabling. The virus can cause blindness due to herpes zoster ophthalmicus if it attacks the trigeminal (fifth cranial) nerve of the eye.”
Those who are pregnant and those who have had a severe reaction to gelatin, neomycin or other shingles vaccine components should avoid the vaccine. Others who should not be administered the vaccine include those with a weakened immune system due to disease or treatment with prolonged steroids or certain types of chemotherapy, as the vaccine is a live, attenuated vaccine. “We suspect that the growing number of people receiving chemotherapy and immunosuppressive drugs may contribute to the increase in those contracting shingles,” explains Dr. Seidman. “Patients with HIV can only receive the vaccine when their CD4 lymphocyte counts are high enough. Oncologists and primary care physicians should give older patients the vaccine before starting chemotherapy.” The take-home message for primary care physicians, warns Dr. Seidman, is that any time patients have discomfort in an odd spot, even when there’s not a rash, physicians should be alert to the possibility of shingles. She states, “Physicians need to educate their adult patients about this disease and the importance of getting vaccinated at age 60. They also need to inform them that it’s uncommon, but not impossible, to get shingles more than once in a lifetime.”
Susan Peeler, MD, MBA, co-founder of the Comprehensive Gynecology Center in Gambrills, Md. Aimee Seidman, MD, FACP, internist at, and founder of, Rockville Concierge Doctors in Rockville, Md.
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HEALTHCARE IT
Keeping populations
healthier As CMS and other payers push providers to shift from fee-for-service arrangements to more population-health-based approaches, physicians are seeking models that work in this new environment. A number of innovative approaches are underway in the Chesapeake region. BY LI N DA HA RD ER
The ACO Approach The Department of Health and Human Services (HHS) has stated that ACOs are a key part of its population health strategy. With over 400 CMS ACOs, and more than 700 total ACOs in the country today, there are now over 23.5 million Americans covered by these arrangements. Dr. J. Michael McWilliams’ review of the original CMS Pioneer ACOs, published May 14, 2015, in the New England Journal of Medicine, found that the first year of the program was associated with modest reductions in Medicare spending. A previous article he authored reported meaningful improvements in patients' reports of timely access to care and also in how well their primary physicians were kept informed about specialty care. The Chesapeake region has a number of ACOs, including one at Baltimore's Greater Baltimore Medical Center (GBMC), one of the few remaining ‘independent’ hospitals. Mary Ely, executive director of Greater Baltimore Health Alliance (GBHA), says, “As an organization we made a commitment to population health. We have a Quadruple Aim — we want to add joy back to the practice of medicine, along with the other Triple Aim goals. Everyone in the 22 |
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Beth Bortz, president/CEO, VCHI. VCHI is focused on the acceleration of the adoption of value-driven models of wellness and health care throughout Virginia.
ACO is greatly committed to what we’re doing. We have a small, high-functioning team with the passion and foresight to approach population health in a systematic and outcome-driven manner.” GBHA has developed a network of about 300 employed and independent physicians who care for 69,000 covered
lives. Of those, about 12,000 are in the Medicare Shared Savings plan, and another 15,000 or so are in valuebased programs with private insurers. However, Ely points out that “We’re payer agnostic — we take care of all patients the same way, regardless of their insurance coverage.”
Secrets to Success Ely continues, “One of the secrets of success is having evidence-based medical guidelines. We especially focus on obesity, smoking cessation, diabetes and hypertension, which are the conditions with both the highest prevalence and the highest costs. We also manage asthma and congestive heart failure.” Ely believes that maximizing the state data from Chesapeake Regional Information Service for Our Patients (CRISP), which provides data in real time, is a critical component of successful care management. “When notified that a patient has been discharged, our staff, including a care coordinator embedded in each practice, can reach out to provide the resources the person needs. We connect with patients that have been discharged from an inpatient stay within 48 hours, and where appropriate schedule a transitionof-care visit within 14 days to meet with the care team. It’s worked extremely well, and has decreased repeat hospitalizations and ED visits.” She adds, “We also offer extended office hours, and supply both medical and behavioral healthcare to make sure that patients get the right care at the right time. We’re currently in a pilot phase to embed psychiatrists in our practices. The value to providing this in the practice allows the provider to address immediate needs for patient care.” As elsewhere, getting patients to change their habits remains a hurdle. “The easier we make it for patients to make lifestyle changes, the better,” Ely states. ”I think in the near future we’ll have some tools to help employers add financial incentives to their benefits package for healthy behaviors such as losing weight or being more active. We’re doing a good job with the 20 percent who need it, but population health is more than just taking care of those with chronic conditions. It also entails preventing chronic conditions and keeping all of our patients healthy.” Advanced Health Collaborative Some 10 hospitals are participating in the Advanced Health Collaborative, a new coalition launched in early 2015 that will include a care management infrastructure including IT, telemedicine,
palliative care, retooling primary care offices, and more. They are seeking to facilitate the Triple Aim of better health, better care and lower costs, primarily through population health and carecoordination activities. The Collaborative’s other members are Adventist HealthCare, LifeBridge Health, Mercy Health Services, Peninsula Regional Health System and Trivergent Health Alliance, which includes Frederick Regional Health System, Meritus Health, and Western Maryland Health System. Its goal is to create a coalition that, without requiring hospitals to merge, can share ideas and implement national best practices, following the redesign of Maryland’s unique all-payer hospital reimbursement system in early 2014.
the state government, although some of our funding comes from the state.” VCHI has five priority areas: z Population health planning and design z Accountable care communities z Quality, payment and health information technology z Healthcare workforce development z Value-based insurance design In early 2015, VCHI was awarded a $2.6-million State Innovation Model (SIM) Round-Two Design Award from CMS, which provides financial and technical support to develop and test state-led, multi-payer healthcare payment and service-delivery models. The models will emphasize regional health initiatives, treatment for those
one of the secrets of success is having evidence-based medical guidelines. —Mary Ely, executive director of Greater Baltimore Health Alliance
Virginia’s Model for Health Innovation Further south, Virginia has launched a statewide effort to implement more population-based health initiatives. The Virginia Center for Health Innovation (VCHI), a unique non-profit organization whose stakeholders include consumers, the business community, providers, health plans, and more, is partnering with other groups to accelerate the adoption of value-driven models of wellness and health care throughout Virginia. “Virginia is a very ‘purple’ state,” comments Beth Bortz, VCHI president and CEO. “While we’re often conflicted about implementation of strategies related to the Affordable Care Act, a decision was made during the McDonnell administration to move forward with some payment models outside the government because our single-term governor makes continuity a challenge. Healthcare leadership recommended housing our entity outside
with chronic conditions, and integration of behavioral health with primary care for those with several comorbid conditions. “We’re the only non-profit grantee in the country,” notes Bortz. “We have to deliver a plan for population health under this grant.” Reducing Core Measures One of the SIM workgroups is the Lt. Governor’s Quality, Payment Reform and HIT Roundtable, which was tasked with developing and approving a plan for population health, including developing a core set of metrics intended to reduce the untenable number of quality/care measures that physicians must meet to receive various incentive payments. Bortz notes, “We realized that reporting on 560 measures, as can be the case with today’s incentive programs, is overwhelming for physicians. We want to develop a core set of fewer than 100 measures that we hope will be voluntarily adopted by the state health SEPTEMBER/OCTOBER 2015
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plan, Medicaid and others. We expect to complete this task by the end of 2015, with monthly meetings and a draft recommendation in mid August 2015. Meanwhile, Virginia Health Commissioner Dr. Marissa Levine is rolling 20-plus population health measures into the core set.”
to do a better job with care transitions and other ways to improve population health.” Kaiser Permanente’s Approach As a long-standing group HMO model that combines a non-profit insurance plan with a care-delivery system of
We realized that reporting on 560 measures, as can be the case with today’s incentive programs, is overwhelming for physicians. —Beth Bortz
A second workgroup is developing Accountable Care Communities, which divide the state into five regions to account for the disparity among the areas. Each area will seek to develop and implement a Regional Transformation Plan, which could be funded in part by a Delivery System Reform Incentive Payment (DSRIP) waiver that supports improvements for the Medicaid population. Another grant was awarded to VCHI and its partners in May 2015 by the Agency for Healthcare Quality and Research (AHRQ) as part of its EvidenceNow Initiative, which helps transform primary care by providing the latest evidence-based information to help patients stay healthy. Bortz views physicians as important drivers of the conversation, but not the sole solution. She believes that getting and sharing data remains one of the Commonwealth’s greatest challenges. “Data and population health go hand in hand. We have a new all-payer claims database that will provide the first report at the end of July, with Medicaid and other payer data, but CMS still won’t relinquish its data. TriCare, which covers federal employees, is the other missing piece. “Since the Center was launched in 2012, we’ve been moving faster than most states on these health issues because all of the relevant parties are on board,” she claims. “We definitely see that stakeholders are committed 24 | CHESPHYSICIAN.COM
employed physicians and owned or contracted hospitals, Kaiser Permanente has been in a unique, but sometimes difficult position in the U.S. Today, however, its model is a good fit with population-health-based approaches, which may be why its growth in the Mid-Atlantic is predicted to hit 15 percent this year. Susan Fiorella, managing director of Strategy and Communications for Kaiser Permanente’s Mid-Atlantic Permanente Medical Group, notes, “We have a serious focus on preventing and managing chronic conditions, such as diabetes and hypertension, and detecting cancer early through timely cancer screenings. We’re rated numberone in the United States for colorectal and breast cancer screenings, and our patients’ blood pressure is checked at every visit, even those to a podiatrist or optometrist. “If a patient has an elevated blood pressure, they get referred to a primary care physician the same day. Even the ophthalmologist is held accountable for ensuring that you get your mammogram if needed,” she adds. Kaiser Permanente has used Epic’s electronic medical records platform for more than 10 years, which alerts doctors to provide the right care at the right time. “Employing physicians and having the same EMR system — including a patient portal for the past decade — helps to coordinate care and emphasize prevention,” Fiorella asserts. “Patients
can sign in to kp.org and view not only their own health information, but also their children’s. They can email their physicians and usually get an answer within one day. We also emphasize fast access to care. Our goal is that 40 percent of specialty appointments are seen within one day.” Fiorella attributes the organization’s ability to motivate physicians to meet preventive performance measures to good data, peer pressure, financial incentives and a model of physician rather than administrator leadership. “The physicians know who’s performing and who’s not.” For the past few years, Kaiser has operated an around-the-clock call center with a House Calls program in which an emergency medicine physician can provide telemedicine consults to prevent unnecessary emergency room visits. In early fall 2015, it will add the option for patients to see their primary care physician via telemedicine instead of in person. Their “hubs” facilities are open 24/7 and include advanced imaging, lab, pharmacy, primary care, and many specialists in a single location to make it easier for patients to access all or nearly all of their care in one place. What all of these approaches have in common is a renewed emphasis on prevention, early detection and care coordination. And all of them depend on good data to help track what’s important. However, as the early CMS ACOs have found, focusing on population health does not automatically cut costs. Even Kaiser, with all of its years of experience in population health approaches, continues to find it challenging to make significant cost reductions. It may be necessary to find more effective ways to impact lifestyle issues such as obesity, and determinants of health such as housing and transportation, before that can happen.
Mary Ely, executive director of Greater Baltimore Health Alliance Beth Bortz, president and CEO, Virginia Center for Health Innovation Susan Fiorella, managing director of Strategy and Communications for Kaiser Permanente’s Mid-Atlantic Permanente Medical Group
T h e O f f i c i a l J o u r n a l o f C e n t e r f o r Ve i n R e s t o r at i o n Vol. 8, Issue 2 June 2015
inside this issue
Lower extremity venous insufficiencccyy MUST be evaluated and treated as a part of ‘Infra-diaphragmatic venous disease’. ‘A FIVE P PAR AR RT SERIES’ By Sanjiv Lakhanpal, MD, FACS Summary: y Our venous system from toes to the right atrium is one continuous system of fancy pipes with anatomic and physiological enhancements to facilitate venous return to the heart. Compartmentalizing the evaluation of this one single system of veins only makes sense se for lower grades (CEAP P 0-1) 0 of venous LQVXIÀFLHQF\ LQ WKH OHJV )RU KLJKHU JUDGHV &($3 RI YHQRXV LQVXIÀFLHQF\ LW LV HVVHQWLDO WR HYDOX X D W H W K H H Q W L U H infra-diaphragmatic venous system. ,Q WKLV ÀYH SDUW UHYLHZ , ZLOO OD\ RXW WKH FRPSHOOLQJ FDVH for such clinical evaluation and for appropriate treatment tailored to the needs of the individual patient if the need is substantiated by a more detailed diagnostic workup. This review will be broken down into the following parts: Editor-in-Chief, President & CEO, Center for Vein Restoration Sanjiv Lakhanpal, MD, FACS
Associate Editor, Director of Research Director of Vascular Labs Shekeeb Sufian, MD, FACS 4HUHNPUN ,KP[VY Kathleen A. Hart ISSN 2159-4767 (Print), ISSN 2159-4775 (Online)
Copyright © 2015 Center for Vein Restoration. All rights reserved.
Part I: The anattomic logic for evaluation of the entire infra-diaphragmatic venous system in patients with advanced lower extremity venous disease. Part II: The physiologic logic for evaluation of the entire infra-diaphragmatic venous system in patients with advanced lower extremity venous disease.
Part III: Pathologic conditions leading to post-ambulatory venous hypertension in the lower extremities.
Part V: Treatment of Infra-diaphragmatic venous insufficiency, venous diseases of the lower extremity and Pelvic Congestion syndrome.
Part IV: Diagnosis of Infra-diaphragmatic venous insufficiency, venous diseases of the lower extremity and Pelvic Congestion syndrome. Continued on Page 2
Lower extremity venous insufficiency MUST be evaluated and treated as a part of ‘Infra-diaphragmatic venous disease’. PART I: THE ANATOMIC LOGIC. Superficial venous system of the lower extremity: The skin and the subcutaneous tissues are drained by the great and the small saphenous veins. Both the GSV and the SSV start from the medial and lateral extensions of the dorsal venous arch respectively.
The Small Saphenous Vein (SSV) begins as the lateral continuation of the dorsal venous arch. It may drain completely into the popliteal vein, have a small extension that continues cranially as the cranial extension, or the entire SSV may continue cranially to drain into the femoral vein or the GSV. The intersaphenous vein starts below the facia and then penetrates the MHZJPH [V JVTL Z\WLYĂ„JPHS [V P[ [OL PU[LYZHWOLUV\Z ]LPU PZ ZLLU PU YKZ VM the limbs with venous disease. SSV valves; More numerous (median 7-10) Range 4-13. Highest valve is close to the termination of the SSV. Valves in H ::= .:= JVUULJ[PVUZ KPYLJ[Z Ă…V^ MYVT MYVT ::= [V .:=
Image 001
The Great Saphenous Vein (GSV) begins just anterior to the medial ankle, ascends medial to the knee ascending along the medial side of the thigh and enters the fossa ovalis 3 cms. inferior and three cms. lateral to the pubic tubercle. It is duplicated in the calf in 25% and in the thigh in 8%. Tributaries of the GSV include: Posterior accessory GSV of the leg (>75%)– joins the GSV distal to the knee, begins posterior to the medial malleolus, anterior accessory GSV of the leg, Posterior accessory GSV of the thigh and anterior accessory GSV of the thigh. GSV usually has at least 6 valves (14-25), with a constant valve between 2-3 cms from the SFJ(85%). The frequency of valves is greater below the knee.
Image 003
Like the rest of our body, the lower extremity is drained by a system of Z\WLYĂ„JPHS HUK KLLW ]LPUZ Âş*SHZZPJÂť Z\WLYĂ„JPHS ]LPUZ SPL Z\WLYĂ„JPHS [V the deep (muscular) fascia. The perforator veins, as the name implies, WLYMVYH[L [OL KLLW MHZJPH [V JVUULJ[ [OL Z\WLYĂ„JPHS ]LPUZ [V [OL KLLW ]LPUZ =HYPJVZP[PLZ PU]HYPHIS` SPL Z\WLYĂ„JPHS [V [OL Z\WLYĂ„JPHS ZHWOLUV\Z fascia - GSV, membranous layer - SSV) fascia, free of any fascial restraints. Reticular veins lie in the sub-dermal connective tissue and the so-called pin veins or spider veins are caused by the dilatation of the dermal plexus of veins. Saphenous fascia is an additional layer of fascia which encapsulates the great saphenous vein. The great and the small saphenous veins are interfascial veins.
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Lower extremity venous insufficiency MUST be evaluated and treated as a part of ‘Infra-diaphragmatic venous disease’. Continued from Page 2
The deep veins in general follow the corresponding arteries. The deep plantar venous arch from around the heads of the metatarsals continues as the medial and lateral plantar veins, which both become the posterior tibial veins behind the medial ankle. In over 80% of the samples they are paired and in about 10% they are triplicate. They perforate the soleus muscle close to its bony arcade and continue as the popliteal vein. The peroneal veins originate in the distal third of the calf. The peroneal receives the large soleal veins. The peroneal and the posterior tibial have constant connections in the distal leg. The peroneal and the posterior tibial form the TP trunk which then joins the popliteal. On the dorsum of the foot the major deep veins continue as the dorsalis pedis veins. The anterior tibial veins ascend in the anterior compartment. The popliteal vein is formed by [OL JVUÅ\LUJL VM [OL JHSM ]LPUZ ;OL WVWSP[LHS HUK [OL MLTVYHS ]LPUZ Y\U around the arteries of the same name. The femoral vein is the continuation of the popliteal vein. The deep femoral vein usually communicates with the popliteal vein either directly or through tributaries.
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The deep veins of the lower extremity: Tibial veins (deep venous system) MVYT I` [OL JVUÅ\LUJL VM [OL TLKPHS HUK SH[LYHS WSHU[LY ]LPUZ ^OPSL VU [OL dorsum of the foot the major deep veins continue as the dorsalis pedis vein.
;OL ZHWOLUV MLTVYHS Q\UJ[PVU HUK JVTT\UPJH[PVUZ ^P[O [OL Z\WLYÄJPHS veins of the lower extremity and the pelvic/abdominal veins: ;OL [YPI\[HYPLZ VM [OL .:= UHTLS` [OL Z\WLYÄJPHS JPYJ\TÅL_ PSPHJ ]LPU [OL Z\WLYÄJPHS L_[LYUHS W\KLUKHS ]LPU HUK [OL Z\WLYÄJPHS LWPNHZ[YPJ ]LPU communicate freely with the deep veins with similar names that drain into the External iliac vein.
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WELLNESS WE LLNESS T Today oday od ay y
What is Pelvic Congestion Synndrome?
By: Vinay Satwah DO, FACOI, RPVI
Many women with Pelvic C Congestion Syndrome spend years ears tryi trying to get an answer as to why they havee this this hi chronic hch pelvic pain. Pelvic Congestion Syndrome is an under-diagnosed conditio which is associated with venous disease in the pelvic area, low abdomen and thighs. Often accompanied by chronic pelvic WHPU HUK VY WYLZZ\YL P[ PZ LZ[PTH[LK [OH[ [OPZ JVUKP[PVU HɈLJ[Z TVYL [OHU VUL [OPYK VM HSS ^VTLU :VTL[PTLZ Z\ɈLYPUN ^P[O [OPZ condition for years, many of these women are told the problem PZ UV[ K\L [V H ZWLJPÄJ TLKPJHS JH\ZL HUK TH` IL ¸HSS PU [OLPY head.” However, recent advancements have allowed physicians at Center for Vein Restoration to show that the pelvic pain may IL K\L [V ]HYPJVZL ]LPU YLÅ\_ JH\ZPUN WLS]PJ ]LUV\Z PUZ\ɉJPLUJ`
PAINFUL P AINFUL SYMPT SYMPTOMS OMS CAN CAN INTERRUPT INTERRUPT DAILY DAILLY ACTIVITIES ACTIVITIES
The symptoms related to Pelvic Congestion Syndrome include pelvic pain associated with standing and sitting, which worsens throughout the day. This chronic pain is typically dull and aching PU UH[\YL 7H[PLU[Z VM[LU L_WLYPLUJL YLSPLM MYVT WHPU ^OLU S`PUN ÅH[ and when legs are elevated. The symptoms may worsen following intercourse, during menstrual periods, and during pregnancy. (ZZVJPH[LK Z`TW[VTZ PUJS\KL OLH]PULZZ MH[PN\L HJOPUN VM [OL SLNZ ^P[O ]HYPJVZL ]LPUZ VU [OL ]\S]H HUK VY I\[[VJRZ Similar to varicose veins in the legs, the valves in the pelvic veins that help return blood to the heart against gravity become ^LHRLULK HUK KVU»[ JSVZL WYVWLYS` ;OPZ HSSV^Z ISVVK [V ÅV^ backwards and pool in the vein causing pressure and bulging veins. In the pelvis, varicose veins can cause pain, heaviness and HɈLJ[ [OL KYHPUHNL VM [OL \[LY\Z V]HYPLZ HUK ]\S]HY YLNPVU
VENOGRAM: TTHE VENOGRAM: HE M MOST OST A ACCURATE CCURA ATE TEST FFOR OR DIA DIAGNOSIS GNOSIS
Many women with Pelvic Congestion Syndrome spend years trying to get an answer to why they have this chronic pelvic WHPU 3P]PUN ^P[O JOYVUPJ WLS]PJ WHPU PZ KPɉJ\S[ HUK HɈLJ[Z UV[ only the woman directly, but also her interactions with her family, friends, and her general outlook on life. Our patients will undergo a thorough history and physical. Those with a high suspicion may undergo pelvic ultrasound and venography. Thought to be the most accurate method for diagnosis, a venogram is performed by injecting contrast dye in the veins of the pelvic organs to make them visible during an X-ray. Once a diagnosis is made by a Center for Vein Restoration physician, if the patient is symptomatic, a pelvic venogram with embolization should be done. Embolization is a minimally invasive procedure performed by the interventional team using imaging for guidance. During the outpatient procedure, the faulty, enlarged veins are sealed in order to relieve the painful pressure. After treatment, patients should expect a low level of pain and to spend H JV\WSL VM KH`Z VɈ [OLPY MLL[
MULLTIPLE PRE MULTIPLE PREGNANCIES PREGNANCIES CAN CAN MEAN MEAN H HIGHER IGHER RISK RISK
7LS]PJ *VUNLZ[PVU :`UKYVTL [`WPJHSS` HɈLJ[Z ^VTLU PU [OLPY child bearing years. As the uterus expands during pregnancy, [OLYL PZ PUJYLHZLK WYLZZ\YL L_LY[LK VU [OL WLS]PJ ÅVVY HUK ]LPUZ Post-partum, the uterus eventually contracts and although the WYLZZ\YL VU [OL WLS]PJ ÅVVY PZ YLSPL]LK [OLYL PZ YLZPK\HS KHTHNL to the pelvic veins. Therefore, the ovarian veins increase in size YLSH[LK [V WYL]PV\Z WYLNUHUJPLZ >VTLU ^OV»]L OHK [^V VY more pregnancies and hormonal increases are at particular risk.
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A venogram may be performed, involving the injection of dye in the veins of the pelvic organs.
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QUESTIONS QUESTIONS & Ans Answers swers In each issue of Venous Review, our medical team answers questions we’ve received from referring physicians.
This issue’s guest Q & A Editors are
Theresa M. Soto, MD FFAACS, RPVI
Micchelle Nguyen, MD
medication prescribed and emergency symptoms that require urgent evaluation in an emergency room. The patient is typically followed up in the office in one week to assess for compliance with and side effects of the medication. A repeat scan is completed to assess for progresZPVU Z[HIPSP[` VM [OL [OYVTI\Z H[ [OPZ [PTL as well.
end yo Q: If If I ssend youu a SSTAT TAT D DVT V T rrule-out, ule-out, and it it iiss positive, positive, what what do do you you ddo? o? What W h at and iiff iitt is is negative? negative?
A: 0M [OL WH[PLU[»Z K\WSL_ ZJHU PZ WVZP[P]L patient history and examifor DVT T.. A full patien nation is completed in order to evaluate for pulmonary embolism (PE), venous thromboembolism (VTE) risk factors and possible contraindications to the use of blood thinners. We notify the referring physician with the positive result and N P ] L [ O L W YV ] P K L Y [ O L V W [ P V U V M [ YL H [ P U N managing the thr ombus. Should the referring physician prefer, the CVR physician will start the patient on a blood thinner, typically Xarelto or Lovenox and prescription grade compression stockings. The CVR physician thoroughly counsels the patient on the diagnosis of DVT T;; risk ris and symptoms of PE; risks, benefits and side effects of the
Thereafter follow up will be completed as needed and at 4-6 months to evaluate for any residual or chronic venous changes. The patient is co-managed with the primary care physician and a hematologist in order to determine the ideal length of anticoagulant treatment. T Testing esting ffor an underlying clotting disorder may be completed after completion of anticoagulant [OLYHW` WLUKPUN [OL WH[PLU[»Z YPZR WYVMPSL and history. In the rare event of an acute extensive thrombus involving a large segment of the deep vein, the patient will be referred to the emergency room for intravenous anticoagulation and possible thrombolytic therapy. 0M [OL WH[PLU[»Z ZJHU PZ ULNH[P]L MVY +=; the CVR physician will elicit a history from the patient and complete a limited physical examination. A full venous duplex scan may be recommended at this time in order to evaluate for venous inZ\MMPJPLUJ` HZ H JH\ZL VM [OL WH[PLU[»Z SLN pain. Pending the results, the physician may recommend additional follow up with another specialist to further inves[PNH[L [OL WH[PLU[»Z ZV\YJL VM WHPU ;OL CVR physician will again notify the referring physician of the findings and recommendations; final disposition of the pa[PLU[»Z MVSSV^ \W ^PSS IL JVVYKPUH[LK ^P[O the referring physician in every case.
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you need need ttoo uuse Q: Why Why don’t don’t you se aany ny anesan e s tthesia hesia fo for procedures procedures — aaren’t aren’t tthe he for ppatients atients in in pain? pain?
A: At CVR, all our procedures are com-
pletely ambulatory. This means that your patients can drive themselves to their procedure and then drive themselves home. For endovenous ablations, only local anesthesia is used to numb the skin. Then, once we have accessed the vein, we will also instill tumescent anesthesia, which is a mixture of lidocaine, saline and bicarbonate around the vein. This will provide additional anesthesia. Patients are awake the entire time, conversing with us. If any discomfort is felt, we can add more tumescent anesthesia until the patient is comfortable. After the procedure, patients are able to immediately ambulate, and they experience minimal residual effects of the local anesthetic. 6\Y NVHS PZ [V PTWYV]L `V\Y WH[PLU[»Z quality of life without causing any major interruptions in their everyday life.
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STRONGER Together CVR Expands in Michigan
Two great companies just joined, to make one perfect fit. In April of this year, Center for Vein Restoration was proud to announce its expansion to Grand Rapids, Michigan through the acquisition of Grand Rapids Vein Clinic. The expansion marks an exciting milestone for CVR, which already serves western Michigan WH[PLU[Z PU 2HSHTHaVV 7VY[HNL HSVUN ^P[O V[OLY JSPUPJHS locations in Connecticut, the District of Columbia, Maryland, New Jersey, New York, Pennsylvania and Virginia. The Grand Rapids Vein Clinic was founded by Joseph Marogil, 4+ H SLHKLY PU [OL [YLH[TLU[ VM ]LUV\Z PUZ\ɉJPLUJ` PU [OL .YHUK Rapids Community for over 20 years. His partner, Laura Kelsey, MD, joined the practice in 2005, and has made the treatment of this KPZLHZL OLY ZVSL MVJ\Z ¸=LUV\Z PUZ\ɉJPLUJ` PZ H JVUKP[PVU [OH[ HɈLJ[Z TVYL [OHU TPSSPVU (TLYPJHUZ HUK ^L ILSPL]L [OH[ [YLH[PUN this potentially serious problem is a right, not a privilege,” said CVR 7YLZPKLU[ HUK *,6 :HUQP] 3HROHUWHS 4+ ¸;OH[»Z ^O` ^L»YL WYV\K to expand our practice to serve more patients than ever and bring them genuine relief. ¸*=9 PZ HISL [V IYPUN ^VYSK JSHZZ Z\WWVY[ ZLY]PJLZ [V [OPZ UL^ WHY[ULYZOPW THUHNPUN IPSSPUN Z[HɉUN HUK HSS [OL [HZRZ [OH[ VM[LU [HRL H WO`ZPJPHU»Z MVJ\Z H^H` MYVT [YLH[PUN WH[PLU[Z 3VJHS WH[PLU[Z will have access to an expanded suite of advanced treatments for ]LUV\Z PUZ\ɉJPLUJ` HUK HJJLZZ [V H SHYNL 7H[PLU[ :LY]PJLZ JHSS JLU[LY VɈLYPUN WLYZVU [V WLYZVU HZZPZ[HUJL [V KPZJ\ZZ [YLH[TLU[ options, answer insurance questions, and make appointments,” he ZHPK ¸;OPZ PZ H WLYMLJ[ L_HTWSL OV^ V\Y WYHJ[PJLZ JHU IL Z[YVUNLY together.”
Dr. Kelsey brings extensive experience in the minimally invasive treatment of varicose veins. )VHYK *LY[PÄLK PU .LULYHS :\YNLY` ZOL ^HZ educated at the University of Michigan and 4PJOPNHU :[H[L <UP]LYZP[`»Z *VSSLNL VM /\THU Medicine, and completed her residence training in Grand Rapids. She joined the Grand Rapids Vein Clinic in 2005 to focus exclusively on the treatment of venous disease, excelling PU [OL [YLH[TLU[ VM ]LUV\Z PUZ\ɉJPLUJ` :OL PZ WHZZPVUH[L HIV\[ education and has presented at international meetings on the subject of blood coagulation, deep venous thrombosis, prophylaxis, and the treatment of other venous disease. She is a member of the American College of Phlebology, and serves as president of the alumni board of the M.S.U. College of Human Medicine.
The Center for Vein Restoration clinic in Grand Rapids is located at 1720 Michigan Street N.E. Contact the team there at (616) 454-8442 or (800) FIX-LEGS.
If you are a practice looking to partner with a larger organization, VY PM `V\»YL H WO`ZPJPHU SVVRPUN [V QVPU VUL VM [OL TVZ[ K`UHTPJ practices in the country, please feel free to contact us at (240) 965-3900 or e-mail us at strongertogether@centerforvein.com.
ABOUT DR. MAROGIL AND DR. KELSEY Founder of Grand Rapids Vein Clinic, Dr. Marogil brings 20 years of experience in the minimally invasive treatment of varicose veins. ( )VHYK *LY[PÄLK NLULYHS Z\YNLVU +Y 4HYVNPS was trained at Butterworth Hospital (currently Spectrum Health). Dr. Marogil started his practice in general surgery in Grand Rapids in 1971. In 1986, he joined the American college of Phlebology and started the Grand Rapids Vein Clinic soon after. Gradually Dr. Marogil focused his practice on the exclusive treatment of varicose and spider veins.
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C COMMUNITY OMMUNITY Outr Outreach each
Center for Vein Restoration’s Team has continued continu its momentum of reaching local residents at events and providing free screenings.
Along with White Plains Hospital, CVR sponsored the “Indulge: Fashion + Fun for Moms” event at the Westchester Mall in White Plains, NY. The May 7 event provided local moms with a much-needed opportunity to treat themselves to a night out to celebrate motherhood through a fun, fashionable and informative shopping experience. CVR staffff pictured: Nicole Pabon, Community Outreach Specialist, Nimsi Gonzalez, Community Outreach Coordinator, and Bella Rivera, Community Outreach Specialist.
Our New Yorkk CVR team was proud to provide vein health education to customers at the Hudson Square Pharmacy in Midtown Manhattan. This event was held in conjunction with WCBS 880 AM radio. Pictured is Community Outreach Coordinator Nimsi Gonzalez.
CVR’s Community Outreach Team: Helping Spread Awareness of Vein Health
Our Virginia team was out in force at the Southern Women’s Show, April 17-19 at the Richmond Raceway Complex. Along with health education, the event featured fashion, and cooking demonstrations. Celebrity appearances included GRAMMYY and Stellar-nominated vocalist Cynthia Jones. Pictured greeting visitors is Meron Hagos, CVR Community Outreach Specialist.
CVR was proud to sponsor the WYCB 1340AM and WPRS 104.1FM 13th Annual Prayer Breakfast. The March event honoring 20 local pastors was held in Martins Crosswinds in Greenbelt, Maryland. Stephanie Jones, Community Outreach Manager and Marsha Withers, Clinical Coordinator represented CVR at the event attended by 1,500 guests.
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Lower extremity venous insufficiency MUST be evaluated and treated as a part of â&#x20AC;&#x2DC;Infra-diaphragmatic venous diseaseâ&#x20AC;&#x2122;. Continued from Page 3
a) avalvular femoral vein, b) superior epigastric vein, c) superficial circumflex iliac vein, d) median circumflex vein, e) obturator vein, f) inferior gluteal vein, g) superficial external pudendal vein, h) branches of obturator vein, i) deep external pudendal vein, j) long saphenous vein (from phlebolymphology. org) Ext iliac vein: Begins at the inguinal ligament, courses along the pelvic brim, ends anterior to the SI joint by joining the internal iliac vein to form the common iliac vein. Tributaries anastomose freely with the corresponding Z\WLYĂ&#x201E;JPHS ]LPUZ HUK [OL VI[\YH[VY ]LPUZ! KLLW PUMLYPVY LWPNHZ[YPJ ]LPUZ KLLW L_[LYUHS W\KLUKHS ]LPUZ W\IPJ ]LPUZ KLLW JPYJ\TĂ&#x2026;L_ PSPHJ veins. Internal iliac vein: Short trunk formed by the union of its extrapelvic (Gluteal {superior & inferior}, internal pudendal and obturator) & intrapelvic tributaries (lateral sacral visceral {rectal, vesical, uterine and vaginal}. They drain the presacral venous plexus and the pelvic visceral plexus. These WSL_\ZLZ HUK [OL HKKP[PVUHS Z\WLYĂ&#x201E;JPHS WSL_\Z WYV]PKL MYLL JVTT\UPJH[PVU across the midline.
The Inferior Venae Cava: is the largest venous trunk in the body. It is formed by the union of the two common iliac veins in front of the right side VM [OL IVK` VM [OL Ă&#x201E;M[O S\TIHY ]LY[LIYH HIV\[ [^V HUK H OHSM JLU[PTL[LYZ (one inch) to the right of the median plane. In its ascent, it lies upon the bodies of the lower three lumbar vertebrae, the right lumbar and renal arteries, and the right crus of the diaphragm, by which it is separated from the aorta. It passes through the caval opening in the diaphragm opposite the eighth thoracic vertebra, pierces the pericardium and immediately enters the right atrium of the heart. In its upward course it receives the lumbar, the right testicular or ovarian, the renaI, the right phrenic, the right suprarenal, and the hepatic veins. The veins tributary to the inferior vena cava generally follows the same course as the corresponding arteries. Because of the position of the inferior vena cava to the right of the median line, the veins entering it from the left are longer than those from the right side.
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Common Iliac vein: -YVT [OL :0 QVPU[ [V [OL YPNO[ ZPKL VM [OL Ă&#x201E;M[O S\TIHY vertebrae. RCIV â&#x20AC;&#x201C; only tributary is the right ascending lumbar vein (collects blood from the lumbar veins and drains into the Azygos vein). LCIV â&#x20AC;&#x201C; left ascending lumbar vein (same as right) and the median sacral vein.
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Ovarian vein: Provide drainage to the Parametrium, cervix, mesosalpinx, pampiniform plexus. It forms a rich anastomotic venous plexus with the Paraovarian, uterine, vesical, rectal and vulvar plexus. 2-3 trunks form a single ovarian vein at L4. Left ovarian vein drains into the LRV. Right Ovarian vein drains into the IVC. The ovarian veins have an average diam. of 5mm. Valves are present mainly in the distal third. Absence of valves in 15% on the left side and 6% on the right side.
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Lower extremity venous insufficiency MUST be evaluated and treated as a part of â&#x20AC;&#x2DC;Infra-diaphragmatic venous diseaseâ&#x20AC;&#x2122;. Continued from from Page Page88
INPATIENTS INPATIENTS WIT WITH H PPELVIC ELLVVIC VENOUS VENOUS HYPERTENSION, HYPERTENSION, THE THE IN INTRAPELVIC TRAPELLVIC A AND ND EEXTRAPELVIC XTRAPELLVIC VE VENOUS COMMUNICATIONS MA MAY AY OO OPEN NOUS COMMUNICATIONS PEN UP (AS (AS ESCAPE VEINS) SAPHENOUS ES CAPE VEI NS) TO TO FORM FORM NON SAP HENOUS VARICOSITIES VARICOSITIES IIN N TTHE HE LLOWER OWER EEXTREMITIES. XTREMITIES.
GLUTEAL VVARICOSITIES ARICOSITIES AS ES ESCAPE CAPE VEINS VEINS FR FROM OM THE THE PEL PELVIS LVIS 3V^LY L_[YLTP[` ]LUV\Z PUZ\É&#x2030;JPLUJ` TH` YLZ\S[ MYVT H WYPTHY` WH[OVSVN` in the veins of the lower extremity (GSV -75%, SSV -10%) or within the veins of the pelvis (15-20%). If the pathology lies in the veins of the pelvis, the venous hypertension may be transmitted from the Pelvis to the lower extremity through the escape veins (non-saphenous varicosities) and presLU[ ^P[O ]LUV\Z PUZ\É&#x2030;JPLUJ` VM [OL SV^LY L_[YLTP[` PU [OL HIZLUJL VM HU` pathology in the lower extremity veins. In such cases it is imperative to PKLU[PM` [OL WH[OVSVN` PU [OL WLS]PZ HIKVTLU HUK [OL [YLH[TLU[ OHZ [V IL focused towards the pathology in the pelvis. Up to twenty percent of the patients presenting with lower extremity venous disease have the etiology of their disease in the pelvis.
These non-saphenous veins (NSV) are located in the watershed areas as; Buttock (through the gluteal veins), perineal veins, Vulvar veins, posterolateral thigh (internal iliac system through the femoral vein), lower posterior [OPNO WVWSP[LHS MVZZH RULL WVWSP[LHS MLTVYHS ]LPU HUK HSVUN [OL WLYPWOLYHS nerves such as the tibial and sciatic nerve (internal iliac through the gluteal veins).
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Image 001: http://www.microsurgeon.org/ An atlas of microsurgery techniques and principles. Image is from their image repository, not in an article. http://www.microsurgeon.org/images/toevenoussystem.jpg Image 002: Epidemiology of Chronic Peripheral Venous Disease. Originally in Gloviczki P, and Bergen JJ eds. Atlas of Endoscopic Perforating Vein Surgery Vhttp://intranet.tdmu.edu.ua/data/kafedra/internal/surgery2/classes_stud/en/med/lik/ptn/Surgery/6/TOPIC%2020.%20 DISEASES%20OF%20THE%20VEINS.htm Image 003: http://www.nuvelaesthetica.com/GALLERY2/NuVelaBeforeAfter/images/Saphenous-Perforator-Leg-Veins.jpg http://www.nuvelaesthetica.com/ A Medical Esthetics Laser and Vein Center. From their gallery not associated with any article or person. Image 004: The hemodynamics and diagnosis of venous disease, Journal of Vascular Surgery, Volume 46, Issue 6, Supplement, 2007, S4-S24 http://dx.dol.org/10.1016 ,PDJH KWWS QXUVH SUDFWLWLRQHUV DQG SK\VLFLDQ DVVLVWDQWV DGYDQFHZHE FRP 6KDUHG5HVRXUFHV $GYDQFHIRU13 5HVRXUFHV &RQWHQW &RQWHQW,PDJHV QS BS Ć&#x201C;J JLI http://nurse-practitioners-and-physician-assistants.advanceweb.com/ In their gallery, not associated with any article or person ,PDJH KWWS MDS SK\VLRORJ\ RUJ FRQWHQW 9HQRXV HPSW\LQJ IURP WKH IRRW LQĹ´XHQFHV RI ZHLJKW EHDULQJ WRH FXUOV HOHFWULFDO VWLPXODWLRQ SDVVLYH FRPSUHVVLRQ DQG SRVWXUH Barry J. Broderick , Gavin J. Corley , Fabio Quondamatteo , Paul P. Breen , Jorge Serrador , GearĂłid Ă&#x201C;Laighin Journal of Applied Physiology Published 1 October 2010 Vol. 109 no. 4, 1045-1052 DOI: 10.1152/japplphysiol.00231.2010 ,PDJH KWWS ZZZ PGDQGHUVRQ HV VLWHV GHIDXOW Ć&#x201C;OHV HGLWRU YDULRV DQDWRPLD VLVWHPD YHQRVR MSJ )URP 0' $QGHUVRQ &HQWHU ZHEVLWH Ĺ&#x160; FDQĹ?W Ć&#x201C;QG VRXUFH ,PDJH KWWS ZZZ PGDQGHUVRQ HV VLWHV GHIDXOW Ć&#x201C;OHV HGLWRU YDULRV DQDWRPLD VLVWHPD YHQRVR MSJ )URP 0' $QGHUVRQ &HQWHU ZHEVLWH Ĺ&#x160; FDQĹ?W Ć&#x201C;QG VRXUFH Image 010: Phlebolymphology.org ,PDJH KWWS XSORDG ZLNLPHGLD RUJ ZLNLSHGLD FRPPRQV *UD\ SQJ +HQU\ *UD\ Ĺ&#x160; $QDWRP\ RI WKH +XPDQ %RG\ )UHH 8VH Image 012: http://lucy.stanford.edu/circulation.html. Stanford.edu Image gallery, not tied to article ,PDJH 6RXUFH 8QNQRZQ ,PDJH KWWS PHGLFLQH VWRQ\EURRNPHGLFLQH HGX VGPSXEĆ&#x201C;OHV VW\OHV SXEOLF 3HOYLF FURSSHG VKRSSHG B MSJ )URP 6WRQ\ EURRN PHGLFLQHĹ?V ZHEVLWH FDQQRW Ć&#x201C;QG RULJLQDO VRXUFH RU DUWLFOH 6RXUFH 6HUYLHU FRP Image 015: Source: Servier.com Image 016: http://phl.sagepub.com/content/27/6/270/F20.large.jpg. Phlebology September 2012 vol. 27 no. 6 270-288. Three-dimensional modelling of the venous system by direct multislice helical computed tomography venography: technique, indications and results - ) 8KO Ĺ&#x2013; 9DULFRVH 9 HLQ 6XUJLFDO &HQWHU $YHQXH 9LFWRU +XJR 3DULV Ĺ&#x2013;85',$ 5HVHDUFK 8QLW ($ 8QLYHUVLW\ 3DULV 'HVFDUWHV UXH GHV VDLQWV SÂŞUHV 3DULV )UDQFH &RUUHVSRQGHQFH - ) 8KO 0' DYHQXH 9LFWRU +XJR Ĺ&#x160; Ĺ&#x160; 3DULV Ĺ&#x160; )UDQFH Email: jeanfrancois.uhl@gmail.com
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Administr ative Administrative Proffessionals es Professionals offessionals Sales Pr Professionals Community Outreach Outreach Contact us Find out more about how you can become part of the CVR team. Visit V isit i it www www.centerforvein.com w.centerforvein.com .ce and follow the e career link to apply apply. y.. Or submit your resume and cover letter to: hr@centerforvein.com Attention: Human Resources
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MD, Militano, homas Militan 11.. Sanjiv Lakhanpal, Lakhanpal, MD, FACS 2. 2. ShekHHE 6XĆ&#x201C;DQ, ShekHHE 6XĆ&#x201C;DQ, M D, FACS FACS 33.. TThomas o, MD, MD, FFACS, ACS, RPVI 4. Frank Frank Sbrocco, Sbrocco, MD 55.. Khanh Nguyen, Nguyen, DO, RPVI 6. 6. Eddie Fernandez, Fernandez, MD 77.. SStĂŠphane tĂŠphane CCorriveau, orriveau, MD 8. 10.. Richard Nguyen,, MD 11. MD, Nguyen,, MD 14. Edelman,, MD 15 15.. Henry Meilman, 8. Rory Rory CC.. Byrne, Byrne, MD 9. 9. SSean ean K. K. Stewart, Stewart, MD 10 Richard Nguyen 11. Arun Chowla, Chowla, M D, FACS FACS 12. 12. Vinay Satwah, Satwah, DO, FACOI 13. 13. Michelle Nguyen 14. Mark Edelman Meilman, MD 16. 16. Anuj Shah, Shah, MD 17.Lawrence 17.Lawrence Starin, Starin, MD 18. 18. Shubha Varma, Varma, MD 19. 19. Theresa Theresa Soto, Soto, MD, MD, FACOG, FACS, FACS, RPVI 20. 20. Duc Le, Le, MD 21. 21. Arvind Narasimhan, Narasimhan, MD 22. 22. Seema Kumar, Kumar, MD, MD, MPP 23. 23. Lauren Lauren Best, Best, MD 24. 24. Michael Banker, Banker, MD, FACS, FACCP, FACP, RPVI 25. David Shevitz, MD 26. Kourosh C. Ghalili, MD 27. Alfred Jump, MD, MS 28. Laura Kelsey, MD 29. Joseph B. Marogil, MD 30. Arlen G. Fleisher, MD, FACS, RPVI, RVT
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From The
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Editor-in-Chief, President & CEO, Center for Vein Restoration Sanjiv Lakhanpal, MD, FACS
T h e O f f i c i a l J o u r n a l o f C e n t e r f o r Ve i n
R e s t o r at i o n
Itâ&#x20AC;&#x2122;s been quite a busy time for us here at Center for Vein Restoration. Since January weâ&#x20AC;&#x2122;ve opened 10 new clinics, bringing our total of 38 locations across Connecticut, the District of Columbia, Maryland, Michigan, New Jersey, New York, Pennsylvania and Virginia. Such continued, vibrant growth has been a challenging and rewarding undertaking. We believe that thereâ&#x20AC;&#x2122;s a great opportunity in the community for local, specialized medicine to complement the care people traditionally receive in larger institutions and we are FRPPLWWHG WR PRGHUQL]LQJ KHDOWKFDUH WR EH D PRUH HIĆ&#x201C;FLHQW DQG DFFHVVLEOH VHUYLFH WR SDWLHQWV 7KDQNV WR RXU SK\VLFLDQ OHG EXVLQHVV PRGHO ZKLFK HPSKDVL]HV FROODERUDWLRQ FDPDUDGHULH DQG VXSSRUW Ĺ&#x160; DORQJ ZLWK \RXU FRQWLQXHG UHIHUUDOV ZHĹ?UH SURXG WR UHSRUW ZHĹ?UH able to serve more patients than ever. ,Q WKLV HGLWLRQ RI 9HQRXV 5HYLHZ ZH DUH ODXQFKLQJ WKH Ć&#x201C;UVW LQ D SDUW RULJLQDO VHULHV GLVFXVVLQJ WKH LPSRUWDQFH RI LQFOXGLQJ HYDOXDWLRQV SHUIRUPHG EHORZ WKH GLDSKUDJP DV SDUW RI GLDJQRVWLF ZRUN XS IRU YHQRXV GLVHDVH $OVR LQ WKLV HGLWLRQ ZH H[DPLQH DQ XQGHU GLDJQRVHG FRQGLWLRQ LQ IHPDOHV DVVRFLDWHG ZLWK YHQRXV GLVHDVH 3HOYLF &RQJHVWLRQ 6\QGURPH We also check in with our Community Outreach team to see what theyâ&#x20AC;&#x2122;ve been up to in our local communities. Finally, we showcase WKH DFTXLVLWLRQ RI WKH *UDQG 5DSLGV 9HLQ &OLQLF LQ ZHVWHUQ 0LFKLJDQ DV DQ H[DPSOH RI RXU 6WURQJHU 7RJHWKHU SURJUDP ZKLFK KLJKOLJKWV RXU XQLTXH SK\VLFLDQ OHG EXVLQHVV PRGHO QRW RQO\ DV D ZD\ WR EULQJ VXSHULRU FDUH WR ORFDO SDWLHQWV EXW DOVR DV D JUHDW SODFH WR SUDFWLFH medicine.
Associate Editor, Director of Research Director of Vascular Labs Shekeeb Sufian, MD, FACS
7KDQN \RX DV DOZD\V IRU UHDGLQJ 9HQRXV 5HYLHZ :H KRSH \RX Ć&#x201C;QG WKLV LQIRUPDWLRQ LV XVHIXO WR \RX DQG \RXU SUDFWLFH Yours in good health, Sanjiv Lakhanpal, MD, FACS (GLWRU LQ &KLHI
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Profile
SPONSORED CONTENT
Rumors of the Death of Independent Practice are Premature SEAN SCHEIDT
Cloud-Based EHR Vendor Cyfluent Helps Physicians Remain Autonomous
Lawrence Walsh, president of Cyfluent. Walsh believes that Cyfluent will play a major role in guiding practices through the next CMS practice transformation phase, allowing physicians to maintain their independence.
A
LTHOUGH MANY have heralded the death of the independent physician practice, recent AMA data show that the trend toward employment by hospitals and other entities is far slower than predicted. According to the AMA, some 50.8 percent of physicians still own their practice today. Many physician owners are seeking ways to keep their independent practice viable rather than lose their autonomy. The challenges for independent practices are numerous, especially keeping current with changing regulatory and reimbursement trends. Beginning this year, physicians and other eligible professionals (EPs) will experience a one-percent reduction in 38 | CHESPHYSICIAN.COM
Medicare reimbursements for each year they don’t meet Meaningful Use (MU) requirements. That penalty will increase up to five percent by year five. Providers that have not yet met MU requirements or who do not have 2014-compliant EHR systems will be penalized not only by CMS, but also by other payers and regulatory bodies. Aggregate penalties and regulatory costs associated with non-compliance could be unsustainable for most independent practices. Given these penalties and the trend to value-based reimbursement models and coordinated-care-delivery models such as Accountable Care Organizations (ACO) and Patient Centered Medical Homes (PCMH), a critical component of a successful medical practice today is an electronic medical records system.
Unfortunately, too many EMRs in place today stem from the “traditional” client/ server delivery model — they are both costly and cumbersome, and they don’t reflect the doctor’s actual workflow. The traditional EHR vendor offered a capital and time-intensive approach that may be difficult to sustain as incentives and reimbursement decrease, while regulatory and payer requirements increase. Rick Greenberg, vice president of sales for Cyfluent, Inc., witnessed the “traditional” sales experience firsthand during his tenure with one of the nation’s largest EHR/PM vendors. He recalls, “A typical small-practice client/server system could cost well over $100,000 up front and still be competitive. EHR costs were made more affordable by the promise of American Recovery and Reinvestment Act incentives, would take months to implement, and would continue with annual maintenance fees. These days, with Cyfluent, the practice pays nothing up front, can leverage their existing network, and be running within a few days at a cost comparable to that of professional journal subscriptions.” Cloud-Based PM/EHR Supports Independent Practices
In contrast to the predominant client/server systems of yesterday, a growing number of practice management and EHR vendors are offering cloudbased services. Cyfluent, one of the most established Health Information Technology (HIT) vendors in the region with a deep national EHR/PM user base, is at the forefront of the new cloud-based service model designed to benefit independent physicians. Cyfluent combines all clinical and administrative elements of Practice Management into one cloud-based eco-system priced with inexpensive monthly subscription fees.
Dr. Peter Uggowitzer, president of Carol Family Medicine in Hampstead, Maryland, has been managing a fully computerized, independent family practice and configuring his own computer networks since 1999. Dr. Uggowitzer explains, “Being an independent physician has become more and more difficult as reimbursements have declined and overhead has increased. The Cyfluent software, with its innovative web-based design and MU2 compliance, has remained well ahead of larger competitors at a much lower cost. Behind the software stands a very competent support team that has worked closely with my office staff over the last 15 years.” Cyfluent/CRISP Pilot Connects Physicians With Limited Connectivity
An example of the importance that independent physicians play in the new “connected” medical healthcare paradigm is a pilot project created by Cyfluent and the Chesapeake Regional Information System For Our Patients, Inc. (CRISP) — Maryland’s regional Health Information Exchange (HIE). Most regional hospitals are connected to CRISP in an effort to improve coordination of care; however, until now, providers without an EHR were not able to share data with the HIE. In an effort to include more independent physicians, Cyfluent and CRISP are conducting the pilot to evaluate if claims-based data can be useful in broad care-coordination efforts. This project is the first of its kind in the nation, where claims data is being
transmitted electronically and shared by a regional HIE without requiring an EHR — ultimately connecting thousands of independent physicians throughout the region. Brandon Neiswender, VP of Operations at CRISP, comments, “There are thousands of Maryland providers with limited connectivity, but all of them file claims. We want to show that administrative network connectivity can be useful at a regional and statewide level, by building a smart routing and consent notification system that can identify gaps in care.” Lawrence Walsh, president of Cyfluent, states, “We estimate over 55 percent of Maryland physicians are still not sending encounters to the HIE. Being connected will be increasingly critical to electronically coordinate care, qualify for discounts, avoid penalties and participate in value-based reimbursement programs.” PRACTICE TRANSFORMATION: The Next Phase for Independent Physicians
CMS is now promoting “practice transformation” through its “Transforming Clinical Practices Initiative” (TCPI) as the next goal in the practice management technology evolution, seeking to bring the transformational experience to as many independent physicians as possible. Walsh believes that Cyfluent will play a major role in guiding practices through the next transformation phase; noting, “Independent physicians are NOT DEAD — they simply require connectivity and compliance assistance. Cyfluent is uniquely qualified to offer both the software and assistance required to transform an independent practice into a more competitive and responsive model by employing our own nationally certified software that controls all major access points to a clinician’s office. “More than software, it takes the commitment and expertise found within our team to provide the guidance that independent practices require to compete with the large healthcare systems, while providing their personal brand of medical treatment,” Walsh adds.
Integrated System Needed to Manage an Independent Practice
Most healthcare practice vendors rely on third-party partners and software bridges between applications to provide for missing components within their given EHR/PM product line — making workflow integration and single-vendor support difficult. Cyfluent’s eco-system integrates administrative and clinical processes into one system for streamlined patient care, including: z Practice Management (PM) Includes ICD10 wizard, scheduling, reporting, A/R management, unlimited electronic claims, and electronic remittance. z Clinical Records (EHR) Mimics the paper note for ease of use, making all sections of a progress note visible from one screen. z E-Prescribing Operates with a single click, enhancing accuracy and patient satisfaction with automated checks for drug contraindications, dosing alerts and generics. z Patient Portal Allows patients to manage their medical information via mobile device or web and enables access to electronic intake forms. z Provider Support Guaranteed real-time support through an integrated chat during normal business hours. z Electronic Claims and Revenue Cycle Management Tools
Consolidated billing for medical claims across multiple payers. An EHNACaccredited clearinghouse, Cyfluent meets/exceeds performance criteria for Electronic Data Interchange (EDI). z Integrated Document Management (DM) Using generic scanners, the Cyfluent system will scan and file any patient document at various entry points integrated into the practice workflow. For more information, visit Cyfluent.com.
SEPTEMBER/OCTOBER 2015
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CHESAPEAKE
Physician YOUR PRACTICE. YOUR LIFE.
Maryland/DC/Virginia www.chesphysician.com
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Strategize and increase the power of your marketing to Chesapeake-based physicians, healthcare executives and stakeholders via chesphysician.com and with Chesapeake Physician eNews blasts. Chesapeake Physician eNews exceeds all leading industry digital performers. Drive a higher volume of targeted traffic with Chesapeake Physician online.
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ADVERTISER INDEX Community Radiology Associates ..................................2 communityradiology.com Pain & Spine Specialists of Maryland ...........................5 passmd.com PNC .................................................................................................6 pnc.com/hcprofessionals AMP Systems .............................................................................8 ampsysllc.com Hospice of the Chesapeake .............................................16 hospicechesapeake.org St. Agnes Profile....................................................................17 TeamSaintAgnes.com Center for Vein Restoration ............................................25 centerforvein.com Papercamera............................................................................37 papercamera.com Severn Savings Bank ..........................................................37 severnbank.com Mojo Media, LLC ...................................................................37 mojomedia.biz Cyfluent .....................................................................................38 cyfluent.com Symphony Placements.......................................................40 symphonyplacements.com Everseat .....................................................................................40 everseat.com Center for Vein Restoration ............................................43 centerforvein.com Center for Vascular Medicine .........................................44 cvmus.com
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COMPLIANCE
Working With Older Patients: What Physicians Need to Know About Legal Capacity
I
By Terry Douglas, Attorney
N 2015, AN ESTIMATED 238,000 people living in Maryland, DC and Virginia have Alzheimer’s. Chances are that some of them are your patients. When no clear instructions are in place, a conflict can arise between physicians, the aging patient’s wishes, and his or her adult children. Two examples of scenarios that may occur in your practice follow.
Directive and to share his wishes with the family. The presumption is that the patient is competent. As long as patients have mental capacity — understand the consequences of their actions — they can make a decision about their medical care,housing or other legal matter. The law does not prevent a patient from making a bad decision.
Scenario #1: You receive a letter from an attorney who informs you that your patient, John, a 74-year-old retiree, wants to sign a new power of attorney and update his will to disinherit one of his children. The attorney wonders if John has the capacity to sign a legal document and requests an evaluation.
Scenario #2: Elizabeth is a 65-year-old widow who lives alone. After a recent fall in the bathroom, she made an appointment with you. Her daughter, Anna, came in with her. The daughter reports that, after her father died, her mother has gone downhill. The house is dirty, her mother wears pajamas all day and eats microwave dinners. Anna wants to move her mother into an assisted living facility and take over her bank account. Anna downloaded a power of attorney from the Internet, and asked your RN and PA to witness Elizabeth’s signature. The witness clause stated that Elizabeth is of sound mind and under no undue influence.
What would you do? During the mental
health assessment, you notice that John can’t recall everything, but knows his name and date of birth. John talks about his new girlfriend and tells you that he would like his children to assist him when the time comes. You determine that John has the capacity to execute a power of attorney and a will. You write a brief report including the referral source, the patient’s age, gender, date of evaluation, length of time you’ve known the patient, current symptoms (if any), diagnoses, and additional notes about his appearance or condition. You send John home and compliment him for getting his legal affairs in order. Powers of Attorney (legal or medical) provide clear instructions and identify the person authorized to carry out those instructions. Ask the patient to give you a copy of his Advance Health Care
What would you do? Ask Anna to step
out of the room while you talk privately with Elizabeth. If Elizabeth has the ability to choose, ask her what she wants and remind her about confidentiality. Elizabeth tells you that her daughter has financial problems and that she’s afraid that Anna will take all her money and sell her house. If your patient signs and dates the document, it’s up to you whether or not you or your employee should sign as a witness. Although there is no legal restriction, you may want to use some
caution if the patient is in a hospital or healthcare facility, or if you suspect duress. Signing such a document could create a conflict between your medical practice, your staff and the patient. What if the patient’s mental capacity is borderline? A patient with mild
memory loss can have the capacity to sign a power of attorney or refuse medical treatment. As the physician, you can always choose to conduct a more extensive evaluation. z
z
z
Determine if there is something else going on. Is the patient
dehydrated? Is her medication too strong? Does she have on a working hearing aid? Has she eaten today? Reach out to your resources. Ask a neurologist, a geriatric psychologist or a social worker for their assessment. Involve a geriatric care manager.
These individuals have special skills and experience to serve older adults and their families. Each patient is different. Take time to listen to them and, with their consent, talk to their family. In the end, it’s about building life-long relationships, not just providing medical services. When in doubt, consult with your ethics committee or your malpractice insurance company before taking action. This is information only and not legal advice. Terry Douglas is an attorney and mediator with a law practice based in Annapolis, Md., that focuses on helping older adults with their life-care planning. She can be reached at terry@lawterry.com.
SEPTEMBER/OCTOBER 2015
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ISTOCK@FLOWNAKSALA
OUR BAY
The Canada geese migration route, through the Chesapeake Bay region, heralds the autumn days ahead of shorter and crisper days. The migratory path is known as the Atlantic Flyway.
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I S Y O U R PAT I E N T F R U S T R AT E D W I T H
Chronic Pelvic Pain? Pelvic Congestion Syndrome (PCS) is a condition which is associated
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