M.D. Update Issue #68

THE BUSINESS MAGAZINE OF KENTUCKY PHYSICIANS AND HEALTHCARE ADMINISTRATORS February 2012

Pediatric Cardiologist Doesn’t Miss a Beat

An advocate for reducing Kentuckians risk factors for cardiac disease and improving access to life-saving care, Dr. Juan Villafañe is addressing the unique cardiac needs of children and adults in Kentucky.

Special SectioN

Volume 3, Number 2

Cardiology

Louisville Cardiologists Bring TAVR to KY Effects of Cleveland Clinic Affiliation Radial Cath Gaining in Popularity Hypothermia in ER Improves Chances of Survival

The Leader in Heart Care.

Saint Joseph Heart Institute is at the forefront of cardiovascular services in Kentucky, providing the most comprehensive care in the region.

But being the region’s leader in pioneering heart care isn’t new to us. Saint Joseph is the site of the state’s first heart cath in 1954 and central Kentucky’s first open-heart surgery in 1959. Our groundbreaking legacy also includes Lexington’s first heart catheterization lab, first balloon angioplasty, first Chest Pain Emergency Center and first da Vinci® heart surgery in Kentucky.

Using the most sophisticated equipment and techniques to diagnose and treat heart disease, our unmatched team of cardiologists, heart surgeons, nurses, and other healthcare professionals provides the latest treatments - from common problems to life-threatening conditions.

Yes, we’re proud of our many accomplishments. We want you to know why you can trust your heart to the veteran team and staff at the Saint Joseph Heart Institute who performed 951 open-heart procedures last year alone, as well as more than 18,700 procedures in our Cath and EP labs.

SaintJosephHeartInstitute.org

First Row: Second Row: Third Row:

Simply, your heart matters to us.

Richard Blake, MD; Richard DiNardo, DO; S. Michelle Morton, MD; John Thomas, MD; Donald Wakefield, MD; Naresh Anjur-Kapali, MD; Michael Schaeffer, MD; Steve Lin, MD; Jonathan Waltman, MD. John Sartini, MD; Hamid Mohammad-Zadeh, MD; David Cassidy, MD; Lon Keith, MD; William Jeffrey Schoen, MD; Sameh Lamiy, MD; Suresh Rekhraj, MD; Thomas Goff, MD; Nezar Falluji, MD; Dermot Halpin, MD. Michael Sekela, MD; David O’Reilly, MD; M. Jason Zimmerman, MD; Mark Tussey, MD; Richard Floyd, IV, MD; Robert Salley, MD; Theodore Wright, MD; Kiran Saraff, MD; Mubashir Qazi, MD; David Keedy, MD; Paul Randhawa, MD.

Contents Cover story

Pediatric Cardiologist Doesn’t Miss a beat

February 2012 Volume 3, Number 2

2 letters 3 HeadliNes 3 Jesse adams, md 4 dermot HalpiN, md 7 FiNaNce 8 law 11 iNsuraNce 12 pHysiciaN ViewpoiNt 12 sureNder saNdella, md 15 Gery tomassoNi, md 16 coordiNatioN oF care 18 coVer story 21 special sectioN cardioloGy 28 News 31 allied HealtH

An advocate for reducing Kentuckians’ risk factors for cardiac disease and improving access to life-saving care, Dr. Juan Villafañe is addressing the unique cardiac needs of children and adults in Kentucky. By Jennifer s. newton Page 18

31 audioloGy 32 arts

On the COver:

Dr. Juan villafañe of Children’s Heart specialists, PsC, of Louisville

sPeCiaL seCtion cardioloGy

21 Louisville Cardiologists bring tavr to Ky

24 radial Cath Gaining in Popularity

23 effects of Cleveland Clinic affiliation

26 hypothermia in er Improves Chances of Survival

February 2012 1

Letters volume 3, number 2 February 2012

froM tHe DesK of

Jennifer S. Newton, Editor-in-Chief

As the new Editor-in-Chief of M.D. UPDATE, I am thrilled to have the opportunity to work with the Kentucky healthcare community in a new capacity. With nearly 10 years of experience in healthcare media and marketing in Kentucky and southern Indiana, I hope that I am a familiar face to some of you. For those of you I haven’t yet met, I look forward to putting M.D. UPDATE to work for you.

As is evident in this issue, healthcare professionals are advocating every day for successful outcomes and improved access to topnotch care, utilizing innovative procedures and customized treatment plans. In this digital age, accurately and effectively communicating quality healthcare information can make a difference in the lives of patients, the practice of physicians, and the business of healthcare systems, which is why I believe M.D. UPDATE is the perfect platform to further our common goals.

As an independently owned media company, M.D. UPDATE, and its publishers Mentelle Media, LLC, strive to provide open, compelling, and positive healthcare media. For years, M.D. UPDATE has been building a community, encouraging discourse, and providing a forum to connect Doctors-to-Doctors and Business-to-Business. In 2012, we are launching a cross-platform, new media strategy to connect doctors and businesses with the informed healthcare consumer.

In addition, our digital assets and Integrated Physician Marketing program provide comprehensive, multimedia marketing tools to help you grow your business.

Contact us today to see what M.D. UPDATE can do for you. The marketplace is ever-changing, and reform is on the horizon. Together we can lead the conversation and put Kentucky’s healthcare issues front and center.

Jennifer S. Newton Editor-in-Chief jnewton@md-update.com

suBMit your Letter to tHe eDitor to Jennifer s. newton at Jnewton@MD-uPDate.CoM 2 M.D. uPDate

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GrapHic desiGNer

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HeaDLines

Jesse adams, iii, MD, Cardiologist, Leader, activist, Puzzle Master A multi-dimensional approach to cardiovascular care in Kentucky By giL Dunn Cardiologist Jesse Adams, III, MD, describes the relationships of professional and community organizations such as the American Academy of Cardiologists (ACC) and the American Heart Association (AHA) as “pieces of a puzzle.” It is that puzzle through which he is “committed to working collaboratively with family practice physicians, internists, OB/GYNs, hospitalists, ER doctors, business leaders, and anyone who has been touched by heart disease.” In Kentucky, that’s a pretty good-sized puzzle, which Adams approaches from a multidimensional perspective that includes local, state, and national issues.

Adams is the current governor-elect of the ACC, president of the Kentuckiana chapter of the AHA, and a member of Jewish Medical Center Cardiologists, the oldest cardiology group in Kentucky, founded in 1922. He and his partners provide a full range of cardiovascular care throughout the Greater Louisville metro area and in rural clinical areas such as LaGrange, Bardstown, Fort Knox, and southern Indiana.

Fitting the puzzle pieces together on a daily basis between patients and fellow cardiologists is what motivates Adams.

Steering a course through troubled waters, during a perfect storm, might be another metaphor to describe the challenges facing cardiologists today in Kentucky.

When wearing his American Heart Association president’s hat, Adams lists the well-known Kentucky challenges: a state that is a national leader in heart disease; some of the highest rates of adult and childhood obesity; high tobacco use; and a growing rate of tobacco use among adults under 30. “It appears that unless something changes,” says Adams, “we will have a generation that lives shorter lives than its parents, and that has never happened before.”

Persuading legislators to fund smoking cessation programs through Medicaid is one initiative that Adams is tackling. He strongly believes that the cost benefit of reducing tobacco use versus patient care from the heart and lung disease caused by

smoking is obvious. The challenge, he month’s cover story), Adams is dedicated acknowledges, is getting new state programs to the chapter’s mission to “advocate for funded in difficult economic times. He quality cardiovascular care through educapoints however to North Carolina, another tion, research, promotion, development, tobacco growing state that has state-funded and application of standards and guidelines tobacco-use programs, which have shown and to influence health care policy.”

“The current political process is arcane, dramatic improvements in reducing smoking. “If it can be done in North Carolina, to say the least,” says Adams. “An evoluwhy not in Kentucky?” asks Adams.”

As a practicing cardiologist, Adams sees first-hand how recent Medicare payment reductions have negatively impacted his practice, such as reducing reimbursements for Cardiolite stress tests, a standard diagnostic tool, as much as 25 to 40 percent. “Many of the cuts we’ve seen in the last few years under healthcare reform have focused specifically on what cardiologists do,” says Adams. “As a small business, when your income is reduced with no input from yourself, it’s tough.”

Patient care remains his primary concern, including addressing the risk factors of heart disease: diet, exercise, lifestyle, and genetics. He laments the “portion distortion” that has overtaken American eating habits while lifestyle has reduced physical activity.

Jesse adams, III, MD, a cardiologist with Jewish He encourages his patients to find a Medical Center Cardiologists, Jewish Physician time and place to be active, and assists Group, advocates that although daily patient them in developing a plan that meets care should be a physician’s primary concern, the needs of their individual situation. the current healthcare climate necessitates Walking is an easy and effective way to physicians getting involved on a larger scale. add exercise to a patient’s lifestyle, but for some of his more rural patients, it can be difficult to accomplish. He has tionary change will take place because the helped patients develop exercise routines current healthcare delivery system in the that include, “walking in the neighborhood, US is not sustainable.” This is why he around the airport, around the house, and actively participates in organized medicine and healthcare associations. His 360-degree even laps around the bedroom.” approach to healthcare, seeing the local, the Micro and the Macro state, and national implications of chalIssues of healthcare lenges and solutions, gives him a global Being governor-elect of the Kentucky ACC perspective that benefits his patients, colgives Adams the opportunity “to lead and leagues, and the community. “Daily, the serve his fellow cardiologists.” (His three- most important thing I do is take care of the year term as governor begins in March patient sitting in front of me,” says Adams.

2013.) Working on the Board of Directors “But on a larger scale, it is incumbent upon for current ACC Governor Juan Villafane, us to get involved to address the problems MD, FACC, (who is featured in this we all face.” ◆ February 2012 3

HeaDLines

new graft will repair formerly inoperable abdominal aortic aneurysms By giL Dunn leXiNGtoN A Central Kentucky cardiothoracic and vascular surgeon will be the first in Kentucky to provide a minimally invasive graft for the treatment of previously inoperable abdominal aortic aneurysms (AAA).

Dermot Halpin, MD, FACS, of Surgical Associates of Lexington, has been selected by Cook Medical of Bloomington, IN to be one of 50 surgeons nationwide – and the first in Kentucky – to insert the fenestrated endovascular graft for complex abdominal aneurysm repairs. FDA approval for the device, called the Zenith Flex AAA Endovascular Graft, is projected for spring of 2012.

According to Halpin, most patients who present with juxtarenal and suprarenal AAA’s are turned away because the complications from open abdominal surgery are too great. Elderly with pulmonary distress and coronary artery disease, these patients are poor candidates for open abdominal surgery. Furthermore, aneurysms juxtaposed or above the renal arteries make traditional stents un-useable.

Cook Medical’s Zenith Fenestrated Flex Graft will allow the surgeon to stent abdominal aortic aneurysms, at or near the renal arteries through a minimally invasive technique. “This is groundbreaking surgery

Dr. Dermot halpin of Surgical associates of Lexington.

in complex abdominal aortic aneurysm treatment,” says Halpin, who first became aware of the new technology after hearing about it from an Australian cardiovascular surgeon at a CME event in 2010.

Halpin then traveled to Australia to see the device in use. Accompanied by surgeons

Since urging SJh administration to commit to the hybrid surgical suite five years ago, halpin and his hybrid surgical team have performed hundreds of successful complex abdominal aortic surgeries. (L-r) bob Shanes, rn; Danny edwards, rt(r); Jennifer Grimes, rn; Josh Johnson, rt(r); Kristi Sherlock, rt(r); David hoffman, St. 4 M.D. uPDate

from Florida, Arkansas, and Ohio, including Roy C. Greenberg, MD, director of endovascular research at the Cleveland Clinic, the surgeons observed live and telesurgery implantations of the device. They also toured the Cook Medical plant in Brisbane, gaining hands on bench experience with implantations and observed the meticulous construction techniques used in customizing each graft from CT scans. That is when Halpin decided, “This is a technology we need in Kentucky and in the US.” Now, patients who require AAA repair can avoid the lengthy hospital stays, months of recuperation, renal failure and subsequent kidney dialysis that marred the open surgical approach.

Each Zenith Fenestrated Flex Graft is custom made for the individual patient’s anatomy allowing for the specific location and orientation of left and right renal arteries.

The graft requires precise placement by the surgeon who must align the renal arterial ports, which is achieved by pre-surgical CT mapping and angiography of the site.

Zenith Fenestrated Flex Grafts must be implanted in a hybrid radiology surgical suite such as the one at Saint Joseph Hospital in Lexington where Halpin has assembled his expert surgical team. “The 3D imaging is absolutely necessary to align the openings in the fenestrated graft to the renal arteries,” emphasizes Halpin. “We must be within millimeters to be successful.” Since urging SJH administration to commit to the hybrid surgical suite five years ago, Halpin and his hybrid surgical team have performed hundreds of successful complex abdominal aortic surgeries.

According to information provided by the manufacturer, a clinical study of 280 patients in the US compared patients treated with the Zenith AAA Endovascular Graft to patients with open abdominal surgery with highly favorable results. As in most minimally invasive

surgeons interested in using the Zenith flex fenestrated graft will face several challenges. to deal with these challenges, Halpin is creating an aortic Center of excellence in Kentucky. surgeries there was less blood loss, less trauma, shorter hospital stays and quicker returns to normal pre-operative function by the patients with the new graft.

Post operative surveillance is a key component of the treatment, says Halpin.

Although rare, there is potential for graft migration, so a follow-up CT scan after 6 months is required. Complications in the clinical study were less than 2%.

aortic Center for excellence

Surgeons interested in using the Zenith Flex Fenestrated graft will face several challenges.

First is the extensive pre-op planning for the

design and construction of the custom graft.

Second is the precision CT guided surgery technique needed to insert the graft then align and connect the arterial ports. Third is the post op surveillance regimen. To deal with these challenges, Halpin is creating an Aortic Center of Excellence (ACE) in Kentucky.

As medical director of the ACE, Halpin is developing protocols for the continued training of cardiothoracic and vascular surgeons in complex aortic pathology including abdominal aneurysms, pararenal and juxtarenal aneurysms, thoracoabdominal aneurysm and percutaneous aortic valve.

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The FDA will monitor the deployment of the Zenith Flex Fenestrated Graft at selected surgical sites. Through ACE, Halpin plans to have his surgical team at Saint Joseph Hospital participate in the FDA introductory training process so they can aid in the training of teams in other states. “The planning and insertion of the fenestrated grafts exceeds the skill level of most cardiothoracic surgeons without additional training,” he says.

By creating what Halpin calls “a superior care center for aortic patients,” ACE’s highly trained surgical team will focus on the treatment of aortic disorders. “I know the need is there and patients will be far better served.” ◆ learn more about this device online.

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finanCe

a wild ride to nowhere Last year was one of the most challenging ever for investors and advisors alike. In fact, a member of my peer council titled his year end letter a “Wild Ride to Nowhere” describing the near-breakeven performance of the S&P 500 index. The index started and ended the year at 1257, but took a roller coaster ride to get there. Dividends added only 2.2%. Stocks peaked at the end of April 2011 and then we saw a drop in early August of about 18% within a week.

The market see-sawed inside a trading range hitting its low point at the beginning of October. Astonishingly, the volatility for the S&P 500 was 1% or more up OR down per day for 81 trading days after the April high. On 35 days, the S&P 500 closed with a daily gain or loss of 2% or more most of that coming between August and November.

Perhaps we have seen a breakout since the index has moved back up to about where it was in July of last year. However, it is still about 2% below the peak. The rapid run up in stocks appears to be simply resulting from pent up demand for risk. It’s Risk On! in industry jargon, although you would not know it from the anemic daily volume which was about half that of the previous year. We need buying volume if this rally is to be sustained. January also ushered in Q4 earnings season, but they were hard to come by. Only 59% of companies in the S&P 500 met their estimates and profit margins fell to 8.23% in the fourth quarter compared to 8.95% for the second.

2011 was a better year for bonds than it was for stocks. The Risk Off! crowd took charge. Actually, it was the European and Japanese debt issues that took center stage.

More on Europe in a minute. The 10 year yield on U.S. Treasuries fell from 3.7% in February to a low of 1.7% before closing the year at 1.9%. Reminder: when yields fall, bond prices go up. The broad bond market, as measured by the Barclays Aggregate Bond Index, gained 7.8% for the year.

The big story throughout the year was Europe and its affect on the world’s econo-

mies and markets.

It is still the big story and headlines what could go wrong in an otherwise recovering year.

The news from Europe appears to have shifted

BY Scott neal from Greece to Italy and on to Portugal. The question about Greece is how it and its neighbors will deal with a default. There is much for all the rest of the world to learn from the handling of this situation. Can the remaining powers pick up the pieces? Will an implosion of Greek debt be contagious and spread to its neighbors, especially these two just mentioned?

Portugal sovereign bonds are paying above 14% at this writing and its leaders are denying that they are considering options for restructuring their debt. That is code for planning for default (otherwise known as bankruptcy).

Back to Greece. Some ask how the problem is contagious. If the first country to default issues new currency at what

GDP. Sound familiar? It should.

The Euro could present other problems.

There is legitimate concern about the adequacy of the European Stability Facility, its bailout fund. Credit downgrades are always a threat to sovereign governments. Italy’s refinancing of such a large amount of debt could be met with resistance.

Our greatest concern for the foreseeable future is that a default, probably Greek, will occur at about the same time as those Italian bonds come due. The result could be a run on banks throughout Europe. The bond market will not like that and interest rates will be bid up with devastating implications for growth and economic stability throughout the world.

A small crisis suddenly morphs into a catastrophe reminiscent of our own housing market / mortgage crisis that turned 2008 into a global recession.

The key is to remain nimble. We have said this before. Do not get sucked into rallies that could fall apart. But don’t be scared of the markets either. There is money to be made, but risk control is key.

On an optimistic note, our economist, Dr. Woody Brock just published a book American Gridlock, Commonsense Solutions to the Economic Crises. In it, he

the big story throughout the year was europe and its affect on the world’s economies and markets would amount to a 50% devaluation against the Euro, it will likely be given both debt forgiveness and a credit lifeline in order to avert civil strife. Other nations will likely follow suit resulting in serious economic disruption. This would be great a relief to a country dealing with the kind of austerity that they are facing. They are trying to slash government spending by 1.5% of their

paints solutions to America’s most perplexing problems. He tackles health care in a way that nobody else has touched. Read it and let’s have a discussion.

Scott neal is President of D. Scott neal, Inc. a fee-only financial planning and investment advisory firm. reach him at 800-344-9098 or via email at scott@dsneal.com ◆ February 2012 7

Law

on the enforcement radar Medicaid Audits and the 2012 OIG Work Plan

aDDitionaL text By MoLLy Lewis Unlike the Department of Health and Human Services Office of Inspector General (“OIG”) which publishes a Work Plan each year, the Department of Medicaid Services (“Medicaid”) generally does not publish guidance on the areas which it plans to investigate and/or audit. In fact, Medicaid’s website states … “Medicaid does not provide guidance on how companies should bill for services, but will direct you to applicable regulations. If you receive direction from staff about how to bill, the Department will not be bound by such instruction, unless it was given by a Director or Commissioner.”

Because the federal integrity programs are now moving through the process, Kentucky Medicaid providers are starting to see lots of audit activities. Unlike the OIG audits, we don’t know the precise subject matter of the Medicaid audits, but the process for appeal is outlined below in addition to the areas announced for review by the OIG. In addition to the audits that Medicaid contracts for under its Surveillance Utilization Review System (“SURS”), the Medicaid Integrity Program provides for another type of review and audit process that is overseen by CMS. Under the Medicaid Integrity Program, Review Medicaid Integrity Contractors or MIC’s have been contracted to analyze Medicaid claims data to identify aberrant claims and potential billing vulnerabilities through data mining of all paid Medicaid claims using the Medicaid Statistical Information System.

Once problem areas are determined, CMS vets the providers that have been identified with Medicaid and other state agencies and then provides leads to Audit MICS that actually perform post-payment audits of all types of Medicaid providers and identify overpayments. If, after an audit is performed, an overpayment is determined, then an audit report is prepared and forwarded to CMS and Medicaid. When CMS finalizes an audit report, the State must repay the Federal share of the overpayment to CMS within 60 calendar days, whether or not the State recovers, or seeks to 8 M.D. uPDate

recover the overpayment from the provider. The State is responsible for issuing the final audit report to the Provider and must follow its administrative process. The proBY Lisa english hinkle hikle vider may exercise whatever appeal or adjudication rights are available under state law when it seeks to collect the overpayment amount identified in the final audit report.

Medicaid appeal Process

Providers and particularly physicians should pay close attention to the correspondence that they may receive from the Department of Medicaid and its auditors and contractors. As the Medicaid Integrity Contractors gear up, physician practices are starting to see the results of audits as the Department of Medicaid starts the collection phase.

While the process is confusing, some of the letters contain very important deadlines and requests for information that if ignored, will be used against providers at later dates.

By regulation, Kentucky has established an important appeal process for challenging Medicaid audits in 907 KAR 1:671.

While the regulation is complicated and the processes and procedures vary based upon what type of audit is involved, there are several significant notices that providers and their staff should watch for. These include a Demand Letter or a letter that announces adjustment of rates. While the Demand letter is what most physician practices may receive, it should allow a provider to request a dispute resolution meeting with Medicaid. Importantly, the regulation requires that all issues that may later be appealed be addressed at this meeting. Usually, the meeting involves Medicaid staff and the Auditors. While the dispute resolution is described as informal, the regulation requires issues to be raised and evidence presented. After this meeting, if

a provider is not satisfied, the provider may proceed to an appeal before a hearing officer that is employed by the Cabinet for Health and Family Services. During this hearing, Medicaid carries the burden to establish an overpayment, which it usually does by calling the auditor as a witness and introducing the reports. If a provider is not successful at the hearing level, then an appeal may be taken to Franklin Circuit Court.

Importantly, no collection or recoupment efforts are to be undertaken during the time that a provider is challenging Medicaid’s demand for repayment. Given the current backup in processing appeals, these challenges can significantly benefit a provider by putting off repayment if an overpayment has been made. Please note, however, that Medicaid may take the position that an overpayment must be repaid within 60 days of the determination under the Health Care Reform Act regardless of the administrative appeal process.

the 2012 OIG Work Plan

The Office of Inspector General of the United States Department of Health and Human Services (OIG) released its Work Plan for fiscal year 2012. At the beginning of each fiscal year, the OIG issues its annual Work Plan, which describes current audit, enforcement and evaluation activities and those the agency plans to initiate in the upcoming year. The Work Plan also provides a general view of the OIG’s investigative, enforcement and compliance activities. Basically, the Work Plan informs health care providers what is on the OIG’s enforcement radar in the coming year.

Physicians should know what areas that the OIG is concerned about and review their own practices to ensure compliance with regulatory requirements. The following are some of the highlights for physicians from the FY 2012 Work Plan.

Physicians and Suppliers: Compliance with assignment rules

The OIG will review the extent to which providers comply with assignment rules and

determine to what extent beneficiaries are inappropriately billed in excess of amount allowed by Medicare. Physicians participating in the Medicare program agree to accept payment on an assignment for all items and services furnished to individuals enrolled in Medicare. Medicare considers the assignment as a written agreement between beneficiaries and their providers. By accepting assignment of their right to be reimbursed for services, providers agree not to bill beneficiaries for services and accept the amount Medicare pays. In other words, the provider accepts the amount Medicare pays as the full reimbursement. This means that providers may not bill beneficiaries in excess of the Medicare payment. Physicians can bill beneficiaries for the co-pay. Physicians should check their billing practices to assure that no balance billing is made for Medicare patients.

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Physician billing for Incidentto Services

The OIG plans to review physician billing for “incident-to” services to determine whether payment for such services had a higher error rate than that for non-incident-to services.

Medicare Part B pays for certain services billed by physicians that are performed by non-physicians incident to a physician office visit. A 2009 OIG review found that when Medicare reviewed physicians’ billings for more than 24 hours of services in a day, half of the services Medicare Part B paid claims for were not performed by a physician.

Medicare found that 21% of those services not performed by physicians were performed by unqualified personnel. The OIG believes that improper use of incident-to services can result in over-utilization and expose Medicare beneficiaries to care that does not meet professional standards of quality. Physicians should be aware that if they are billing for incident-to services that those services must be performed with the required level of supervision by proper personnel.

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Physicians’ Place of Service errors

The OIG will review physicians’ coding on Medicare Part B claims for services

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Law

performed in ambulatory surgical centers and hospital outpatient departments to determine if the claims were properly coded for place of service. Federal regulations

services were performed, with Medicare paying a higher amount when a service is performed in a non-clinical setting, such as a physician’s office, than when a service is

Medicare regulations provide for different levels of payments to physicians depending on the location where the services were performed. provide for different levels of payments to physicians depending on where services are performed. Medicare pays a physician a higher amount when a service is performed in a non-facility setting, such as a physician’s office, than it does when the service is performed in a hospital outpatient department or in an ambulatory surgical center.

Physicians should be mindful that coding is proper when the place of service is different than the office.

OIG plans to review physician coding of place of service on Medicare Part B claims for services performed in ambulatory surgical centers and hospital out-patient departments. Medicare regulations provide for different levels of payments to physicians depending on the location where the

10 M.D. uPDate

performed in a hospital out-patient department or, with certain exceptions, in an ambulatory surgical center.

Coding of evaluation and Management Services

The OIG plans to review evaluation and management (E & M) claims to identify trends in the coding of these services and to ensure that providers providing these services submit codes that accurately reflect the services provided. The OIG is focusing on 2009 claims as it found that Medicare $32 billion for E & M services, representing 19% of all Medicare Part B payments.

As always, physicians should be diligent in their coding and documentation so that documentation supports the level and type

of visit performed. This is an area that will be on the OIG’s radar screen for years to come as well.

Audit and enforcement activities are on the rise as the federal integrity programs are reaching the provider audit level. Even though we don’t know the areas for these audits, providers should become acquainted with the appeal process. For 2012, physicians should be mindful of the OIG’s areas of concern as outlined in the 2012 Work Plan and be prepared for potential audits and other enforcement activities in the coming year.

A complete copy of the OIG FY 2012 Work Plan can be downloaded from the OIG website at www.oig.hhs.gov and clicking on the link to publications.

Lisa english hinkle is a Partner of Mcbrayer, McGinnis, Leslie & Kirkland, PLLC. Ms. hinkle concentrates her practice area in health care law and is located in the firm’s Lexington office. She can be reached at lhinkle@mmlk. com or at (859) 231-8780.

Molly nicol Lewis is an associate of Mcbrayer, McGinnis, Leslie & Kirkland, PLLC. Ms. Lewis concentrates her practice in healthcare law and is located in the firm’s Lexington office. She can be reached at mlewis@mmlk. com or at (859) 231-8780. this article is intended as a summary of newly enacted federal law and does not constitute legal advice. ◆

insuranCe

Disability income insurance Decoded louisVille Specialists are a critical part of the world of medicine. Internists, pediatricians, neurologists, and other specialists are knowledgeable and able to read an x-ray, but may miss what the trained radiology specialist, who examines scores of such images each day, sees as a matter of course.

In the same respect, parents will most likely first visit the pediatrician when her child has a head ache, not a neurologist.

Why do individuals seek the assistance of specialist for their health needs, but not necessarily for their financial needs?

Of course most educated adults can spot the common cold and balance their own checking account, but when issues become more complex, why not seek the help of an expert in that field?

Disability income insurance is becoming increasingly vague, and the need for having an expert review is more important than ever.

Disability income insurance is becoming increasingly vague, and the need for having an expert review is more important than ever.

A trained professional who understands the legal language insurance companies employ and can spot the subtle details that can alter the entire nature of a policy is crucial in making an informed decision. Furthermore, an individual who is not beholden to a specific insurance company can typically determine the best possible plan for the client’s specific needs.

One specific aspect of disability insurance the can be unclear is the definition of Total Disability and Own Occupation. Many companies are stating Own Occupation

provisions when, in fact, it’s almost a misrepresentation. Insurance companies define Own Occupation in a myriad of ways:  Unable to perform substantial and material duties of regular occupation, meaning no matter what in this world one be qualified to do, if they cannot continue their current occupation in the same manner they did yesterday due to a disability, they would be viewed 100% disabled and collecting 100% of the benefit.  A loss of earnings of at least 20% and unable to perform duties.

This type of contract is very vague due to the words “perform duties”.

Are those the specific duties that one performs to earn a living? Are those the duties another individual in the same specialty may do to earn a living? Or are those any duties that a person with a medical degree is qualified to execute?  Unable to do material and substantial duties of own occupation and not gainfully employed. The words “gainfully employed” are scary. Who makes that call? Typically not the insured.  Unable to perform main duties of regular occupation and not employed in any occupation.

Again the words “any occupation” are vague. For example, one may not be able see patients in the practice, but may be able to manage the office. That’s an occupation, and the contract would not pay a benefit.  Unable to perform substantial and material duties of regular occupation for the first 12 months (or 24 months) of total disability, BY

Calvin r. rasey

thereafter not gainfully employed.

This is a great contract for one or two years, but after that period of time an individual may lose their benefits if they are able to work somewhere somehow.

The contracts that have included “not gainfully employed” within their definitions are now written Own Occupation without too much emphasis on that one little – very important – caveat. The companies that have changed their definitions imply that their responsibility is to insure one’s income, not occupation. Unfortunately, most disabled physicians know they need more than simply income coverage.

Interpretations of definitions are far more stringent when viewed by the claims and legal departments than by the marketing department and claim filing time is by far the worst time to debate with the claims personnel, and the legal department has no sympathy for “Well, I thought…”

Own Occupation is not the only clause in insurance policies that has an indistinct definition, phrases such as “NonCancelable, Guaranteed-Renewable” are finding new meaning in the small print of some disability plans. It is imperative that individuals seek the help of a disability specialist that is completely independent, representing only the client’s needs and interests. Someone who can analyze and interpret the often-confusing definitions employed by all of today’s disability insurance contracts.

A disability plan needs to fit one’s needs and occupation, and the plan needs to be 100% intact when and if the client is in need.

Calvin r. rasey is president of Physicians Financial Services II, LLC. you can reach him (502) 893-7001 or 1-800-928-8834.

“Securities Offered through Securities america, INC.*Member FINRA/SIPC • Calvin R. Rasey • Registered representative. advisory Services offered through Securities America Advisor’s, INC.• A registered Investment Advisor Calvin R. Rasey • Investment Advisor Representative.

Physicians Financial Services II, LLC and Securities america Companies are nOt unDer Common Ownership. representatives of Securities america do not offer tax or legal advice.” . ◆

February 2012 11

PHysiCian viewPoint

the History of invasive Cardiology stiff wires were placed inside flexible catheters with the use of a heat fixation method to permanently shape the catheter. At that time, these catheters were made to order and specifically shaped to match the size and shape of the subject.

So, initial Judkins catheters in l967 and l968 were manufactured in a limited number of fixed tips and shapes. These are still used currently.

By Dr. surenDer sanDeLLa New albaNy, iN. The history of medicine is an interesting field. When you look at some of the milestones in cardiology, you can go as far back as 1628 when William Harvey described blood circulation or l860 when Rene Laennec invented the stethoscope or l903 where the electrocardiograph was developed by Willem Einthoven. The first successful open heart surgery was done in l952 by John Lewis, an American surgeon, but it is invasive cardiology that has made some rapid strides in the recent past.

If you look at the birth of invasive cardiology, it started in l711 when Stephan Hales placed catheters in the right and left ventricle of a living horse and was furthered when Claude Bernard described cardiac physiology in l840. But it was not until Werner Forssman, in l929, created an incision in his own left antecubital vein, inserted a Foley catheter-like device into his venous system and under fluoroscopy into his right atrium, and walked up to the radiology department and documented the procedure by having a chest x-ray, that invasive cardiology materialized. Werner Forssmann did share the Nobel Prize in medicine in l956 with Andre Cournard, who did most of his work on hemodynamic measurements. Before Forssman placed a catheter in his own body, there was a fear that intrusion into the heart could be fatal, so he experimented on himself to prove that it could be done. He was consequently fired from his position and went on to become an urologist.

Fast forward from l927 to l958 when Charles Dotter began doing coronary anatomy visualization with sequential radiographs. It was Dr. Mason Sones, a pediatric cardiologist at Cleveland Clinic, who was doing an aortic root arteriography and accidentally entered the right coronary artery of a child and did a right coronary arteriogram with 30 cc’s of contrast injected, causing the patient to go into ventricular fibrillation. Luckily, sinus rhythm was successfully restored by precordial thump. Therefore, the 12 M.D. uPDate

the era of Interventional Cardiology

Surender Sandella, MD, FaCC, FFCaI, is a board-certified interventional cardiologist with Cardiovascular associates of Southern Indiana.

first selective coronary arteriogram was done accidentally. Until that time, it was believed that even a small amount of contrast injected into the coronaries could be fatal. Then in the 50s, they started doing cut-down procedures with soft tissue dissection until arteries and veins could be visualized and punctured, which was known as the Sones technique.

The percutaneous approach was developed by Sven-Ivar Seldinger in 1953.

The Seldinger technique was initially used mostly to do peripheral arteriograms and venograms until it was used to do coronaries in the early 60s by Ricketts and Abrams and by Judkins in l967.

Melvin Judkins in the late 60s was instrumental in developing the pre-shaped or specialized shaped catheters to reach the coronary arteries better and perform selective coronary arteriograms. His initial work involved shaping stiff wires and comparing these shapes to radiographs of the ascending aorta to determine if the shape appeared promising. Then these

It was not until l964 that Charles Dotter and Melvin Judkins used a balloon-tipped catheter to treat atherosclerotic vascular disease of the left superficial femoral artery of a patient. This use of balloontipped catheters started the era of interventional cardiology. Andreas Gruentzig performed the first successful percutaneous transluminal coronary angioplasty known as PTCA or PCI (which is percutaneous intervention) on a human being on September 16, 1977 at the University Hospital of Zurich. The results of the procedure were presented at an American Heart Association meeting two months later to a stunned audience of cardiologists. Subsequently, in the next three years, Gruentzig performed coronary angioplasties in 169 patients in Zurich while teaching the practice of coronary angioplasty to the field of budding interventional cardiologists. So, the PTCA procedures were initially performed on patients with stable coronary artery disease. Then afterwards, it was used in people who failed streptokinase for acute myocardial infarction.

In the early years of coronary angioplasty, there were a number of serious complications, like abrupt vessel closure after balloon angioplasty, which occurred in approximately one percent of the cases, often necessitating emergency bypass surgery. Vessel dissection was a frequent issue as a result of improper sizing of the balloon relative to the arterial diameter or the natu-

ral course of balloon angioplasty. Later, restenosis occurred in up to 50 percent of individuals who underwent PTCA, often causing a recurrence of symptoms and necessitating a repeat procedure.

Intra-Coronary Stents

It was not until l986 that the first successful intra-coronary stents were deployed. The first stents were self-expanding Wallstents.

Therefore, it quickly became a method to treat some of the complications due to PTCA, which decreased the incidence of emergency bypass from acute complications post-balloon angioplasty.

It was quickly realized that restenosis was significantly lower in individuals who received an intra-coronary stent when compared to those with just balloon angioplasty.

Some of the problems faced with initial stents were sub-acute thrombosis, which was as high as 3.7 percent at that time, and post-procedure bleeding, due to anticoagulation and anti-platelet agents used to prevent stent thrombosis.

Stent technology significantly improved from self-expanding to balloon-expanding Palmaz-Schatz intra-coronary stents, which were developed in l989. The initial results of Palmaz-Schatz stents were excellent compared with balloon angioplasty and had a significantly lower incidence of abrupt closure and peri-procedural myocardial infarction. Later, restenosis rates were also significantly improved with Palmaz-Schatz stents compared to balloon angioplasty, however, mortality remained unchanged compared to balloon angioplasty.

In the 90s, anti-platelet therapy with ticlopidine hydrochloride, and subsequently clopidogrel bisulfate, was proven to be better than warfarin in preventing subacute thrombosis. The optimal duration of anti-platelet therapy is still being debated in the 21st century.

There was significant development in technology and the skills required for doing percutaneous interventional cardiovascular procedures. This necessitated the institution of a specialized fellowship in interventional cardiology.

JOINING THE FIGHT AGAINST CHRONIC ILLNESS

YMCA OF CENTRAL KENTUCKY Chronic Health Initiatives Diabetes • Cancer • Heart • Obesity

Learn more at www.ymcaofcentralky.org February 2012 13

PHysiCian viewPoint

Drug-eluting Stent therapy

The Achilles heel for intracoronary stenting was in-stent restenosis due to neointimal hyperplasia from scar tissue. Even though there was a very high peri-procedural success rate with stenting, in-stent restenosis was between l5 and 30 percent and possibly higher in some sub-groups of individuals. Initially, they tried heparincoated Palmaz-Schatz stents, but it was not until the Cordis division of J&J developed the Cypher stent, a stent that would release the chemotherapeutic agent Sirolimus over time, that restenosis was overcome. Initial studies showed zero restenosis at six months, which led to the approval of the Cypher stent in 2002 in Europe and in 2003 in the United States.

There have been refinements on the stent

invasive cardiology was born in l711 when stephan Hales placed catheters in the right and left ventricle of a living horse. it would be another 275 years before the first successful intra-coronary stents were deployed. platform as well as the drug agent used.

So, in essence, there has been a significant improvement in invasive therapies in cardiology that have taken giant steps from selective coronary arteriography, to the initial development of open heart surgery and bypass, and subsequently to non-surgical ways of treating atherosclerotic coronary artery disease with PTCA – initially in l977,

Healing Growth 14 M.D. uPDate

then with stents beginning in the mid-80s, blossoming in the 90s, and now with drugeluting stents in 2000. I personally feel like it is an exciting time to be in the field of cardiology because there have been significant improvements in the care of cardiac patients right in front of my eyes, whether it is in invasive therapies or non-invasive therapy with medical management. ◆

winnerÊofÊth eÊ20 12 landscaperÊofÊth eÊ year award

PHysiCian viewPoint

Lexington Cardiac research foundation Plays Key role in Development of new Cardiovascular treatments

By Dr. gery toMassoni Research is an essential scientific tool to evaluate the latest, most advanced therapeutic and diagnostic methods. Because heart disease is so prevalent in central and southeastern Kentucky, the Lexington Cardiac Research Foundation (LCRF) at Central Baptist Hospital (CBH) plays a significant role in the development of new cardiovascular (CV) treatments.

While it is unusual for a non-academic hospital to conduct research, LCRF performs cardiovascular research at a high level. As a result, your patients have access to leadingedge treatments they would otherwise have to travel long distances to receive from academic medical venues.

The Unify Quadra™ cardiac resynchronization therapy (CRT) defibrillator and Quartet™ Left Ventricular Quadripolar Pacing Lead is an example of this type of treatment. It is the latest in cardiac pacing technology. CRT devices are designed to optimize the heart’s pumping function and help the heart perform in its most natural state by synchronizing the left and right ventricles of the heart though timed electrical impulses.

The Quartet lead help solves some of the present day problems both during and following the CRT implant procedure. This is accomplished by the presence of four electrodes on a single lead instead of the current industry standard of two electrodes. The additional electrodes provide more ways for a physician to configure an optimal pacing strategy. Having four electrodes provides more options to effectively regulate the patient’s heartbeat.

Due to differences in patient anatomy or results that can’t be foreseen during the procedure, complications can arise after placing the lead. One example of a pacing complication is a high pacing threshold.

Patients who already have scar tissue formed in the heart may require very high energy delivery from their CRT device in order to capture the left ventricle. The higher energy demands shorten the lifespan of the battery.

A second complication is the unintentional

leXiNGtoN

Gery tomassoni, MD, is a cardiologist and electrophysiologist with Lexington Cardiology at Central baptist.

stimulation of the diaphragm or the heart’s phrenic nerve. Phrenic nerve stimulation (PNS) can result in significant pain to the patient.

Unfortunately, approximately 10 percent of patients experience pacing-related lead complications with 5 percent requiring a second surgical procedure. The Quartet lead can help avoid these complications and reduce the need for reoperation by providing additional pacing configurations.

Therefore, patients receiving the device can feel more confident that their procedure will be successful.

This pacing system is expected to become an industry standard as a result of its ability to reduce the impact of these complications because of the health and economic benefits it can provide.

The Watchman® device trial is another example of a new CV treatment. Stroke is a complicating factor for patients with atrial fibrillation (AF), an abnormal heart rhythm. Most strokes associated with

AF are thought to be due to migration of blood clots that form in the left atrial appendage (LAA).

When the atrium loses its ability to contract, blood pools in the appendage, providing an environment to clot.

These clots can dislodge and migrate through the bloodstream up to the brain causing a stroke.

The Watchman device is a mechanical based solution designed to close off the LAA. The device is introduced into the heart via a flexible tube (catheter) through a vein in the groin.

It is designed to seal off the LAA thus reducing the risk of stroke and eliminating the use of blood thinning medications such as warfarin. The results of a randomized study comparing the Watchman device to long term warfarin therapy (PROTECT AF) were published in The Lancet in August 2009 and Circulation in January 2011. The study found in over 1065 patient years of follow up that the combined rate of stroke and cardiovascular death was 3.0 per 100 patient years in the device group vs 4.9 per 100 patient years in the warfarin group, resulting in a reduction of 38% in the Watchman group. As for safety of the device, as expected with a device vs drug trial, there was an up front risk associated with the procedure (7.4 vs 4.4 per 100 patient years with a relative risk of 1.69 for the device patients). Central Baptist was a site in the PROTECT AF trial and is currently participating in the second confirmatory PREVAIL Study.

Dr. Gery tomassoni is medical director of Lexington Cardiac research Foundation. If you are interested in a study for one of your patients, contact LCrF at (859) 260-4489. ◆ February 2012 15

CoorDination of Care

Heart Centers Help Patients Heal

By Megan switZer leXiNGtoN The health care system has become increasingly more complex and unfortunately the patient is left trying to find their way through the labyrinth of physicians, tests, procedures and hospitals. At Central Baptist Hospital, two centers, The Center for Atrial Fibrillation and Heart Rhythm Disorders and the Heart and Valve Center, have been designed to make the patient’s life easier and ultimately improve coordination of care between providers, patients and families.

Affecting millions of people in the U.S. alone, atrial fibrilla-

tions, the most sophisticated devices as well as the latest in minimally invasive procedures are available. Unique to the center is the A Fib coordinator, Lynn Mattingly, RN, who educates the patient and advises them on treatment options, arranges any necessary testing. Initial appointments typically last at least an hour allowing for ample time for in-depth education, and to assuage the patient’s fears. Mattingly reports that at least one

at Central Baptist Hospital of Lexington, new heart care centers have emerged to improve coordination of care between providers, patients, and families. patient told her they “had a real opportunity to discuss my concerns and questions about my condition.”

After every appointment, Mattingly communicates to the patient’s primary cardiologist and or primary care physician on the plan of care. She often facilitates getting a patient in to see one of the electrophysiologists sooner when their condition warrants. The care coordination the center is able to provide is critical when multiple providers are involved and to avoid wasteful duplication of diagnostic testing, perilous polypharmacy and confusion about conflicting care plans.

While coronary artery bypass grafting (CABG) volumes have decreased over the last 5 years due to drug-eluting stents, valve procedures have increased significantly.

What used to be considered “traditional” surgery can now be done with minimally invasive, robotic and percutaneous tech-

a Fib coordinator Lynn Mattingly, rn, (left) and Liza Crall, MSn, aPrn, cardiothoracic nurse navigator.

tion (A Fib) is a disorder of growing concern within the medical community. A Fib is not a benign disease. It doubles the risk of death in both men and women, with much of this excess mortality attributable to a significant risk of stroke. Treatment of atrial fib is not the most straightforward proposition with several treatment options available, each involving some form of medical management with antiarrhythmic or anticoagulation drug therapy.

The A Fib Center serves as a comprehensive source for the management of atrial fibrillation and other abnormal heart rhythms by providing state of the art options in the diagnosis and therapy of these disorders. As a center for research and clinical practice, the newest medica16 M.D. uPDate

niques. The rising acuity of cardiac surgical patients has played a significant and challenging role. Indicative of this phenomenon is the surging incidence of the many comorbidities among CABG patients in recent years, including diabetes, renal insufficiency, cerebrovascular and lung disease.

In the fall of 2011, the Heart and Valve Center at Central Baptist was opened as one strategy to deal with the complexity of care delivery. Utilization of a nurse navigator role has been key tenet of care in the center.

Liza Crall, MSN, APRN, cardiothoracic nurse navigator, is a nurse practitioner who follows all cardiac surgery patients through the entire experience from the point of entry through follow-up care and continued care. She consults with the patient and helps to explain the different surgical techniques and what the surgeon has decided will be the most beneficial to the patient. The nurse navigator role coordinates care throughout the treatment process by rounding daily to facilitate care, providing information to the patient and family, facilitating decision-making. “This was an enjoyable experience!” said a patient and his wife who recently visited the center for their cardiac surgery pre-admission care visit. By supporting and guiding the patient, she eases the stress and helps with questions and education after diagnosis and throughout treatment. “It is very fulfilling to know we can make such an impact on a patients and their family’s life,” says Crall.

Megan Switzer, MSn, aPrn, FnP-bC, CCPC, works with Central baptist’s Cardiac network development. you can reach the a Fib Clinic by calling (859) 260-aFIb [2342]; reach the heart and valve Center by calling (859) 260-CabG [2224]. ◆

Feel better.

????????

when it comes to advanced cardiac treatment we have everything your heart could desire.

Baptist Health provides access to some of the region’s most advanced specialists, therapies and treatments.

Some of the most advanced cardiac technology and techniques are just a heartbeat away at Baptist Hospital East.

Radial artery catheterization, a procedure available at fewer than 10 percent of the hospitals in the country, allows cardiologists to perform catheterizations through a tiny incision in the wrist, resulting in less pain and shorter recovery times.

© 2012 Baptist Healthcare System, Inc. / Member, Baptist Healthcare System

In Baptist East’s Chest Pain Center, patients with symptoms can be seen directly by an experienced cardiologist, to get to the heart of their problem more quickly.

BAPTIST HOSPITAL EAST

And when open heart surgery is needed, Baptist’s cardiothoracic surgeons are some of the most respected in the region. For more information, visit baptisthealthky.com or call (502) 897-8131 for a physician referral.

CARDIAC CARE baptisthealthky.com

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BAPTIST HOSPITAL NORTHEAST

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BAPTIST EASTPOINT

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BAPTIST URGENT CARE

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BAPTIST MEDICAL ASSOCIATES February 2012 17

Cover Story

Pediatric Cardiologist Doesn’t Miss a Beat

An advocate for reducing Kentuckians’ risk factors for cardiac disease and improving access to life-saving care, Dr. Juan Villafañe is addressing the unique cardiac needs of children and adults in Kentucky.

By Jennifer S. newton When asked about the forms of electrophysiological congenital conditions he sees in his practice as a pediatric cardiologist, Juan Villafañe, MD, FACC, FHRS-CCDS, FAAP, describes one condition – supraventricular tachycardia (SVT) – as a diagnosis where kids’ heartbeats can reach over 300 beats per minute. When you hear about the depth and breadth of Villafañe’s work, you cannot help but equate his dedication and spirit with an outpacing heart.

Villafañe began practicing pediatric cardiology in Kentucky in 1986. He specializes in congenital heart Dr. Villafañe specializes in pediatric defects, non-invasive cardiac electrophysiology, and paceelectrophysiology and helps people of makers. His practice, Children’s Heart Specialists, PSC, any age with congenital heart defects. services newborns, children, adolescents, young adults, LOUISVILLE

18 M.D. UpDate

Complex congenital heart defects, which involve structural abnormalities to the valves, arteries, or veins, can be detected using echocardiography.

and a selected group of adults with pacemakers and complex congenital heart defects with locations in downtown Louisville, Elizabethtown, Bardstown, Shelbyville, Danville, and LaGrange, Kentucky.

A professor of Pediatrics for the University of Kentucky, Villafañe’s professional pursuits also include his election as the governor of the American College of Cardiology (ACC) in Kentucky, from 2010 to 2013. Comprised of 39,000 members across the United States, the ACC’s web site describes the organization as being “dedicated to enhancing the lives of cardiovascular patients through continuous quality improvement, patient-centered care, payment innovation, and professionalism,” a message Villafañe seems to take to heart. The ACC is overseen by a Board of Governors, like Villafañe, who are each elected to a three-year term and serve as liaisons between the local community and national leadership. In his role as governor, Villafañe has worked not only to improve treatment options for cardiac patients but also to advocate for prevention issues, which have a profound effect on patient outcomes, particularly in Kentucky where obesity and tobacco-use are high.

a COaLItION OF LIKeMINDeD aDVOCateS

In 2010, Villafañe formed a coalition of 12 major organizations to address the issues of childhood obesity and tobacco use. By bringing together representatives from the American Heart Association (AHA), the American Academy of Pediatrics (AAP), and the American Medical Association, Villafañe initiated an alliance on two of Kentucky’s largest risk factors for cardiovascular disease. The group now includes representatives from the ACC, AHA, AAP, Department of Health, Greater Louisville Medical Society, University of Louisville, and University of Kentucky, among others. They meet regularly to advocate for children with childhood obesity, and now, for the second year, Villafañe and the ACC have teamed up with the AHA to meet with legislators in Frankfort and lobby for a smoke-free Kentucky. “We have an epidemic of obesity,” says Villafañe, citing

Kentucky’s rate of childhood obesity as one of the highest in the nation. “And we have a big problem with tobacco. We need to work on it together and solve this problem.”

CONGeNItaL Heart DeFeCtS

The March of Dimes estimates that annually in the United States, 35,000 infants, or 1 in every 125, are born with heart defects. In fact, congenital heart defects (CHD) are the number one cause of birth defect-related deaths in infants.

Complex congenital heart defects involve structural abnormalities to the valves, arteries, or veins supplying the heart.

Complex conditions can include hypoplastic left ventricle, where the main pumping chamber is rudimentary; ventricular septal defects (VSD), where a large hole in the ventricle is often seen with other anomalies such as obstructive, missing, or leaky valves;

out specialized providers. “Fifteen years ago, many of those complex congenital heart kids did not survive, depending on the etiology of their disease,” says Villafañe. He cites the example of hypoplastic left heart syndrome in which two-thirds of patients now survive into adulthood. “Now there are over one million adults that survived out of childhood, and they need follow-up. The problem is so big there are now more adults with congenital heart defects than children.”

Specialized centers now exist in larger cities around the U.S. focusing solely on complex congenital heart diagnoses, but in smaller states and rural areas, the only option for these adult patients is to be followed by pediatric cardiologists. The adverse result is that 50 percent of adults with CHD do not get the follow-up they need and are therefore at greater risk for sudden death, heart failure, or severe disability.

with advancements in complex congenital heart defect care, we are now facing a dilemma. there are over one million adult survivors of childhood CHD that need specialized providers to manage their follow-up care. an atrioventricular (AV) canal defect, a large hole in the middle of the heart; or tetralogy of Fallot, which not only indicates a large hole but also obstructed vessels or valves.

While complex heart defects do typically require surgery, advances in treatment options for CHD have improved survival rates. Unfortunately this has created an entirely new dilemma – a population with-

In fact, Villafañe identifies the problem as so crucial, he and a colleague from Columbus, Ohio, are presenting the issue of improving follow-up care for adults with CHD to the Board of Governors of the ACC at an upcoming leadership conference. Their proposal is a national initiative involving partnering the Adult Congenital Heart Association (ACHA), an organization FebrUary 2012 19

Cover Story

of adult and child patients, with physicians interested in helping them. “We’re going to implement a new plan to improve follow-up care for adults with CHD but also to educate both general cardiologists and patients.

We need to create more awareness,” says Villafañe. “In general, throughout the US, there are many cardiologists who for whatever reason don’t follow them [adult CHD patients] anymore.” The program is proposed to begin with five pilot states.

result in an “orchestra” of arrhythmias.

arrhythmias

Referenced at the beginning of this article, tachycardia or SVT in young children is treated with medication in most cases until the children are old enough to undergo endo-

to treat them is beta-blockers. With them we can reduce the risk by more than half,” says Villafañe. Patients with long QT syndrome are at risk for torsades de pointes, a polymorphic ventricular tachycardia much like v-fib, which can cause fainting, seizures, or death.

According to Villafañe, he does not see a lot of

CarDIaC eLeCtrOpHySIOLOGy

In addition to congenital heart defects, Villafañe also specializes in electrophysiology.

“Many patients with complex congenital heart defects can also have arrhythmias, where the heart is not beating regularly,” says Villafañe.

The electrical conduction system of the heart includes a natural pacemaker called the sinus node, which controls the contractions and pumping of the heart by transmitting electrical signals through the atrial chambers to the atrioventricular (AV) node and from there to the ventricles.

Cardiac electrophysiology deals with the disorders of the heart’s electrical conduction system. “What we see the most of in kids are called extra heartbeats or premature beats,” says Villafañe. As common as onein-four children, if the heart is normal, they are not considered complex cases. Villafañe’s practice includes a pacemaker, defibrillator, and arrhythmia clinic to address the needs of his complex heart patients.

pacemakers

Complex conditions necessitating an artificial pacemaker can include failure of the sinus node, typically occurring in children who have undergone open heart surgery and sustained damage to the sinus node; congenital AV block, which involves the inability of the sinus node to communicate with the AV node and carries a two percent incidence of sudden death; and surgeryinduced AV block.

Another form of congenital electrophysiological defect Villafañe sees in his practice includes complex heart problems associated with many or absent spleen(s), which may 20 M.D. UpDate

Children’s Heart Specialists staff (l-r) alex rivera, bilingual front desk assistant; Christy Chandler, eKG tech; Juan Villafañe, MD, Faap, FaCC; Debbie Metz, executive secretary; Melissa Cushman, administrative services; angela robinson, medical assistant; and Donielle Gregory, rCS, cardiac sonographer.

cardial radiofrequency ablation, which is successful in 90 percent of cases. On the other hand, ventricular tachycardia (VT) is quite serious. “The incidence of sudden death, depending on etiology of the VT, is anywhere between one and six percent, which is pretty high,” says Villafañe. In some cases VT can degenerate to ventricular fibrillation (v-fib) and result in death. While this is seen often in adults with cardiac disease, it is rarer in children. Bradyarrhythmia refers to a slower than normal heart rate and can induce fainting from a lack of optimal blood flow to the brain.

Defibrillators

Long QT syndrome is a congenital abnormality pertaining to the relaxation of the heart, and depending on the subtype of the syndrome, has a mortality rate of 0.3 to one percent per year in children. “What we use

defibrillators in children, but they are sometimes used in risky cases of long QT syndrome.

Short QT syndrome can also produce sudden death in children. “I was the first to publish a report on short QT syndrome in kids because it’s very rare,” attributes Villafañe. He is currently writing an article on an international study of 22 young patients with short QT syndrome, nine of whom have defibrillators, in centers across the Netherlands, France, Italy, Canada, and the US. Additionally, catecholaminergic polymorphic ventricular tachycardia and Brugada syndrome are syndromes that are rare in children but can induce sudden cardiac death.

However, despite all the clinics and medical opportunities Villafañe provides for his patients, he believes that is only part of his job. “I think we have to advocate for our patients, whether they are one-year-old or 80-years-old, and we need to get together and fight for them,” he says. ◆

SPeCiAl SeCtion  CArDiology

transcatherer Aortic valve replacement

Jewish Hospital and UofL Physicians Bring Procedure to Kentucky By JEnnIfEr S. nEwtOn LOUISVILLE Physicians at Jewish Hospital are changing the prognosis for Kentuckians with severe aortic stenosis. Primarily a disease of the elderly, cardiothoracic surgeon Matthew Williams, MD, University Cardiothoracic Surgical Associates and assistant professor Thoracic and Cardiovascular Surgery, UofL, estimates, “The rate of treatment for patients with severe aortic stenosis in the U.S. is only about 50 percent,” leaving half of patients with no treatment options and the worst possible outcome. However a new procedure, transcatheter aortic-valve replacement (TAVR), is providing an option for patients deemed inoperable.

Williams and interventional cardiologists Michael Flaherty, MD, PhD, and Naresh Solankhi, MD, performed the state’s first TAVR on December 21, 2011. In the procedure, a transfemoral approach is used to feed a wire from the groin to the aorta and across the aortic valve using fluoroscopy. A balloon is used to open the valve, and then a second balloon, with a new bovine pericardial valve mounted on the outside, is passed into the diseased valve and precisely positioned using fluoroscopy and echocardiography. The balloon is inflated, and the new valve is operational. “Patients are off the ventilator within an hour of the procedure and can go home basically on the third day,” says Solankhi, who is with Medical Center Cardiologists (part of Jewish Physician Group). “There is really no blood transfusion, no opening of the chest, no major surgery, no anesthesia, just some sedation and ventilation, and patients will ambulate six hours after the procedure.”

The procedure is done in a catheterization lab that functions as a hybrid operating room in case physicians need to convert to an open procedure.

The physicians agree that bringing the technology to Kentucky has been a team effort between cardiology and cardiothoracic surgery. Flaherty, director of Structural Cardiac Interventions and ResearchDivision of Cardiology, UofL, initiated the structural interventions program at UofL and Jewish Hospital after training at Johns Hopkins and credits the program’s existence

Interventional cardiologists Naresh Solankhi, MD, cardiothoracic surgeon Matthew Williams, MD, and interventional cardiologists Michael Flaherty, MD, phD, performed the state’s first transcatheter aortic-valve replacement (taVr) late last year.

as an asset in partnering with device-maker Edwards Lifesciences. Solankhi trained at St. Paul’s Hospital in Vancouver, British Columbia, under TAVR pioneer John Webb, MD. Solankhi also cites a large volume of patients and Jewish Hospital’s capability for complex procedures as deciding factors in pursuing this technology.

Though Flaherty and Solankhi are more practiced in percutaneous procedures, Williams is a critical component. “In the early stages, Edwards Lifesciences requires us to do surgical cut-downs to expose the vessel used in the leg so as to prevent any early complications with our transfemoral

approach,” says Flaherty. So, a surgeon is integral in exposing the vessel, but the goal is for all three physicians to be interchangeable. “Our hope is that it will always be a team approach. When you do these, you find out how important it is to have several disciplines in the room,” says Flaherty.

The Edwards SAPIEN transcatheter aortic valve is the first device of its kind to be approved in the U.S. for commercial application in cases where patients are deemed inoperable or are at extreme risk for traditional open surgery. “There is also currently an FDA-approved trial of lower risk patients, who are operable but still a relatively high surgical risk (with a predicted mortality rate of four percent or higher), comparing the device to open surgery,” says Williams. In addition, there is a completed

Using the balloon-expandable edwards SapIeN aortic valve shown here, physicians at Jewish Hospital can now treat patients with severe aortic stenosis who are not eligible for surgical valve replacement.

FebrUary 2012 21

CArDiology trial that has been published in the New England Journal of Medicine and is awaiting FDA judgment, comparing the device to high risk open patients, which is different from the extreme risk already approved.

Advantages of TAVR include less physiological insult to the patient and a reduction in recovery time from six weeks to two, but there are drawbacks as well. “There appears to be a slightly higher risk of stroke from the first two trials from what we think is debris being knocked off the valve and going into the brain, which may limit its widespread application,” explains Williams. “The other main concern is that the seal between the new valve and the old valve isn’t perfect all the time, so the rate of leakage around the valve is slightly higher than open surgery.”

While the doctors agree that the future holds more widespread application of the technique, their visions are slightly different. According to Flaherty, a PARTNERCommunity Supported Agriculture (CSA) members receive 22 weeks of the finest, freshest foods grown in Central Kentucky. Over 300 acres certified organic.

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tAvr provides access to a technology that was not available before. for a huge gap of patients with severe aortic stenosis that were likely dying because of lack of treatment, the procedure represents an option that will lead to better treatment and better health for the people of Kentucky.

II trial will offer a transapical approach option, allowing physicians to do the same procedure through the apex of the heart.

The PARTNER-II trial is also evaluating a newer, smaller iteration of the device, the Edwards SAPIEN XT™. “What I see in the future is the device is going to get smaller and smaller and be much more useable by other operators, such that we have widespread use in the future, like in the case of coronary stents,” says Flaherty. Williams predicts a more limited market penetration of 30 to 40 percent in 10 years because anatomically some patients will not fit the requirements and many have comorbidities that require other procedures to be done at the time of surgery. Solankhi foresees implications for other diagnoses. “In the future, there are techniques that will allow us to treat the mitral valve, another common heart condition, in that same way, but we are a long way from that,” he says. ◆

SPeCiAl SeCtion  CArDiology

fulfilling a Promise

One year ago, Pikeville Medical Center announced an affiliation with Cleveland Clinic’s Heart Surgery Program. Today, PMC cardiologist Bill Harris and cardiothoracic and vascular surgeon Dennis Havens tell us how patients have benefited from the deal. By MEgan C. SMIth PIKEVILLE It was just one year ago when says. “The extremely complex cases can be one second – means a great scan can be Pikeville Medical Center president and sent to Cleveland in a short period of time, achieved in less time than one heartbeat.

CEO Walter E. May announced the hospi- when necessary, a move that is literally a It can perform full body scans in just 10 tal’s affiliation with Cleveland Clinic’s Heart phone call away.” seconds.

Surgery Program. Heralded as an opportuPMC interventional cardiologist Bill nity to bring groundbreaking advancements On the Cutting edge of Harris points out that “the 320 slice CT scanner allows Pikeville to conduct many in cardiac care to the region, the affiliation technology promised an exchange of best practices According to PMC administrators, the hos- more cardiac CT studies than before, since among the centers’ physicians and staff, as pital will soon be the only one in the the imaging and 3D reconstruction is lightwell as greater access to high quality care world with two 320 slice CT scanners years better than the 64 slice CT scanner.”

Continuing its commitment to employ models developed by the Cleveland Clinic. on the same campus. These scanners are technology for the improvement of patient PMC cardiothoracic and vascular sur- the fastest and most accurate available. geon Dennis Havens, MD, says the affiliation has delivered on all of its promises.

“Our affiliation with the Cleveland Clinic has brought some exciting new dimensions to our service line,” he says.

The affiliation has sent more than 25 PMC nursing staff to Cleveland for training, where nurses from OR, ICU, and cardio Currently, PMC has installed one Toshiba care in an environment of increasing volumes, thoracic vascular unit (CTVU) experienced Aquilion One 320 slice CT scanner inside PMC has opened a new convertible electrothe way Cleveland Clinic nurses manage large the Emergency Department. The second physiology (EP) lab using Toshiba EP mapvolumes of complex cases. Then, they brought scanner is being installed in the hospital’s ping systems. The new EP lab will be led by that same level of care back to Pikeville.

Michael Antimisiaris, MD, cardiologist and Radiology Department.

The affiliation means that PMC now has The new scanner puts critical infor- electrophysiologist, and will help reduce the access to Cleveland’s protocols, which Havens mation in the hands of physicians faster incidence of stroke and heart failure among says better standardizes the patient care. than ever before. Imaging an entire patients with atrial fibrillation, or Afib.

Since the affiliation began, PMC has organ in a single rotation – that’s less than In addition to the Cleveland Clinic affiliation and acquisition of the latest technoloadopted an enhanced time-out process gies, Harris points out increased manpower called the Pre-Closing Checklist. “It has and growing facilities have attributed to been found to be very concise and exceedPikeville’s success in the past year. The ingly thorough in ensuring patient safeheart team has also welcomed three new ty,” says Havens. physicians: cardiologist Thomas Helton, Currently, PMC’s Heart Institute is MD, formerly with the Cleveland Clinic; growing about 20% annually, and cardiologist Denzil Harris, MD; and Havens believes the growth will vascular surgeon James Poliquin, MD, also continue over the next several formerly with the Cleveland Clinic. years. “Through our affiliation The Heart Institute has also affiliwith Cleveland Clinic, and ated with other hospitals throughthe addition of new service out the region. lines and staff, PMC has Currently, Pikeville Medical strengthened our ability Center’s Heart Institute physicians to care for complex carhave offices located in Pikeville, diac patients, eliminating Dr. bill Harris, interventional cardiologist, and Dr. Dennis Havens, Paintsville, Whitesburg, Hazard, South the need for travel to surcardiothoracic and vascular surgeon, reflect on developments since Williamson, and Grundy, Virginia. ◆ rounding referral areas,” he pMC’s affiliation with the Cleveland Clinic.

the affiliation means that PMC has access to Cleveland’s protocols, such as an enhanced time-out process called a Pre-Closing Checklist, that better standardizes patient care.

FebrUary 2012 23

SPeCiAl SeCtion  CArDiology

it’s all in the wrist

Louisville Cardiology Group Embraces Radial Artery Catheterization to Decrease Risk of Complications by JeNNIFer S. NeWtON

Interventional cardiologist William C. Dillon, MD, with Louisville Cardiology Group, part of Baptist Medical Associates, estimates that 90 percent of cardiac catheterizations performed in the U.S. today are executed percutaneously through the femoral artery. “Initially all heart catheterizations were done in the brachial artery in the elbow and done by cut-down, which was pretty aggressive,” says Dillon. By the middle 1990s, transfemoral cardiac catheterizations were the standard.

Dillon and two of his Louisville Cardiology Group partners, Thomas Tu, MD, and Rebecca McFarland, MD, are offering a further evolution of the procedure – radial artery catheterizations – which emerged from an effort to try and reduce bleeding and complications from transfemoral procedures. “If you look at the most common problem after a heart cath, just a diagnostic cath, it’s usually a vascular problem or a bleeding problem,” says Dillon. “For angioplasty, by far, the biggest risk is bleeding afterwards.”

After a transfemoral coronary procedure, a nurse must hold pressure on the leg to stem the bleeding, and the patient must lie flat for a couple of hours. With percutaneous coronary interventions, the patient must lie flat for up to six hours.

Angioplasty patients are typically on anticoagulants, which intensify bleeding problems. Additionally, the increasing age of patients and obesity are contributing factors to the use of blood thinners and more complications. “What’s become obvious is that bleeding is a surrogate for bad things to happen to that patient, including dying, being in the hospital longer, and much more increased morbidity,” says Dillon. Blood transfusions are also an indicator of a poor prognosis.

LOUISVILLE

24 M.D. UpDate

abOVe: bleeding

complications are reduced by an average of 70 percent with radial artery catheterization vs. femoral artery catheterization.

LeFt: William C. Dillon, MD, Interventional Cardiologist with Louisville Cardiology Group

advantages of radial artery Catheterization

The anatomical advantages of the transradial technique are simple. The radial artery

is extremely superficial and easy to compress due to its position in front of the radius bone, such that compression can be accomplished with one finger. One of the biggest patient satisfaction benefits is that patients are able to get up almost immediately.

From a medical perspective, bleeding complications or the need for blood vessel repair are decreased by 70 percent on average.

According to Beth Mylor, manager of Louisville Cardiology Group’s outpatient cath lab, they began the process of incorporating transradial procedures about two years ago and have done approximately 400 in total. “We carefully selected patients at first to make sure arteries were brisk enough and could handle catheters and that the patient was onboard with us doing something new,” says Mylor. Dillon says he and Tu made the decision to “go all in” and do every patient possible utilizing the

radial approach. “We’ve had a dramatic reduction in access site problems where we go in … and a dramatic reduction in bleeding problems,” he says. “Patients unanimously would prefer to have it in the arm as opposed to the leg, the ones who’ve had catheterization through both access routes, because it’s not very painful at all,” says Dillon.

What It takes

Utilizing the radial artery is a little more difficult for the operator. Smaller vessels and more time spent getting into the vessel are some of the challenges. The only definitive contraindication for the procedure is a lack of good blood flow in both arteries that feed the hand. The procedure carries a three to eight percent risk of the radial artery blocking off after a catheterization through the wrist, but as long as there is double perfusion from the wrist to the hand to begin with, it is not a major problem. There are also cases where they try the radial artery but are unable to do it and have to switch over to the femoral.

Dillon and Tu have extended the procedure to heart attack patients who present in the Baptist East emergency room as part of the hospital’s streamlined process to evaluate chest pain patients and treat in the cath lab. Dillon describes the process as stressful because there is a rush to treat these patients, and this approach takes a little more time. However, he feels that for an operator experienced in the technique, it is worth the time and effort for patients

thomas tu, MD, Interventional Cardiologist with Louisville Cardiology Group

that make sense. If, however, a patient needs a pacemaker or balloon pump or has other mitigating factors, they revert to the femoral artery.

Dillon credits his partner Tu, who was trained to do the procedure as a fellow, with mentoring him in the transradial technique.

McFarland also learned the technique in fellowship and recently joined them in utilizing the procedure. “It really is a technique you need to be in and doing lots of them because it is harder to do, and there is a learning curve,” says Dillon. The technique is slightly different and utilizes a micropuncture needle. There are some catheters specially designed for the radial artery, but generally they are able to use standard catheters: a 6 French in men and a 5 French in women.

Staff support is an equally critical factor in making the procedure possible. “I can’t

rebecca McFarland, MD, Interventional Cardiologist with Louisville Cardiology Group

give Beth Mylor enough credit. She’s been pushing us forward and was very enthusiastic and learned how to do it, and with that we took it over to Baptist East to the inpatient side and brought them up,” says Dillon. Mylor credits a little education and a lot of positive attitude from their staff for making this successful. “I think that our staff has phenomenal support from our physicians because they are very skilled and very good. We don’t follow them blindly, but we follow them. If they say they want to try something, then that’s what they do,” says Mylor.

Concludes Dillon, “Once people see the advantages, they really embrace it.” ◆

FebrUary 2012 25

SPeCiAl SeCtion  CArDiology

therapeutic Hypothermia for resuscitated Cardiac Arrest

Floyd Memorial physicians utilize hypothermia to dramatically improve survival rates By JEnnIfEr S. nEwtOn

In medicine, most new therInterventional cardiologist apies require years of slow, methodical Srini Manchi, MD, says research and face at least a moderate amount therapeutic hypothermia is of resistance to change before actually being a wonderful concept where implemented. In the case of therapeutic each specialist or care hypothermia, a striking increase in survival provider does their part. rates led to remarkably rapid acceptance and implementation.

Two studies published in peer-reviewed medical journals in the early 2000s demonstrated the dramatic results achieved with the adoption of therapeutic hypothermia for patients with a return of spontaneous circulation (ROSC), meaning those who are resuscitated from cardiac arrest. In 2005, the American Heart Association included therapeutic hypoemergency room physician thermia in its guidelines for thomas Harris, MD, says patients suffering cardiac therapeutic hypothermia is all about improving survival rates arrest outside the hospital. and neurologic recovery after According to Floyd Memorial cardiac arrest.

Emergency Medicine physiSrini Manchi, MD, cian Thomas Harris, MD, the with Cardiovascular studies’ remarkable results prompted a wide- Associates of Southern Indiana, explains spread reaction in the medical community. “If the physiology behind the method. “With you look nationally prior to the hypothermia cardiac arrest you have very little blood era, you’re looking at 10 percent survival-to- flow to the body. Low blood flow means discharge for out-of-hospital cardiac arrests, lower oxygen flow to the tissues, and low and in some of the more proficient places, oxygen to the brain or other tissues causes maybe double that,” says Harris. “In one the body to start metabolizing an anaerobic study, they improved from 19 percent to 49 pathway,” says Manchi. However, with the percent survival rate.” introduction of therapeutic hypothermia, A survival rate that essentially doubles lower body temperatures result in a lower may be the most obvious benefit, but metabolism rate, minimizing the damage better neurologic function and a better to tissues. Harris adds, “The complication quality of life at discharge are also pri- rate for people who are cooled is basically mary benefits. Interventional cardiologist the same as those not cooled, so there isn’t

nEw aLBany, In

26 M.D. UpDate

really a downside to it.”

the protocol

For patients resuscitated in the field or shortly after they arrive in the ER, the concept is to bring their core temperature down to about 91 or 92 degrees Fahrenheit.

This is accomplished by methods as low-tech as placing ice packs on the patient in areas of high blood flow, such as the groin, axilla, and the back of the neck, and administering cold IV fluids. Higher tech tools include a cooling blanket and esophageal or rectal probes to constantly monitor temperature. The goal is to reach the targeted temperature within two hours of the initial event, and the faster the better. The temperature is then maintained for about 24 hours before the patient is rewarmed.

Cooling begins in the field, where EMS personnel administer cold IV fluids to patients resuscitated from cardiac arrest when possible. The criteria for therapeutic hypothermia treatment include nontraumatic cardiac arrest in patients over 18, who have return of spontaneous circulation (ROSC) within 60 minutes of the event, and are comatose. Cooling must begin within six hours of the ROSC.

Your Cure for the Cash Flow Blues a team of Care providers

The technique would not be possible without the variety of caregivers who are critical to its implementation. “In addition to EMS people in the field, it’s a continuum of care process,” says Manchi. The process begins with bystanders or family members who first administer CPR, first responders and EMS, multiple physician specialists – including ER physicians, cardiologists, neurologists, pulmonologists, and intensivists – and CCU or ICU nurses. Harris agrees, “We’ve been pretty aggressive here in getting the pre-hospital aspect,” citing that ambulances in New Albany carry chilled normal saline to start cold IV fluids in the field. “We’ve developed a protocol within the hospital to make sure everyone is on same page and make treatment as routine and expected as possible,” says Harris.

ER physicians are the gateway and the catalyst for this technique. They evaluate patients, begin lowering temperatures with ice packs and IV fluids (if they have not already been started), and consult cardiologists. If an arrest is the result of a myocardial infarction (MI), patients are whisked to the cath lab for treatment, with cooling started concurrently.

Cardiac arrest can also be caused by a primary arrhythmia or unidentified cardiomyopathy.

Cardiologists are integral in determining the cause of the cardiac arrest, which is

can cause potassium to go very high and can cause cardiac arrest,” says Manchi.

In addition to cardiac interventions, cardiologists use ultrasound to confirm the LV ejection fraction, manage hemodynamics and medications, and sometimes put in a balloon pump for patients with severe damage to the heart muscle. Once a patient is transferred to CCU or ICU, neurologists monitor brain function with the use of EEGs, and pulmonologists oversee oxygen levels and check for pneumonia.

Harris describes the interaction between emergency medicine physicians, cardiologists, and other treating physicians as a “seamless transition.” He attributes the team mentality and success to the overwhelming research, the backing of professional organizations such as the American College of Emergency Physicians and the American College of Cardiology, and the use of a universal protocol. Nurses are another critical component in successfully executing the protocol, as they are charged with a significant amount of time in carefully monitoring these patients.

“There has been a big effort to improve cardiac awareness and the chain of treatment, but there was sort of this ceiling on overall survival rates,” says Harris. Despite efforts to educate the public to call for an ambulance, better notification of EMS, and placing automated external defibrillators in

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research and anecdotal evidence demonstrate that prior to hypothermia treatment, patients may have survived but would have more likely had severe neurological impairment. with therapeutic hypothermia, the result is better neurological function and better quality of life at discharge. crucial in preventing further arrest. Cardiac catheterization in used to determine if there is any blockage causing an arrhythmia and to correct it. If there is a primary arrhythmia, the irregular heart beat restricts blood flow to the heart and brain. “That can happen mainly due to chemical abnormalities, low potassium or magnesium levels, or some patients go into renal failure, which

public places, the survival rate was still 10 to 15 percent. That rate has been improved by the use of therapeutic hypothermia in many communities.

With its marked success, hypothermia is now being evaluated for minimizing brain injury in the case of stroke and pediatric trauma, but those treatments are still in the experimental phase. ◆ FebrUary 2012 27

newS  eventS  ArtS

Neuroendocrine and NeuroOncology Specialists Join Markey’s team

SenD your newS iteMS to M.D uPDAte > news@md-update.com

Surgical while continuing to perform surgeries at Jewish Hospital Shelbyville.

Plans are also underway to further increase Louisville Surgical’s presence in Shelbyville beyond Theuer’s outstanding work.

Louisville Surgical is a general surgical group, which has provided surgical services to Louisville patients for more than 30 years. Their primary office is located on the campus of Sts. Mary & Elizabeth Hospital (SMEH) in Louisville.

Bariatric specialists at Louisville Surgical have developed the only program in the area designed exclusively for the care and management of the LAP-BAND® System.

The program has been recognized nationally for its success with more than 2,500 of the procedures performed at SMEH by Louisville Surgical.

Other sub-specialties for this surgery practice include advanced breast care, advanced laparoscopy, and endoscopy.

LEXIngtOn Two new specialists have joined the oncology team at the University of Kentucky Markey Cancer Center.

Lowell Anthony, MD, specializes in the treatment of neuroendocrine tumors and gastrointestinal cancers. At Markey, Anthony will lead and develop the Lowell anthony, MD N e u r o e n d o c r i n e Clinical Oncology Program. He will focus his research efforts toward Phase II trial in neuroendocrine tumor patients with the anti-FGF agent dovitinib (TKI258) in addition to developing other clinical trials for neuroendocrine Hack joins baptist Medical associates Dixie tumors.

John Villano, LOUISVILLE Michael Hack, MD, family MD, PhD, specialmedicine, has joined Baptist Medical izes in the treatment Associates’ 9070 Dixie Highway of brain cancers. He location.

John Villano, MD, phD will develop UK’s Hack is a 2000 graduate of the Clinical NeuroUniversity of Louisville School of Oncology Research Program, serving as its Medicine. He completed his family medidirector. His research focus will include cine residency with the Trover Foundation developing clinical trials for neuro-oncology in Madisonville tumors. Villano will also serve as an associ- in 2003. Hack ate professor of medicine in the UK College was previously a pharmacist and of Medicine. graduated from Louisville Surgical associates the University of Joins JHSMH Kentucky School LOUISVILLE Jewish Hospital & St. Mary’s of Pharmacy in HealthCare announces that Louisville 1990 with high Surgical Associates has signed an agree- distinction. He is ment to become part of the their organiza- board certified in Michael Hack, MD tion. This practice includes Drs. Joseph family medicine.

Blandford, Joel Garmon, Vincent Lusco, Rodney McMillin, John Olsofka, Bryce UK Cardiothoracic Surgeon Named 2011 Lung Health Schuster, and Robert Stewart.

JHSMH also announced that Chris Champion Theuer, MD, will be joining Louisville LEXIngtOn Sibu Saha, MD, cardiothoracic 28 M.D. UpDate

american Lung association CeO barry Gottschalk presents the 2011 Lung Health Champion award to Dr. Sibu Saha. (photo courtesy of Lori arrowood, aLa)

surgeon at UK, was recently recognized for his lifelong contributions to the fight against lung disease by being named the recipient of the 2011 Lung Health Champion Award from the American Lung Association in Kentucky.

Sts. Mary & elizabeth Hospital Opens New Interventional Cardiology Lab

LOUISVILLE Sts. Mary & Elizabeth Hospital (SMEH) recently opened the hospital’s new renovated interventional cardiology lab, one of 40 pilot projects in the United States.

The Jewish Hospital & St. Mary’s Foundation was the recipient of $594,000 in federal funding to purchase equipment for the lab, which will help residents of south Louisville to receive quality care more quickly.

Previously, those same patients had to be transported to another facility across town.

The new lab enables doctors at SMEH to perform emergency angioplasty onsite in an effort to open blocked arteries within minutes of arriving at the hospital.

Arun Ummat, MD, of Bluegrass Cardiology Associates has been performing interventional cardiology procedures for three decades. He practices at SMEH, but until recently he could only perform the interventions at other facilities, such as Jewish Hospital.

“With cardiology, the sooner you get care for the patient, the better,” said Ummat.

“Until this time, we have had fragmented care in cardiology because we had to send patients elsewhere for a procedure after their diagnosis. Sts. Mary & Elizabeth has been a community hospital for many years and this facility will benefit both the patients and their families.”

newS

ephraim McDowell Health opening new specialty center

The latest phase completed includes the unique hybrid operating room, which comDanVILLE Ephraim McDowell Health bines the most advanced and high-quality announces the opening of the new Ephraim imaging technology with surgical operative McDowell Specialty Center in Danville. capabilities to create a unique operating The Specialty Center will house Ephraim room environment as well as: McDowell’s Cardiology, Vascular, and 42 bed pre-operative and post anesthesia Pulmonology specialty practices. It will also care unit (PACU); Surgical pathology area; be the new home of the Commonwealth Family waiting area; Anesthesia workspace Neuroscience Center. Located at 216 West and offices; Staff lounges and conference Walnut Street, the center is directly across room; and Central Sterile Supply.

Advantages to a hybrid operating room the street from the City Parking Garage. include greater accuracy of surgical proceThe new facility will offer an enhanced dures, reduced recovery time, reduced risk patient experience with improved access of postoperative complications and need for and convenient parking. Even though sevtreatments in the hospital’s intensive care eral specialty practices are moving into the unit, according to Jay Zwischenberger, MD, clinic, there is additional space for future surgeon-in-chief for UK HealthCare. growth. The Clinic will house Ephraim McDowell Cardiology (Drs. Grigsby and Messerli), Ephraim McDowell Pulmonology KMa Offers Free (Dr. Imtiaz), Ephraim McDowell Vascular physicianFacts reports to (Dr. Weintraub), and Commonwealth Members Neuroscience Center (Dr. Nidhiry).

LOUISVILLE To help physicians begin their education on new reimbursement and pubregion’s First robotic Hybrid licly available physician data, KMA offers Operating room to Open at free PhysicianFACTS reports to KMA

UK Chandler Hospital

LEXIngtOn UK has opened its long anticipated hybrid operating room, as well as eight new, state-of-the-art, multi-purpose operating rooms, as the most recent phase of construction and expansion at the UK Albert B. Chandler Hospital is completed.

Neurosurgeon Justin F. Fraser, MD, discusses the benefits of the new hybrid operating room (Jan 25 2012).

Website, as well as other publicly available information. To request your KMA PhysicianFACTS report, download the form at www.kyma.org and send to Sarah Nielsen at nielsen@kyma.org.

Norton Keeps anthem thru 2015

LOUISVILLE Anthem Blue Cross and Blue Shield and Norton Healthcare announce the extension of Anthem health care coverage for those using Norton Healthcare facilities through to the end of January, 2015. This extension comes well in advance of the October, 2012 end date of the current agreement. Terms of the agreement extension were not disclosed.

This agreement covers all Norton Healthcare facilities and employed physicians. Anthem members enrolled in Blue Access/Access (PPO), Blue Preferred/ Preferred (HMO), Blue Traditional/ Traditional or Medicare Advantage HMO/ PPO will continue to receive covered services from Norton Healthcare at the highest level of benefits, with limited out of pocket costs.

Study Finds Warfarin Underutilized in Women

members. The individualized report shows physicians what information is currently available about them on the first iteration of the government’s Physician Compare

LEXIngtOn Rabab Mohsin, MD, an internal medicine resident at UK, won the 2011 Young Investigator Award from the Kentucky Chapter of the American College of Cardiology, for research done with Alison Bailey, MD, of the UK Gill Heart Institute.

Mohsin received the award at the KentuckyACC annual meeting held at UK. The award was for research conducted in conjunction with the Kentucky Women’s Health Registry. Working with KWHR, Mohsin, Bailey, and fellow investigators identified women who reported arrhythmia (irregular heartbeat) identification and treatment. Specifically, the investigators worked to determine whether prescription warfarin (an anti-coagulant known as a safe and effective treatment for atrial fibrillation) was being appropriately utilized among a population of Kentucky women with selfreported atrial fibrillation.

FebrUary 2012 29

newS

Survey data revealed that among the group of women who would be expected to be receiving warfarin, only 30 percent were receiving the drug. Overall, Mohsin, Bailey and fellow investigators concluded that warfarin anticoagulation treatment for atrial fibrillation is underutilized in the group of Kentucky women studied, and that this underutilization is not attributable to economic or educational disparities.

Darnell appointed to National quality improvement committee

DanVILLE Ephraim McDowell Health is proud to announce that Vicki A. Darnell, president and CEO, Ephraim McDowell Health, has been appointed to a National healthcare quality improvement committee.

The Premier healthcare alliance board of directors has appointed 10 top U.S. hospital and health system leaders to a pair of stockholder committees. The committees help to lead the alliance’s more than 2,500 hospitals and 80,000-plus other sites in efforts to transform and improve health care.

The Quality Improvement Committee (QIC) and the Group Purchasing and Member Relations (GPMR) Committee, with expert executives from 37 Premier members and outside representation from the Institute for Healthcare Improvement, serve in an advisory capacity to Premier’s board of directors.

Owned by hospitals, health systems and

Vicki a. Darnell, president and CeO, ephraim McDowell Health

other providers, Premier maintains the nation’s most comprehensive repository of clinical, financial, and outcomes information and operates a leading health care purchasing network.

Daugherty Named editor of Major Journal

Alan Daugherty, PhD, DSc, senior associate dean for research in the UK College of Medicine and director of the UK Saha Cardiovascular Research Center, has recently received two major honors from the American Heart Association, including being named editor-in-chief of a major scientific journal.

Daugherty has been named the new editor-in-chief of the AHA journal Arteriosclerosis, Thrombosis, and Vascular Biology (ATVB). He will assume this role during the first half of the 2012 calendar year. ATVB is a pre-eminent peerreviewed academic journal chronicling

LEXIngtOn

the latest advancements in cardiovascular research.

Daugherty also recently accepted a 2011 ATVB Special Recognition Award in Vascular Biology. This award honors an outstanding member of the American Heart Association’s Council on Arteriosclerosis, Thrombosis, and Vascular Biology.

Presented during the recent AHA Scientific Sessions in Orlando, Fla., the award recognizes major contributions to the affairs of the scientific council over a continuing period of time, as well as substantial professional alan Daugherty, phD, DSc contributions to the field.

baptist Healthcare System CIO Named Leader in Global It

St. MathEwS IDG’s Computerworld announces Jackie Lucas as a 2012 Premier 100 IT Leaders honoree. This year’s Premier 100 spotlights 100 leaders from both the technology and business sides of companies for their exceptional technology leadership and innovative approaches to business challenges.

Lucas is vice president and chief infor-

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mation officer (CIO) for Baptist Healthcare System, Inc. She was selectJackie Lucas, CIO, ed from more than baptist Healthcare 1,000 nominations, and shares her honor with CIO peers from companies such as Hilton, Intel Corporation, Blue Cross Blue Shield, Target, Raytheon, Wells Fargo, Toyota, and more.

Lucas joined Baptist’s Information Technology (IT) management team in 1993 and served in several corporate IT director roles over strategic projects, clinical and revenue cycle systems, integration and databases and program management before rising to vice president and CIO in 2006.

perry joins baptist Medical associates

Whitney Perry, APRN has joined CBC Group: Consulting in Blood Disorders & Cancer, a part of Baptist Medical Associates. Perry holds a bachelor’s degree in nursing from Bellarmine University and is a 2010 graduate of the Bellarmine University family nurse practitioner program.

LOUISVILLE

Whitney perry, aprN

AllieD HeAltH  AuDiology

Sooner rather than Later Is Now the right time to Have your Hearing tested?

familiar, you may not be aware of what you are missing. If you don’t hear it, you don’t miss it. “Hearing Loss” has become your new normal.

As good as your brain may be at adapting, the effort

first time hearing users with mild hearing loss. These newest instruments provide immediate benefits and immediate acceptance on the part of the user.

People who believe they have only slight hear-

required to do this puts an enormous amount of fatigue on you.

A quick, simple evaluation by a certified audiologist can identify early hearing loss and provide solutions to take the stress off your auditory system with new innovative technology specifically designed for

ing loss often make the mistake of thinking there is no help available. They believe they must wait until their loss is “severe” before they can benefit from hearing instruments.

Fortunately, today’s technology is successful long before the severe stages of hearing loss. ◆

By KAtHryn SAnDuSKy, AuD LEXIngtOn The human brain is an amazing thing.

Our brains do an incredible job of compensating and adapting when changes take place in our system(s) as we age, especially early hearing loss.

You may notice that, even with early, slight hearing loss, you have found ways to compensate. Simple techniques such as turning your head or leaning closer in order to hear conversation more easily. It is possible you may be adapting by avoiding social situations where you’ve noticed it is difficult to hear and understand. By adapting and coping, you may feel like you’re getting by just fine.

If this is sounding

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FebrUary 2012 31

ArtS elements of gardens and Healing

By Bill HenKel “We must go out and re-ally ourselves to Nature every day. We must make root, send out some little fiber at least, even every winter day. I am sensible that I am imbibing health when I own my mouth to the wind.”

- Henry David Thoreau A well designed garden is like a West Highland Terrier, they refuse to be ignored.

The magnetic mystery of a garden attracts us for many varied reasons.

The beginning may be a veiled glimpse of a meandering path in the distance as it disappears. Perhaps it is a faint fragrance from a distant memory, or the musty pungent aroma of old boxwoods…luringyou into a hidden nook with the inviting bench….the quiet trick le of a fountain.

We all stand to gain a sense of stress relief from our time spent in nature, and from this sense of relief the concept of a healing garden is born.

Let’s look at the meaning of the term healing garden. Healing, as you know, means to be restored to health or to remedy.

Gardens, according to Webster, are outdoor plots where plants are grown – a place cultivated for our enjoyment.

A healing garden, therefore, can be a space (out or indoors) where natural elements are combined in an aesthetically pleasing manner to promote relief from some physical condition, stress, and finally to restore some sense of hope. They can be designed for specific users including: Gardens for children Gardens for Alzheimer patients Gardens for the elderly Gardens for psychiatric patients Gardens for visually or physically impaired Hospice gardens Meditation gardens 32 M.D. UpDate

ebD is a design process where decisions about the constructed gardens will be based on evidence or research in order to achieve the best possible outcomes.

Gardens designed for these specific needs require in-depth research and study to be certain the intended user’s program is appropriately considered. Conventional design process may not be sufficient Garden design is a process of matching a users need list with whatever site constraints occur. Most often a owner/user will define the garden design program with the landscape architect’s guidance.

Comparing Design processes

Traditional design processes for healing gardens can be quite similar to the design process for most gardens. That is, after extensive interview and site analysis, the site conditions are married to the user’s needs – hopefully creating a space that beckons to you, compels you to step inside and sample the fruit.

Alternatively, evidence based design (EBD) is a non-traditional design approach employed in the design processes for many health care facilities. EBD is supported through research and post occupancy evaluations (POE). When EBD is applied in healing garden design, there is a strong likelihood for better patient outcomes, reduced staff turnovers, and greater patient satisfaction.

EBD is a design process where decisions about the constructed gardens will be based on evidence or research in order to achieve the best possible outcomes.

When EBD is employed for garden design decisions in health care settings, there is a greater chance of success and improved outcomes for patient, staff, and family. Stress is a major problem and can be relieved by access to nature and gardens restores a sense of privacy and control for patients access to spaces that encourage interaction amongst and between patients, staff and family fosters social support gardens encourage movement and exercise, touching and experiencing the different

spaces in a garden. Mild exercise is restorative having natural distractions takes our minds from our problems, even for a short period of time..this helps.

The above elements support stress reduction and thus contribute to better patient and staff outcomes.

Credential practitioners

The design team for a healing garden might begin with the selection of the landscape architect. In most states, landscape architects are licensed and governed by the state and national agencies. Landscape architects are educated, trained, and licensed in design and construction that will protect the health, safety, and welfare of the public.

Hospital staff and administrators, horticultural experts, and architects should be included when appropriate.

My healing garden design certification training was led by industry experts and pioneers in EBD and POE - Clare Cooper Marcus and Marnie Barnes.

Roger Ulrich, the most recognized and influential EBD healthcare design researcher in the world, was the lead off lecturer. He once stated, “Gardens are cheap compared to staff turnover [for] well designed gardens support the four elements of outcomes, and evidence based design leads to greater chances of success.”

Ulrich concluded that “a successful healing garden is one that improves outcomes for the great majority of users.”

I encourage readers to think of gardens as proven, sound real estate investments that are appropriate for homes, offices, and places of healing. Furthermore, gardens that heal and provide some sense of stress relief may be of even greater value. bill Henkel is owner and partner of Henkel Denmark of Lexington. He can be reached at (859) 455-9577 or bill@henkeldenmark.com. ◆

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