M.D. Update Issue #73

THE BUSINESS MAGAZINE OF KENTUCKY PHYSICIANS AND HEALTHCARE ADMINISTRATORS September 2012

Special Section

Sleep Medicine

Caring for Kentucky’s Children

Volume 3, Number 7

Pediatric Subspecialists at the State’s University Hospitals Provide Leadership, Insight, and a Medical Home for Complicated Pediatric Cases

Pub: MD Update Size: 15.5" x 10"

Client: Saint Joseph Hospital Job No: SJH-37407 Title: Heart Care Faces Ad - Lexington

September 2012 1

Letters

Children and sleep

Volume 3, Number 7 September 2012 Publishers

When my oldest daughter was Remembering my chila week or two old, she startdren’s infant days always leads ed turning blue around her me to a fond recollection of mouth one morning as I was those early zombie days, operholding her in my lap. After a ating on just a few hours frantic call to the pediatrician’s (sometimes minutes) of sleep. emergency line, a whirlwind Our special section this trip to the pediatrician’s office, month is dedicated to Sleep and a subsequent trip to the Medicine. The sleep medipediatric cardiologist, everycine specialists in this issue thing turned out to be normal. remind us how important

BY Jennifer S. Newton Normal … temporary … sleep is to overall health. benign, however you phrase it, Dr. John Dineen of the it’s really the only diagnosis a parent wants Lexington Clinic and Dr. Satish Rao of to hear. However, in some of the pediatric Floyd Memorial agree that sleep has become specialties we covered for this month’s issue, a front-and-center issue in the discussion of the term “cure” is more like a four-letter good health. word and reaching a calibrated level of “norFrom Southern Indiana to Lexington to mal” is a challenging task.

Owensboro to Georgetown, the geography UofL pediatric rheumatologist Dr. of the sleep medicine specialists represented Kenneth Schikler doesn’t use the word here underline that sleep disorders are a “cure” with his patients, only remission, as widespread problem in every area of the he deals with chronic conditions such as Commonwealth and beyond. Dr. Robert juvenile idiopathic arthritis and fibromyal- Pope with the Kentucky Sleep Society is gia. UofL pediatric nephrologist Dr. David hard at work advocating for sleep issues Kenagy is tackling the ever-growing issue in a legislative level, and Dr. Ron Shashy of adolescent hypertension with a new care at Georgetown Community Hospital promodel and advocating for healthier children motes the most efficient, cost-effective treatin Kentucky, in addition to navigating the ments, along with healthy lifestyle factors. treatment of chronic kidney disease.

On another note, our Digital Media UK’s pediatric hematologists/oncologists Publisher and Creative Director Megan – Dr. Vlad Radulescu, Dr. John D’Orazio, Campbell Smith, has been making great and Dr. Sherry Bayliff – treat everything from progress with our new digital platform – hemophilia to vascular malformations to leu- INSIDE HEALTH. You will soon see the kemia. Fortunately, cure is a word used today fruits of her labor. Stay tuned! in the area of childhood cancer, but these physicians are committed to living up to the All the best, survivorship statistics in pediatric cancer and studying a multitude of diseases to further improve treatment.

From a new pediatric dialysis unit at UofL designed specifically for children to UK’s Long-Term Follow Up Clinic for pediatric cancer patients, Kentucky’s state Jennifer S. Newton universities are creating medical homes to Editor-in-Chief better care for children with complicated, chronic, life-threatening issues.

submit your Letter to the editor to Jennifer s. newton at Jnewton@md-update.Com 2 m.D. UpDate

Gil Dunn Print gdunn@md-update.com Megan Campbell Smith Digital mcsmith@md-update.com eDitor in Chief

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Contributors: Dr. Todd Coté Andrew D. DeSimone Kathryn Hansen Dr. Stefan G. Kiessling Scott Neal Betty Spohn

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Contents

sePteMber 2012 voluMe 3, nuMber 7

2 letters

Cover story

4 PhysiCian viewPoint 6 finanCe 7 huMan resourCes 10 legal 11 one on one 12 CoorDination of Care 14 Cover story 19 sPeCial seCtion -sleeP MeDiCine 28 news 31 events 32 arts On the cover: David Kenagy, mD, and Kenneth N. Schikler, mD

Caring for Kentucky’s Children

Pediatric Subspecialists at the State’s University Hospitals Provide Leadership, Insight, and a Medical Home for Complicated Pediatric Cases

by Jennifer s. newton and megan CampbeLL smith page 14

speCiaL seCtion  sLeep mediCine

22 Sleep medicine on Fast track

19 Sleep medicine Frontiers

20 Fighting for Sleep

24 a Scientific approach to predisposing, precipitating, and perpetuating Causes of Sleep Disorders

26 Intellectual Curiosity September 2012 3

physiCian viewpoint

a Companion for the entire Journey by stefan g. KiessLing, md, faap Since its “revitalization� in 2004, Pediatric Nephrology at Kentucky Children’s Hospital (KCH) has grown into a strong division and an integral part of the Department of Pediatrics at KCH. My colleague, Dr. Aftab Chishti, and I are taking care of children with kidney and urinary tract ailments.

The spectrum of renal diseases leading to in- and outpatient referrals includes, but is not limited to, blood or protein in the urine, urinary tract infection, kidney reflux, high blood pressure (which in children is commonly related to abnormalities within the kidney), acute kidney injury, as well as children requiring all forms of renal replacement therapies (dialysis). Care is often provided in concert with a specialist in pediatric urologic surgery.

An integral part of our daily work involves the management of children with complex, irreversible, and chronic kidney disease (CKD), which quite often progresses to dialysisdependent kidney failure and the need for a future kidney transplant. To meet the multidisciplinary needs of these children and their families, our division has grown significantly over the years and now includes two board-certified physicians, one pediatric nurse practitioner with almost 10 years of experience, as well as two full-time nurses, a social worker, and a dietician. We have an in-hospital Hemodialysis unit that is

licensed to provide care for eight children and take care of several children on peritoneal dialysis.

Chronic kidney disease in children is much less common than in adults but often associated with a higher complexity. In contrast to adults, most children with chronic kidney disease are born with urinary tract abnormalities or acquire specific diseases through no fault of their own. The care of those affected is intense, with the goal to optimize outcome focused on physical and cognitive growth. To achieve that goal, frequent visits to the pediatric nephrology

Would you rather be here?

Or HEAR?

Engineered for performance.

4 m.D. UpDate

specialist are necessary, sometimes as often as once a month or more. The children with CKD and their families have always been very special to us because we have the privilege of becoming like a family member to them and their families.

Despite being able to provide most of the care here at KCH, up until two years ago our patients received their renal transplant evaluation and actual transplant at hospitals out of state, posing significant hardship on some of the families. Most of our patients had received care at UK for years, some even since birth, and were hesitant to establish care with a new team of providers even though they knew they would return to UK after the transplant surgery for the long term aftercare. I remember patients asking us, “Are you going to be there when I get my new kidney?” and it was always quite emo-

tional when our answer was “No.” More importantly, a majority of our families lack the resources to travel out of state as it is hard enough for them to get to Lexington.

Fortunately, leadership within Kentucky Children’s Hospital and UK HealthCare realized something needed to change.

In 2010, the most significant achievement so far happened for our team, with the first pediatric kidney transplant being performed at UK in more than a decade and the reopening of the UNOS accredited Pediatric Kidney Transplant Program under the surgical leadership of Dr. Roberto Gedaly and his colleagues. Since that time, we have had several successful transplants and grown into a strong team.

The response we get from families continues to be very emotional as they realize that the doctors and team they are comfort-

able with will now be able to take care of their child without transitioning to a different “short-term” provider team elsewhere.

I am very proud that Kentucky Children’s Hospital and UK HealthCare are able to provide this service for our children and that traveling out of the state of Kentucky is no longer necessary. Dr. Chishti and I can be their companions for the entire journey, which is a very rewarding and positive change for which I am extremely grateful. We can now say “yes” to the families when asked if we will be there when their child comes out of the operating room.

Stefan G. Kiessling, mD, Faap, is associate professor of pediatrics and Division Chief of pediatric Nephrology, Hypertension, and renal transplantation for Kentucky Children’s Hospital at the University of Kentucky. ◆

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September 2012 5

finanCe

Life and taXes It has been said that there is nothing certain that looks at more in this world but death and taxes. Rarely do risk factors would the two get paired up except in a discussion help. We also like of estate taxes. However, this month we will to use a tool that go on an excursion of longevity and the curoffers suggestions rent state of affairs on tax policy and what for improving you should do about both. current wellbeing While performing financial planning as well as longevservices, we have observed that people tend ity. We prefer the to underestimate how long they will live, one constructed even in the face of strong evidence to the by the University

BY Scott Neal contrary. I am sure that you, dear reader, of Pennsylvania’s are doing what you can to help and are Wharton School and it can be found using hopefully witness to the positive outcome. the QR code on this page.

There are many sides to the story however.

That brings us to taxes. Right NOW One is to deny the possibility, let alone the is the time to check in on your 2012 tax probability, of a very long life. projection. The Mayan calendar aside, as When we present the projections of taxpayers we face enormous uncertainty as income, expenses, and net worth to age the end of the year approaches. Tax rates 100, the most common response is along are scheduled to go up on January 1, along the lines of “I hope with the eliminawhen we present the I don’t live that tion of many credlong.” The rather its and deductions proJeCtions of inCome, typical inclination and other incentives is to think that a eXpenses, and net worth to (commonly referred person of 90+ must as the “Bush tax age 100, the most Common to be incapacitated or cuts”). Concurrent response is aLong the that life will surely with this will be be so miserable at sequestration which Lines of “i hope i don’t that age as to be not imposes across-theLive that Long.” worth living. You board spending cuts and I know that’s at the Federal level, not true for a lot of people. leading someone to call it taxmageddon.

The alternative is to begin now, whatevSome think that the changes in the er your current age, to plan for the probabil- tax code will only affect the wealthy. Not ity of life to 100 or even beyond and to take so. The 10% bracket goes away entirely. an objective look at what that life will be.

The so-called marriage penalty will return.

The insurance industry doesn’t help. Itemized deductions and personal exempWhile selling life insurance, they routinely tions will once again be limited. The child remind us that we might not live very long tax credit will be halved. Substantially more and they flash actuarial tables at us to prove taxpayers will be subject to the alternative the point. One major problem is that the minimum tax (AMT). So what to do now? actuarial tables express longevity at a 50% From an investment perspective, it may probability of life expectancy for a very large be good time to harvest losses (if you have population. Ah, the flaw of averages. Do any). Even if you cannot take the full capital we really have to be reminded that we are a loss deduction this year, the losses could be population of one? carried forward and used to offset future Furthermore, the actuarial tables hinge gains, which are likely to be taxed at a on only two factors: gender and age. Like higher rate. Be aware that if you are selling most things, we encourage the use of a securities at a loss there is a little known more robust tool for serious planning. One provision called the “wash sale rule” that 6 m.D. UpDate

generally prohibits you from taking the loss on a security if you have repurchased the same or substantially identical asset 30 days before or after the sale.

Two new taxes kick in for 2013. The Patient Protection and Affordable Care Act imposes an additional 0.9% Medicare tax on wages and self employment income and a 3.8% Medicare contribution tax will apply after 2012 to single individuals with a modified AGI of over $200,000 and married couples with more than $250,000 of MAGI. Interestingly enough, both chambers passed bills this summer that would forestall the drastic changes that are about to appear.

The two could not find agreement however, so the proverbial can has likely been kicked down the road to a lame duck Congress sitting after the November elections. It’s possible that Congress will wait until 2013 to act, if they act at all. Traditional yearend planning is essential. However, this year more than most, the planning should consider both 2012 and 2013. Multi-scenario, multi-year planning is the only prudent play of the hand we are dealt.

Scott Neal is the president of D. Scott Neal, Inc. a fee-only financial planning and investment advisory firm. Questions and comments always welcome. He can be reached at 1-800-344-9098 or via email scott@dsneal.com ◆

Qr UrL: http://gosset.wharton.upenn. edu/mortality/perl/CalcForm.html

human resourCes

the Changing employment Landscape No “Pass” for the Small Practice by betty spohn, ba, msLs, ed.d. (abd) Given the often intense and fast-paced milieu of the medical practice, it can be easy to lose focus on human resources or “personnel” functions other than time-recording and wage and hour. Smaller practices, in particular, may not have an employee designated as HR “director” or “manager,” tasked with the responsibility of tracking federal and state legislation, local statutes, or EEOC guidelines related to employment issues. Written policies articulating very specifically the practice’s position, rules, and procedures relative to social media or the use of criminal background checks, for example, do not exist. Employee Handbook? Too much time and trouble, you may argue, for an employee group totaling just seven individuals.

Those of us who do follow what is happening on the employment landscape know that social media is one of the hot employment law issues now. The crux of that issue: where does the right of the employee to post what he/she pleases about the employer on, say, a personal Twitter or Facebook account (even if it is pejorative, profane, and vilifying) collide with the right of the employer to access what is posted and react with discipline up to and including termination for that employee?

How does the employer gain access to the employee’s posting? What if the employee made his or her posts on a personal computer while off the clock? The courts are currently crowded with legal cases on this one issue.

No one definitive answer or guideline has yet been determined but the message to employers is to make sure you have a legally sound and defensible social media policy in place.

Just this one example underscores the fact that our employment landscape is constantly changing. It changes in response to emerging workplace factors (smart-phone

technology, remote access, etc.), new legislation, amended legislation, the issuance of new guidelines from EEOC – and charges of “Foul!” brought forth by employees who sometimes are more aware than their employers of the changes.

A recent landscape change was the issuance by the EEOC in April 2012 of guidelines clarifying when and how employers should do criminal background checks on current or perspective employees. Impetus? The EEOC determined that current practices of using blanket criminal background check results as part of the applicant selection process could have a “disparate impact” on certain protected classes as legislated by Title VII of the Civil Rights Act of 1964, as amended. The new guidelines offer a process of “targeted assessment” of applicants for a particular position, for instance one that involves handling the employer’s assets, cash transactions, or providing patient care (especially to the elderly or very young). The message for all employers is that there may be legal ramifications if an applicant is not hired because of an arrest or conviction that happened years ago – and the nature of the criminal activity involved was unrelated to the nature of the job now sought by the applicant. (Find more information at www.eeoc.gov/guidance/ arrest_cfm.)

One good screening tool can be interviewing the applicant, and here the employer must also be vigilant. Picture a group interview of an office manager job candidate; he/she is engaging and pleasant, and, in a burst of enthusiasm, one of the interviewers asks, “So, how many kids do you have?” or “You were born and raised in Reykjavik … You speak English so well!”

Training about what not to ask is important for anyone in the practice who participates

in conducting job interviews. This includes avoiding such questions as: Are you a U.S. Citizen? What is your maiden name? How do you feel about supervising women? How many sick days were you out last year? Have you ever filed for Workers Comp? There are many more areas that should be strictly avoided during interviews of job applicants.

For employees already on board, certain other employment legislation and guidelines apply based solely on the total number of individuals employed. The Family Medical Leave Act (FMLA) applies to companies with 50 or more employees; the Americans with Disabilities Act (ADA) if 15 or more employees. Both pieces of legislation have been amended since 2009, resulting in the need for updated policies and practices.

The FMLA, for instance, has been amended to specifically govern military-related leave (more at www.dol.gov/whd/fmla/finalrule. htm).

The Americans with Disabilities Amendments Act, or ADAAA, broadened the definition of “disability” (www.eeoc. gov/laws/statutes/adaa_notice.cfm).

While certainly not an in-depth approach to any of the employment considerations mentioned, the message here can be condensed fairly simply: the small practice will not get a pass because it is small, does not have at least a human resource “presence,” or did not know about the applicable law, statute, or “guidance” in question.

Knowing about and paying attention to the employment landscape will help your practice avoid many of the potential landmines that lurk in that landscape. ◆

betty Spohn, ba, mSLS, ed.D. (abD), is director of business Services for access Wellness Group in Lexington, Kentucky, a counseling group that also provides employee assistance program (eap) services to regional employers. You can reach betty at (859)338-8929 or bspohn@ accesswellnessgroup.com. more information is available at www.accesswellnessgroup.com.

September 2012 7

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LegaL

Kentucky’s new pill mill Law by andrew d. desimone On July 20, 2012, new laws became effective that will impact every physician practicing in the Commonwealth of Kentucky. These new laws explicitly regulate how controlled substances can be prescribed in Kentucky, because of their devastating impact on families and communities. The new laws attempt to control the illegal substances at the dispensing source, although many of the requirements are something that physicians should be doing already, such as performing physical examinations and charting the patient’s past medical history. The new laws leave many questions unanswered. This article will attempt to address the highlights of the new “Pill Mill Law”; however, the new laws are so lengthy that it can only be a short overview. Be advised that failure to follow these requirements may subject the physician to licensure inquiries before the KBML. So what do the new laws require? The new statute, KRS 218A.205, states that before a physician can prescribe a Schedule II or Schedule III with hydrocodone, the physician must (1) obtain a complete medical history and conduct a physical examination; (2) query KASPER; (3) create a written treatment plan listing the objectives of the treatment and potential diagnostic examinations; (4) discuss the risks (addiction) and benefits of the controlled substance; and (5) obtain written consent for the treatment. The physician must routinely monitor the patient during the prescribing period and review KASPER reports every three months. Additionally, the practitioner must keep accurate and accessible medical records that explain the rationale for the prescription. However, the General Assembly created exceptions, such as during surgery, in emergency situations, or with hospice care.

The KBML created further mandatory requirements (regulations), while keeping the mandates required by the General Assembly. However, there are some discrepancies between the two. For instance, the regulation, 201 KAR 9:260, applies

to the prescription of any controlled substance. Moreover, the exceptions created by the KBML are broader than those in the statute (cancer patients and nursing home residents are exempt). However, the General Assembly’s mandates control, and a physician must follow KRS 218A.205, and not the KBML regulation, when prescribing a Schedule II or III (with hydrocodone) controlled substance to a cancer patient or a nursing home resident.

Under the KBML guidelines, to prescribe any controlled substance the physician must (1) verify the identity of the patient by government issued photo ID; (2) obtain a medical history and conduct a physical examination; (3) review KASPER (this does not apply to Schedule IV or V medications with the exception of certain drugs including Ambien, Ativan, Klonopin, Soma, Tramadol, Valium, Versed, Xanax and others); (4) decide the prescription is appropriate; (5) prescribe the medication in the lowest dose for the shortest amount of time; (6) not prescribe longacting or controlledrelease opioids for acute pain; (7) advise the patient to discontinue the use once the pain has resolved; and (8) explain how to safely dispose of the medication.

If the physician prescribes a controlled substance “for a total period of longer than three (3) months,” the physician must (1) obtain a past medical history on the patient and first degree relatives (which history must include illegal or legal substance abuse by the patient); (2) conduct a comprehensive physical examination sufficient to support the prescription of long term controlled substances; (3) obtain the medical records from other practitioners; (4) establish a working diagnosis (listing symptoms

is insufficient); (5) formulate a treatment plan; (6) use screening tools (including a baseline urine drug screen for legal and illegal substances) to ensure that the patient is not addicted to any substance, suffering from psychiatric or psychological condition, or presents a risk of diverting the prescribed medication; (7) obtain an informed consent; and (8) prescribe the medication for the shortest duration and lowest dosage.

When prescribing a controlled substance for longer than three months the physician must (1) evaluate the patient at least once a month; (2) determine if the patient is improving (this includes discussing the patient with family members and other independent sources. If the physician sees no improvement, the physician must order an independent consultation for potential undiagnosed conditions, including potential psychiatric/ psychological counseling.); (3) perform once a year preventive health screening (or ensure that it is performed); (4) review KASPER every three months (if the physician learns that the patient is obtaining controlled substances from other practitioners, without knowledge and approval, the physician must notify law enforcement); (5) perform random pill counts and random urine screens to guard against diversion.

In the ER setting, along with a history and physical exam, the physician must review KASPER. If unable to do so, the physician must document in the patient’s chart that the medical necessity outweighs the risk of unlawful use or diversion of controlled substances. Additionally, the ER physician is “strongly discouraged and shall not routinely” administer IV controlled substances for chronic pain; provide replacement prescriptions for lost, September 2012 9

LegaL

stolen, or destroyed prescriptions; prescribe long-acting or controlled-released substances; or provide more than a three day supply of the controlled substance. If any of these guidelines are departed from, the physician must document the exceptional circumstances at issue.

Despite the importance of preventing diversion of properly prescribed controlled substances, these new laws raise serious questions that will need to be answered.

The new laws are so pervasive that physicians might be considered a “state actor” for civil liability purposes when conducting urine screens and informing police of potential illegal activity. Will physicians simply stop prescribing controlled substances because of these new laws, potentially abandoning patients? Will insurance pay for the additional visits required

10 m.D. UpDate

in the er setting, aLong with a history and physiCaL eXam, the physiCian must review Kasper. if unabLe to do so, the physiCian must doCument in the patient’s Chart that the mediCaL neCessity outweighs the risK of unLawfuL use or diversion of ControLLed substanCes.

under these laws? Does HIPAA prevent the disclosure of KASPER information to police? Does the regulation really mean that a child cannot be prescribed a controlled substance, because the child does not have a photo ID? These and other questions must be answered as the new laws take effect. However, one thing is certain: the new laws have changed the practice of medicine in Kentucky. andrew D. DeSimone is a partner with Sturgill, turner, barker & moloney, pLLC. DeSimone concentrates his practice in the areas of healthcare law and medical malpractice defense. He can be reached at adesimone@ sturgillturner.com or (859) 255-8581. this article is intended as a summary of newly enacted state law and does not constitute legal advice. ◆

one on one

a media tool Kit

Partnership to Eliminate Child Abuse York. They put this video together called Portrait of a Promise, where parents discuss their experience with child abuse. They took the video into the hospital and showed it to new moms and dads and had them sign a document that said, “I viewed this video and I understand how dangerous it is to shake a baby.” They decreased the incidence of abusive head trauma by almost 50%. We started that within Norton Healthcare, and that’s been rolled out to a number of hospitals within the state.

Our Office of Child Advocacy, which posters and informais a Kosair Children’s tion and will be providHospital function, is ing them with some of staffed by a number of the toolkit items. nurses. They, in addition On a parallel plane, to the Task Force, were the UofL School of very instrumental in takMedicine Department ing this program to the of Pediatrics has crestate and getting House ated a division of Bill 285 passed last year Forensic Pediatrics that mandates training for and a Forensic certain groups of people, Pediatric fellowlike nurses, social workers, ship. The American and day care workers. We Board of Pediatrics were not able to get that has now recognized for the doctors, which is Forensic Pediatrics as something that we want Stephen p. Wright, mD, Faap a subspecialty, and because there’s data that we already have two says about half the kids physicians that are board-certified. that come in with devastating injuries have seen a healthcare worker within a couple of How does the partnership weeks … That’s going to be another initiative integrate with the Child abuse we’re working on.

each year in Kentucky between 30 and 40 children die from child abuse and neglect, with another 30 to 60 near fatalities, ranking the state among the worst in the nation. the partnership to eliminate Child abuse was founded earlier this year by Kentucky’s two children’s hospitals and three medical schools, including Kosair Children’s hospital, uofL pediatrics – forensic medicine, Kentucky Children’s hospital, university of Kentucky – department of pediatrics, and university of pikeville – Kentucky College of osteopathic medicine. the indiana medical community has followed suit, including riley hospital for Children at indiana university health, indiana university school of medicine – section of Child protection programs, and peyton manning Children’s hospital at st. vincent, along with dozens of other media outlets, businesses, and organizations in both states. m.d. update’s editor-in-Chief Jennifer newton sits down with stephen wright, md, chair of the partnership to eliminate Child abuse and medical director of Kosair Children’s hospital.

Jennifer Newton: How did the partnership come about?

Dr. Stephen Wright: It probably really started back in 2001-02. We were averaging almost one death a month from nonaccidental trauma in kids, and I just thought, “There’s got to be something more that we can do.” So we started a Child Abuse Task Force at Kosair Chi. One of our initial things was to do some train-the-trainer sessions on pediatric abusive head trauma … and we created posters and provided education for physician offices, nurses, and nursing schools.

Then last fall, within a two week period, we had two babies come in with devastating injuries … I got to thinking, “Is there a way to partner with the news media to get the message out to masses of people?” Thinking of when there are natural disasters and they put up tips on the screen of how to be safe … We went to local media to pitch the idea.

They thought it was a good idea, and they were willing to participate. So we put this partnership together, and word just sort of started spreading.

What have you accomplished so far?

We’ve basically created this media toolkit.

In that toolkit are a number of things: the list of physicians who can speak to the problem, some tip sheets about things to watch out for and how to report abuse, op-ed articles, 30-second public service announcements, and a 14-minute awareness video.

We have physician liaisons that go out locally and throughout the state and visit physician offices, and we’ve provided them with

task Force?

They’re cousins of sorts. The Task Force still meets monthly. Its current initiative is to create a “No Hit Zone” within Kosair Children’s Hospital, Kosair Children’s Medical Center – Brownsboro, and UofL Pediatrics … Basically that’s a program we borrowed from Cleveland Clinic where we train staff on how to react when they see adverse physical contact, whether it’s adult to child, child to adult, or whatever, and let people know, in this institution, we don’t allow any hitting.

The other thing that we’ve done is we’re modeling a program started by neurosurgeon Dr. Mark Dias when he was in New

What are the financial and social implications of this issue?

The economic cost nationally is huge …

It adds up to over $1 billion in annual costs throughout the US … It’s also important to know this issue covers all races, all socioeconomic classes, and all religions. There’s really not any segment of the population that doesn’t have some responsibility for causing these issues.

All of us in the partnership share the mission of working together to care for these kids and try and prevent the next one from getting injured. ◆ September 2012 11

Coordination of Care

daniel’s Care expands to include Longer term pediatric palliative Care by todd Coté, md For more than 30 years, children with lifethreatening or life-limiting illnesses have received special care at Hospice of the Bluegrass. Since 1997, children have also had access to Daniel’s Care, a robust and nationally recognized Hospice program that helps infants, children, adolescents, and their families deal with the day-to-day struggles of living with a life-threatening illness or condition.

Hospice of the Bluegrass is a nationally recognized program that began with home visits and expanded to include collaboration with the Kentucky Children’s Hospital and the UK College of Medicine to help develop pediatric palliative services.

Some common diagnoses for Daniel’s Care patients include neurodegenerative disorders, cancer, inoperable heart defects,

and severe birth defects. Because Daniel’s Care is affiliated with Hospice, parents are sometimes concerned that partici-

pating in the program means giving up hope. That is never the case. With Daniel’s Care, all current treatments may be continued, and do-not-resuscitate orders are not required. This was also recognized by the Patient Protection and Affordable Care Act (PPACA), which became effective in 2010. The PPACA requires state Medicaid programs to pay both curative and hospice services for children under the age of 21.

Pediatricians or primary care physicians refer patients to Daniel’s Care. Each child is served by a team of professionals.

Each member of the Daniel’s Care team has received specialized training to care for pediatric patients. Team members may include a physician, pediatric nurse, chaplain, social worker, expressive therapist, bereavement counselor, home care aide, and volunteers. Daniel’s Care nurses will come

Sturgill Turner’s health care legal team is committed to providing comprehensive legal services to health care professionals, institutions and managed care organizations.

Serving health care providers with integrity.

LEXINGTON ◆ STURGILLTURNER.COM 12 m.D. UpDate

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Abandon the ordinary.

Embrace the extraordinary. to the patient’s home and help with medical care. Social workers and therapists work with the child and other family members on coping with the illness. Chaplains are available to discuss spiritual questions and issues. Home care aides help with patient care and light housekeeping, and volunteers are available for everything from companionship, running errands, and providing transportation to providing a break for the parent or caregiver.

Daniel’s Care may also provide specialized medical equipment like wheelchairs and oxygen monitors, medicines, and emergency funds for food, rent, and utilities.

Daniel’s Care is the only end-of-life pediatric program in northern, central and southeastern Kentucky providing this vital care and support to children with lifethreatening illnesses and their families.

In 2010, Daniel’s Care went through its biggest change since its inception – the addition of longer-term palliative care. The change expanded access to children’s hospice care for Kentuckians throughout the north, central and southeastern parts of the state. Daniel’s Care is now able to see children earlier in their prognosis and can offer a continuum of care from labor and delivery to NICU, PICU, and beyond.

Approximately 50,000 children die in the United States each year, but the dynamics of pediatric care are changing as children are living longer with chronic illness.

Pediatric palliative medicine is growing as we look to evidence-based and measurable ways of handling complex cases.

Daniel’s Care is available to families with or without health insurance, and services are provided with no out-of-pocket expense to the family. While individual donations and grants have enabled Daniel’s Care to provide for the needs of these children when private insurance, Medicare, and Medicaid are insufficient, additional funding is always needed to ensure that these families continue to receive the medical care, medicines, equipment, and support they need.

For more details or to make a referral, visit www.hospicebg.org or contact Donna Armstrong, Daniel’s Care director, at (859) 276-5344 or (800) 876-6005. todd Coté, mD, is Chief medical Officer of Hospice of the bluegrass ◆

The Doctors’ Ball Saturday, October 13, 2012 • Marriott Louisville Downtown Celebrate the amazing things the human body can do.

2012 Honorees

- 6:30 Cocktails & Silent Auction

Ephraim McDowell Physician of the Year Steve Raible, M.D.

- 8:00 A Magical Meal Black Tie and Bedazzled

Community Leader of the Year Henry V. Heuser, Jr.

To RSVP, visit us online: giving.jhsmh.org

Excellence in Community Service Donald Varga, M.D.

To learn more, call 502.587.4596

Excellence in Education Robert Acland, M.B.B.S., F.R.C.S. Excellence in Research Richard Neal Garrison, M.D.

The Doctors’ Ball

Compassionate Physician Award Susan Berberich, M.D.

Sponsors

Presenting:

Platinum:

Diamond:

The Jewish Heritage Fund for Excellence

Gold:

September 2012 13

Cover STory

Caring for Kentucky’s Children

Pediatric Subspecialists at the State’s University Hospitals Provide Leadership, Insight, and a Medical Home for Complicated Pediatric Cases

By JeNNifer S. NeWToN ANd MegAN CAMpBell SMiTh

It’s a tough job – informing parents that their child has an incurable or potentially devastating disease and navigating that child’s long-term treatment. Yet pediatric specialists spend an entire career doing just that. In Kentucky’s major university healthcare settings, pediatric specialists are diagnosing enigmatic disorders, managing chronic conditions, and researching more effective treatments to allow children the simplest opportunity … to just be kids.

University of Louisville

University of Louisville Physicians-Pediatrics is the largest of the UofL Physicians service lines, with 175 medical specialists. Covering everything from adolescent medicine to infectious disease, these specialists, who are all faculty at the UofL School of Medicine, provide clinical care, conduct research, and train pediatric residents. They are the major providers of medical care at Kosair Children’s Hospital.

UofL physicians-pediatric Nephrology

A New Way of Thinking Getting patients to change lifestyle habits is notoriously difficult. Changing the behavioral patterns of adolescents, who view themselves as invincible and are heavily influenced by the actions of their peers, is even harder.

Adolescent hypertension is on the rise in the US but awareness is not nearly at the levels of diabetes or obesity.

David Kenagy, MD, joined the Pediatric Nephrology program in May 2012 and has his sights set on “taking a different approach to hypertension.” Kenagy says, “The nephrologist has a big part in figuring out why hypertension is happening and recommending treatment.”

For some children, hypertension results from specific, treatable diseases of the kidney. But the greatest increase in hypertension is happening to adolescents who have a strong family history of hypertension, a sedentary lifestyle, a high sodium intake, and normal laboratory test results.

He attributes the rising levels of hypertension to improved recognition by pediatricians and an increase in obesity,

14 M.D. UpDate

sodium intake, and sedentary lifestyles.

Kenagy envisions a new approach to adolescent hypertension, designed to change outcomes. He notes that traditional healthcare delivery systems have failed to stem this rising tide. His approach centers on the idea of a shared medical appointment. It is “a method of delivery of healthcare that’s been pioneered in a variety of different settings,” says Kenagy, including obstetrics and well child care. Bringing patients with the same diagnosis together to provide management tactics in a group setting allows patient to learn from and with their peers. Patients still get the benefit of seeing the physician one-on-one. “They’re not just learning from the nurse or dietician practical ways to put this into practice. They’re also in the same room with people who are similar to them from their perspective – similar age, similar gender, similar sociocultural group, similar disease process,” he advocates.

a Support Mission

Kenagy views the Nephrology division’s role as “a support mission for other specialties.”

Kenagy and fellow pediatric nephrologist Sushil Gupta, MD, are often asked to consult on lupus management, blood pressure medications, or determine the cause of sudden changes in kidney function. “In the outpatient environment, a good portion of our work is helping children and their

Kenneth N. Schikler, MD, board certified in pediatrics, pediatric rheumatology, and adolescent medicine.

families to navigate the course after kidney disease begins but long before dialysis or transplantation is necessary,” Kenagy says.

Kenagy and Gupta both have a decade of experience in general pediatrics, an advantage in evaluating the whole patient and augmenting the services of the general pediatrician.

pediatric Dialysis Unit

Kenagy left Rainbow Babies and Children’s Hospital in Cleveland, Ohio, part of Case Western Reserve University, to join UofL last spring. “It was UofL’s enthusiasm about building a pediatric dialysis unit that attracted me to come here,” says Kenagy.

In the US, children constitute only about 1% of patients with end stage renal disease (ESRD), meaning most receive dialysis in centers designed for adults. “Only a few locations in the country have made the decision to tailor their dialysis operations to children,” he says.

The pediatric dialysis unit is in development. The core staff is led by Liz Reed, RN, an administrator from Kosair Children’s, who has extensive experience in transplantation and directs the heart and kidney transplant programs.

Drea Baker, RN, (peritoneal dialysis) and Kathy David Kenagy, MD, board certified in Baker, RN, (hemodialysis and pediatrics and pediatric nephrology.

transplantation) are experienced managers of kidney diseases and are already creating dialysis guidelines.

Plans for the physical plant are in the works. The unit will be located in a new medical building, half a block from UofL’s current pediatric offices, which will house almost all the outpatient offices for every pediatric specialty and will be connected by pedestrian bridges to the hospital.

Kenagy describes it as “a medical home … so the child who not only has a need for dialysis but also has a seizure disorder or lung disease – same building, same parking lot, and same location.” Construction is projected to be complete in 2014.

When it comes to treatment for renal insufficiency, Kenagy much prefers peritoneal dialysis to hemodialysis where appropriate. Offered in the child’s home and administered while the child sleeps, peritoneal dialysis requires more effort on the part of parents but offers a more physiologic, less disruptive, and more convenient care model for many patients. Hemodialysis is conducted in a dialysis center and requires patients to come to the center three to four times a week for two to four hours at a time.

The new center will provide comprehensive kidney care: hemodialysis for some, peritoneal dialysis training and support for others. But for all, the center will prepare for transplantation and provide state-of-the-art care afterwards.

UofL physicians-pediatric rheumatology

A detective’s Work “Basically, rheumatologists all over end up being the depository for patients who don’t fit anywhere else,” says UofL pediatric rheumatologist Kenneth N. Schikler, MD, who likens his job to that of a detective. He and colleague Kara Schmidt, MD, see patients that are referred to them by primary care physicians, infectious disease specialists, oncologists, and orthopedic surgeons for unexplained joint or musculoskeletal pain, general malaise, abnormal lab tests, as well SepteMber 2012 15

Cover STory

as unexplained fevers, rashes, or chronic pain.

A veteran on the UofL campus, Schikler joined the faculty in 1976 as the director of Adolescent Medicine for the Department of Pediatrics. Long before pediatric rheumatology was a board-certified subspecialty, Schikler began seeing children with chronic, undiagnosed rheumatologic conditions, which led to him to “retool” himself in the subspecialty of pediatric rheumatology. In the mid-80s, Schikler was appointed as director of Pediatric Rheumatology by Dr. Billy F. Andrews, the chairman of the Department of Pediatrics at the time.

Fortunately, according to Schikler, most of the complaints children and adolescents are referred for have explanations. Central pain processing disorders, such as fibromyalgia, are the most common diagnoses Schikler and Schmidt see, numbering well over 200 patients. A chronic musculoskeletal pain condition, not an inflammatory disease, fibromyalgia is “associated with fatigue, recurring headaches, recurrent abdominal pain, lightheadedness or passing out frequently in addition to chronic widespread musculoskeletal pain for at least three months,” he says.

It often goes unrecognized, as lab tests and x-rays should be normal and not indicative of an inflammatory process.

Juvenile idiopathic arthritis (JIA) is the most common of the rheumatic inflammatory diseases and is characterized by unexplained arthritis that is present for at least six weeks. It affects between 10 to17 out of every 100,000 children. Other conditions include: systemic lupus erythematosus (SLE), juvenile dermatomyositis, scleroderma, less common vasculitides, and mechanical pain issues.

remission, Not Cure

“We never talk about cure. “We talk about inducing remission,” says Schikler, whose treatment goal is “to have kids function the way kids are supposed to function and have normal childhood and adolescent lives as they progress to adulthood.”

16 M.D. UpDate

Treatments for inflammatory conditions include NSAIDS and immunomodulatory drugs, which can include corticosteroids, chemotherapeutic agents, intravenous immunoglobulin (IVIg), and biologic agents. The biologics are being studied in a number of different clinical trials but are already approved and being used in the clinic for JIA, vasulitides, and lupus. Intraarticular injections of corticosteroids for arthritis and rehab services (physical and occupational therapy) are also employed.

For central pain processing, treatments

iN The ouTpATieNT eNviroNMeNT, A good porTioN of our WorK iS helpiNg ChildreN ANd Their fAMilieS To NAvigATe The CourSe AfTer KidNey diSeASe BegiNS BuT loNg Before diAlySiS or TrANSplANTATioN iS NeCeSSAry. – dr. dAvid KeNAgy include pharmacological agents, aerobic exercise, and cognitive behavioral therapy, an area they found to be of benefit in a study in which they participated and which was published this year. Schikler chairs the Pain Committee for the Childhood Arthritis and Rheumatology Research Alliance (CARRA), which has put together a toolbox for treating patients with juvenile fibromyalgia.

research to target treatments

Stem cell transplantation is currently an end of the line treatment for children with some forms of arthritis, lupus, and systemic sclerosis, but Schikler is closely watching current research in adults with stem cell

infusions. The ultimate goal is to find more targeted treatments. “Things like steroids and methotrexate are fire hoses that target the entire immune system,” he says.

“Every JIA isn’t necessarily caused by the same alteration in one’s immune system or connective tissues. We’re trying to be more precise in understanding the specific defects that would enable more narrow focused targets in treatment, even beyond the great strides provided by the narrower focus of our current array of biologic agents.”

Research currently being conducted at UofL includes approximately 10 rheumatologic studies looking at biologic agents directed at inflammatory cytokines and modulation of the immune system and behavioral outcomes in patients with JIA. Schikler is also the chair of the Section on Rheumatology of the American Academy of Pediatrics, where he is helping to determine national policy in the field.

University of Kentucky Department of pediatric Hematology-Oncology

research, guidance, and prevention Let’s start with some good news.

Most children will survive childhood cancer. According to UK pediatric oncologist John A. D’Orazio, MD, PhD, up to 70% of all childhood cancers are curable.

“These are a very special group of kids who, through no fault of their own, get leukemias and lymphomas, tumors, and other cancers,” says D’Orazio. “The good thing about this field is that most of them can be cured. Fifty years ago, a child with leukemia would come in and the physician would give the family his deepest condolences and morphine, and it would be done in six weeks. But today, leukemia – ALL leukemia in particular – is 85%-plus curable. Some circles even say 90%, and that is directly the result of decades of clinical and science research. We are absolutely dedicated to that cause.”

D’Orazio’s commitment, as a physicianscientist, means he attends to the children

Sherry L. bayliff, MD, MpH, board certified in pediatrics

on UK’s pediatric hematology- and board eligible in pediatric hematology/oncology; oncology service and studies mela- John a. D’Orazio, MD, phD, board certified in pediatrics noma risk and prevention at the and pediatric hematology/oncology; and Vlad C. radulescu, MD, board certified in pediatrics and Markey Cancer Center.

“My research impacts the chil- pediatric hematology/oncology. dren that we see here in a more preventative way,” he explains. “Right now, we Children’s Oncology Group’s survivorship advise patients to stay out of the sun, wear guidelines to help patients and their physisunblock, and please don’t go to tanning cians better manage their health. salons. But, I am working on new ways to “We look for late effects of our chemoapply topical creams and sprays that would radiation, surgery, and all the interventions actually reduce their chances of getting we use to help cure or manage the disease,” melanoma.” says Bayliff, “and so move away from just Many people with fair complexions surveillance or observation for relapse.” By have a deficiency in their ability to produce taking a more predictive stance that, for melanocyte-stimulating hormone (MSH), example, a brain tumor survivor may face the hormone responsible for one’s ability radiation-associated osteosarcoma 10 or 15 to tan, and face a significant risk for mela- years later, Bayliff helps educate patients noma. D’Orazio’s research shows that the about the process of survivorship, being application of the drug forskolin can correct mindful of what to avoid and what to report this deficiency and produce a UV-protective quickly to their physicians. “Our goal is to tan. Furthermore, the drug is shown in mice show them that to be a survivor means to studies to repair the mutations caused by beat all odds.”

UV exposure in as little as 24 hours.

Forskolin, says D’Orazio is “too indis- Hemangiomas and Vascular criminate to be practical,” but as research Malformations narrows in on other ways to manipulate Guidance is a prominent term in Bayliff ’s the hormonal axes of the skin, D’Orazio is vocabulary. In addition to her work with hopeful that his research will have real ben- pediatric cancer patients and survivors, she efit to pediatric cancer survivors for whom helps patients, their families and pediatrimelanoma is “one of the overrepresented cians manage some very difficult, often secondary malignancies later on.” disfiguring vascular disorders through the To help pediatric cancer survivors moni- Pediatric Vascular Anomaly Clinic.

While hemangiomas affect about 10% tor the lifelong effects of chemotherapy and radiation, UK opened the state’s first Long- of newborns, Bayliff cautions that there are term Follow-up Clinic in 2008. Led by still a lot of misunderstandings around the Sherry L. Bayliff, MD, MPH, who is board condition. “Some people call any congenital certified in pediatrics and board eligible in vascular anomaly a hemangioma, but that is pediatric hematology/oncology, the clinic a misnomer,” she says. Rather, hemangioutilizes decades of research contained in the mas are benign tumors of the capillaries in

one select area, often in the head and neck, with a specific life cycle beginning at or within a few months of birth and lasting until age 10. “The capillaries continue to grow for a period of time and will reorganize, collapse, and then start to melt away until they are completely absorbed into the body.” She says much of her work is in helping parents form realistic expectations and guiding them toward trustworthy resources for information and support.

About one-fifth of hemangiomas require intensive medical care, especially when they interfere with vital structures. Some obscure vision or compromise breathing and feeding. “Babies with greater than five hemangiomas may also have them internally on their organs,” Bayliff advises, “and if they grow at a faster pace, they can cause a steal of blood flow and interfere with the function of the heart.” Further complications come from the breakdown and potential ulceration of the hemangioma, and some, if allowed to grow to their full potential can be very disfiguring. In these cases, coordinated interventions are necessary.

Vascular malformations are managed in a similar manner, and while congenital and causing lesions that last a lifetime, they may also manifest later in childhood or be discovered at the onset of puberty. Vascular malformations may involve venous, lymphatic and arterial vessels, or a combination of any the above.

“Klippel-Trenaunay syndrome is the most well-known of these abnormalities,” says Bayliff, “but treating it is very complicated.” Focusing on improved quality of life through symptom management, Bayliff prescribes compression garments, physical therapy, and occupational therapy to alleviate the discomfort and improve appearances. Orthopedics can help with a myriad of complications arising from the syndrome’s bony overgrowths, and plastics can improve surface bleeding through laser resurfacing of lymphatic malformations. Bayliff points out that new medications “will soon be part of the frontline studies,” including the immunosuppressant agent sirolimus, which works to reduce the potential for swelling in SepteMber 2012 17

Cover STory

lymphatic malformations. “What to expect from these conditions, even among pediatricians” says Bayliff, “is not very well known, so providing guidance from the consultation through the management of medications is one of my important roles.”

Hemophilia and Clotting Disorders

Here are three truths about the patients that come into this busy department: They have very special needs. They require preventative care to control symptoms and improve quality of life issues. They require coordinated treatments across specialties and shared management with their primary physicians.

In brief, this is not just a pediatric hematology/oncology clinic but, for many, a medical home.

“Hemophilia was one of the first disorders to use the medical home concept about twenty years ago,” says Vlad C. Radulescu, MD, pediatric hematologist/oncologist and director of UK’s Hemophilia Treatment Center. “We try to help patients with their lifestyle, work, and medical needs in order to prevent bleeds from occurring. Then, we try to achieve this at a minimum expense. It has been proven that in a coordinated setting, the treatment of hemophilia is superior in terms of effectiveness and cost when compared to treatment by a primary care physician.”

Utilizing federal and state funding,

the Hemophilia Treatment Center helps patients of all ages, particularly from central and eastern Kentucky, prevent bleeds and the significant impairments they can cause. According to Radulescu, clinical

WhAT To expeCT froM [heMANgioMAS ANd vASCulAr MAlforMATioNS], eveN AMoNg pediATriCiANS, iS NoT very Well KNoWN, So providiNg guidANCe froM The CoNSulTATioN Through The MANAgeMeNT of MediCATioNS iS oNe of My iMporTANT roleS. – dr. Sherry l. BAyliff

research at the center aims to optimize the timing of the administration of coagulation factor concentrate so as to reduce the risk of developing inhibitors. “Inhibitors not only destroy the clotting factor, which is very expensive,” he says. “They can lead to a situation in which it is very difficult to stop the bleed.”

Radulescu takes a similarly coordinated approach to the treatment of sickle cell disease and other clotting disorders.

Complications from sickle cell disease are well-known to impact the lives of middle aged adults, but the disease can be life-threatening to even the youngest patients. The center monitors these patients periodically to assess organ function, prevent infections, intervene with pain crises, and screen for risk of stroke.

Success in delivering quality care for clotting disorders, he says, is making sure that the team is very familiar with individual patients and their needs, and then being as forthcoming with the primary care physicians as possible.

“Thus, their care is more efficient and effective for the patient,” says Radulescu. “If they can come to a place where the nurse knows everything about them, where all their medical needs can be met in one place, it is much better than going from one doctor to another.”

Physicians will also be interested to learn that the preliminary data from the center’s research into pediatric thrombosis, a clotting disorder that has seen steeply increased incidence in recent years, “suggest that obesity may tip the balance over to clotting. More work needs to be done to determine whether that’s true and to understand the pathways to which obesity leads to clotting,” he says. ◆

Broadening Our Scope of Orthopaedic Care

George P. Boucher, MD

1780 Nicholasville Road, Suite 501 | Lexington | (859) 278-3481 | www.kybones.com 18 M.D. UpDate

SpeCiAl SeCTioN  Sleep MediCiNe

Sleep Medicine frontiers

Transportation Regulations & Adolescent Sleep By KAThryN hANSeN The 14th Annual Sleep Medicine Conference will be held in Louisville on October 26-27, 2012. Sponsored by the Kentucky Sleep Society (KYSS), presentations will examine sleep from both a clinical and an innovative perspective. Keynote speaker, Hon. Mark E. Rosekind, PhD, member of the National Transportation Safety Board, will address how sleep science can enhance transportation safety. Jayme Matchinski, JD, Hinshaw & Culbertson, LLC, will address the status for chain of custody with home sleep testing. Medication use by sleepy drivers will be discussed by Dr. Alan Lankford, chief science officer with Sleep Safe Drivers, Atlanta, Georgia. A new federal transportation bill signed into law in August 2012 is providing the impetus to advocate for safe driving.

Other topics, such as current regulatory standards for managing employees, will be presented by Betty Spohn, MA, Access Wellness Group. Financial expert Terry Crabtree will focus on future financial trends and discuss methods to evaluate and integrate financial monitors to increase fiscal productivity in the practice.

Kentucky Sleep Society executive Director Kathryn Hansen

Sleep deprivation and fatigue contribute to the health and well-being of youth and adults. This year the KYSS, under the direction of President Sarah Honaker, PhD, has strategically addressed adolescent and teen sleepiness and the benefits of a later school start time on adolescent sleep, learning, and overall function.

Frederick W. Danner, PhD, Department of Education, School and Counseling Psychology at the University of Kentucky,

THE KENTUCKY SLEEP SOCIETY PRESENTS THE 14TH ANNUAL

Sleep Medicine Conference Register Today: (859) 312-8880 or KYSS.ORG

will present “Drowsy Driving” and the challenges inherent in trying to do something about it.

Through the KYSS, members have collaborated with the Pritchard Committee to promote support for legislative and educational initiatives. The Pritchard Committee was organized 14 years ago for promoting legislative action to improve educational initiatives and increase community awareness about educational issues. The KYSS position statement will be released at the annual meeting in October.

“The Sleep Medicine Conference celebrates another year of commitment to our mission of providing nationally recognized education for our healthcare providers,” said KYSS Executive Director Kathryn Hansen, “providing innovative education to practicing professionals traveling from six states, to learn from national, regional, and local experts in sleep medicine.” ◆

Keynote Presenter

Hon. Dr. Mark E. Rosekind Member of the NTSB

Innovative perspectives on Clinical Sleep Medicine, Practice Management and Revenue Enhancement.

Chain of custody for home sleep testing.

Medication use by sleepy drivers.

Sleep deprivation among young adults.

Changing drowsy driving behaviors.

Regulatory standards for managing employees.

Increasing scal productivity.

SepteMber 2012 19

SpeCiAl SeCTioN  Sleep MediCiNe

fighting for Sleep

Owensboro Sleep Medicine Specialist Advocates for Treatment of Sleep Disorders By Gil Dunn Robert Pope, MD, a full-time sleep medicine specialist at Owensboro Advanced Sleep Center, is the current chair of the Insurance Committee with the Kentucky Sleep Society. To many physicians his volunteer work might sound like a recurring bad dream or a position that would keep him up at night. Pope takes it in stride, however, saying, “As a physician in private practice, I deal with insurance carriers every day. Having a dialogue with payers and moving forward on behalf of my specialty is something I enjoy and find rewarding. Sleep physicians face challenges in receiving appropriate reimbursement.”

Sleep Medicine has only been recognized as a specialty by the American Board of Medical Specialties since 2007. Findings from the Wisconsin Sleep Cohort study show that 15% of the US population has obstructive sleep apnea, and the number with untreated sleep-disordered breathing is large, with at least 12 to 18 million adults affected. Why the discrepancy?

In Pope’s view it is all about education and advocacy on local, regional, and national levels, and that is the role of the Kentucky Sleep Society (KYSS), of which Pope has been a member since its inception in 1999 and served as its president in 2005 and 2011. The KYSS was one of the first statewide sleep medicine groups in the nation and “was really ahead of the curve,” says Pope.

“Professional education for health care providers and sleep technologists is one the primary missions of the KYSS.” Current advocacy on legislative and insurance issues is important to Pope and the KYSS on two main points. One is statewide legislation to license polysomnography technologists, who are certified by various national organizations but have no current Kentucky licensing mechanism.

Pope believes this is a public safety issue that needs to be addressed by having a licensing 20 M.D. UpDate

board with oversight authority.

A second topic for advocacy is “home sleep testing” for sleep disorders. Clinical guidelines from the American Academy of Sleep Medicine (AASM) define the indications and limitations for home sleep testing (HST) for the diagnosis of

pope in private practice

Pope is a board-certified pulmonologist and internal medicine specialist, taking his residency and pulmonary fellowship at the University of Louisville’s School of Medicine in 1982. While working at Owensboro Medical Health System (OMHS), his interest in Sleep Medicine began due to increasing recognition of patients with OSA. In 2005, Pope left OMHS for St. Mary’s Hospital in Evansville, Indiana, to practice sleep medicine full time. He joined Owensboro Advanced Sleep Center in 2010 and is its medical director.

“We treat the entire range of sleep disorders,” says Pope, “with the exception of pediatric.” This includes OSA and central sleep apnea, insomnia, narcolepsy, circadian rhythm problems such as shift work disorder, restless legs syndrome, REM sleep behavior disorder, and sleeprelated eating disorder. Sleepwalking in adults and violent activity during sleep are investigated also, says Pope.

In recent years numerous studies have shown a link between OSA and cardiovascular diseases including hypertension, myocardial infarction, stroke, pulmonary hypertension, congestive heart failure (CHF), and arrhythmias such as atrial fibrillation. OSA is linked robert pope, MD with obesity, diabetes, mood disorders, and GE reflux. Cheyne Stokes breathing obstructive sleep apnea, but Pope is dis- is a form of central sleep apnea and is commayed that some insurance carriers are monly seen in patients with CHF. Long mandating HST for cost savings when acting opioids are increasingly recognized as it may not be appropriate, such as in the a cause of central sleep apnea. cases where other sleep disorders are susMost patients are referred by their pected, such as sleepwalking, narcolepsy, primary care physician, but many speor central sleep apnea. “This is clearly cialties have an interest in sleep disan area of conflict with insurance carri- orders including cardiology, neurology, ers’ efforts to reduce costs by skirting the psychiatry, ENT, dentistry, occupational guidelines of the AASM. An in-lab sleep medicine, bariatric surgery, and pain spetest is still the standard in many circum- cialists. Pope’s patient population ranges stances. On a local level, the Kentucky from 16 to 99+ years old, about equally Sleep Society can play a role in resolving male and female. “Men are more prone to this conflict,” says Pope.

OSA before age 50 than women, but postmenopausal women are at equal risk,” says

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Pope, adding, “insomnia and restless legs are more common in women.”

behavioral therapy in Sleep Medicine

For insomnia, a non-pharmacological approach is preferred by Pope including stimulus control, cognitive behavioral therapy, progressive muscle relaxation, and sleep hygiene. Pope recommends no televisions or computers in the bedroom. The blue light wavelength from digital devices, particularly in laptops and hand-held devices “sends an alerting message to the brain and makes it hard to sleep,” says Pope, who recommends “reducing exposure to this kind of light before going to bed also.” ◆

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SepteMber 2012 21

SpeCiAl SeCTioN  Sleep MediCiNe

Sleep Medicine on fast Track

ENT Specialist Leads Sleep Center at Georgetown Community Hospital By gil duNN

When Ron Shashy, MD, ENT, was looking for a location to start his private practice, Ear, Nose and Throat Specialists, PLLC, in 2006, the Bariatric Center of Excellence at Georgetown Community Hospital (GCH) factored prominently into his decision process. Shashy knew that 70 to 80% of bariatric patients have sleep apnea and many of them are undiagnosed. “I felt that an accredited sleep center was another service that we could bring to Georgetown Hospital for its bariatric patients,” says Shashy. And he was right. The Sleep Center at Georgetown Community Hospital is in its fifth year, and patient volume continues to grow.

Board certified in both Otolaryngology and Sleep Medicine, Shashy is the medical director of the GCH Sleep Center. He oversees all of the scoring and interpretations of the center’s sleep studies. Shashy led the center through its accreditation process with the American Academy of Sleep Dr. ron Shashy, MD, eNt Medicine (AASM) in 2007. “We reach and exceed the national standards for sleep CPAP (continuous positive air pressure) centers in diagnosing and treating sleep and because it is successful in nearly all of the restless leg disorders,” says Shashy. patients, if they will use it,” says Shashy.

Marketing the GCH Sleep Center is But, he says, half the patient population an additional role that Shashy embraces, with OSA will not use CPAP. Oral appliseeking to educate area primary care physi- ances and corrective surgery are Shashy’s cians on the 80% to 90% of patients who alternatives. are undiagnosed Behavior modiwith sleep apnea. To fication is also receveN AS A SurgeoN, My further this end, he ommended for a conducts seminars majority of patients. firST TherApy for Sleep with prospective He stresses weight ApNeA iS CpAp BeCAuSe iT patients at GCH loss and exercise, educational events both of which are iS SuCCeSSful iN NeArly and meets individupart of his daily life 99% of The pATieNTS, if ally with area genwhile training for eral practitioners, the Ironman triathThey uSe iT properly. oral surgeons, and lon. ”I speak to my – dr. roN ShAShy patients regularly dentists.

“As an ENT on the value of fitphysician, the vast ness,” he says. majority of patients that I see with sleep disHome-based sleep study testing is a new orders have obstructive sleep apnea (OSA). development in sleep medicine that presents But even as a surgeon, my first therapy is a new option for Shashy. Home testing is 22 M.D. UpDate

not as standardized as a clinical setting, he states. However, “I see it as a cost containment measure for patients who have high deductibles, but it’s not for everyone.”

The growing population of patients with sleep disorders is his real concern. The population is getting more obese, which translates to more sleep apnea, diabetes, and hypertension. “The greatest conflict I see is that the payment organizations, such as Medicare and insurance companies, want to spend less on sleep disorders, but the demand is increasing,” states Shashy.

training & Diagnostic approach

Many physicians take a circuitous route to finding the home for their private practice.

In this respect, Shashy is no different. He graduated from the University of Notre Dame in South Bend, Indiana, in 1991, and then spent four years in the U.S. Army as a Blackhawk helicopter pilot, taking a tour in Kuwait. In 1999 he graduated from the University of South Florida Medical School, and then completed his otolaryngology residency at the Mayo Clinic in Rochester, Minnesota. He is board certified in otolaryngology, head-neck surgery, and sleep medicine. After completing his ENT specialty training in 2004, he spent 18 months at a private clinic in Conyers, Georgia, before he and wife Evelyn found Central Kentucky. In 2010, Shashy opened a Frankfort ENT clinic with partner Chad Ahn, MD. Shashy describes his diagnostic method as “a regional approach - anything above the clavicle.” His goal is to take a fresh look at the problem uncovered by the general practitioner. ◆

Sleep Centers of Kentucky and Southern Indiana BAPTIST HEALTH SLEEP DISORDERS CENTERS AASM accredited  Subin Jain, MD, Pulmonary, Critical Care and Sleep Medicine, Medical Director  Mala LaCaze, RPSGT, Clinical Coordinator (mala.lacaze@bhsi.com ) BAPTIST HOSPITAL EAST 4000 Kresge Way Louisville KY 40207 (502) 896 7612 baptisteast.com/sleep BAPTIST HOSPITAL NORTHEAST 1025 New Moody Lane La Grange, KY 40031 (502) 222 8687 CENTRAL BAPTIST HOSPITAL SLEEP DIAGNOSTIC CENTER AASM accredited 1740 Nicholasville Road, Building E Suite 503 Lexington, KY 40503 (859) 260 4300 fax (859) 260 4319 centralbap.com  John R. White, MD, Internal Medicine, Sleep Medicine, Pulmonary and Critical Care  Alexander E. Tzouanakis, MD, Internal Medicine, Sleep Medicine, Pulmonary and Critical Care  Gregory Cooper, MD, Sleep Medicine, Neurology  Gerald Eichhorn, MD, Sleep Medicine, Neurology  Stephanie Sheffield, MD, Sleep Medicine, Neurology  James Winkley, MD, Sleep Medicine, Neurology  L. Brittany Cobb RPSGT, RST, Clinical Coordinator, Brittany.cobb@bhsi.com FLOYD MEMORIAL SLEEP DISORDERS CENTERS AASM accredited 1850 State St. New Albany IN 47150 (812) 949 5550 Floyd Memorial Sleep Lab- Corydon 313 Federal Drive, #040 Corydon, IN 47112 floydmemorial.com/sleep-center  Satish Rao, MD, MS, Neurology, Sleep Medicine  Azmi Draw, MD, Pulmonary, Sleep Medicine  Nuzat Hasan, MD, Pulmonary, Sleep Medicine GEORGETOWN COMMUNITY HOSPITAL SLEEP CENTER AASM accredited 1140 Lexington Road Georgetown KY 40324 (502) 868 1221 (877) 868 1221 Georgetownhosptial.com  Ronald Shashy, MD, ENT, Sleep Medicine

GRAVES GILBERT CLINIC THE PHYSICIANS’ CENTER FOR SLEEP DISORDERS AASM accredited The Medical Arts Building 350 Park Street Bowling Green, KY 42101 (270) 781 8420 or (270)781 5111 ggclinic.com/sleepDisorders.php  Wesley H. Chou, MD, Neurology, Sleep Medicine  J. Randall Hansbrough, MD, PhD, Internal Medicine, Pulmonary, Sleep Medicine  Douglas B. Thomson, MD, M.PH, Internal Medicine, Pulmonary, Critical Care, Sleep Disorders  James L. Salmon Jr., MD, Otolaryngology  Lalith C. Uragoda, MD, Internal Medicine, Pulmonary, Critical Care, Sleep Medicine  Michael J. Zachek, MD Internal Medicine, Sleep Medicine KENTUCKYONE HEALTH JEWISH HOSPITAL SHELBYvILLE 727 Hospital Drive, Medical Annex Bldg Shelbyville, KY 40065 (502) 647-4341 JEWISH HOSPITAL MEDICAL CENTER EAST 3920 Dutchman’s Lane 1st Floor Louisville, KY40207 (502) 259-6566 FLAGET MEMORIAL HOSPITAL Joint Commission Accredited 4359 New Shepherdsville Road Bardstown, KY 40004 (502) 350-5475  Eugene Fletcher, M.D.  Zaka Kahn, M.D.  Warren Shakun, M.D. SAINT JOSEPH BEREA Joint Commission Accredited 305 Estill St., 4th Floor Berea, KY 40403 (859) 986-6524  Jeremiah Suhl, M.D. SAINT JOSEPH EAST Joint Commission Accredited 160 N. Eagle Creek Drive, Suite 302 Lexington KY 40509 (859) 967-5044  Pamela Combs, M.D.  Jeremiah Suhl, M.D.  James M. Thompson, M.D.  Pell Wardrop, M.D.

SAINT JOSEPH LONDON Joint Commission Accredited 1370 West 5th Street London, KY 40741 (606) 877-1096  Muhammad Iqbal, M.D.  Aqeel Mandviwala, M.D. 1780 Forest Drive Corbin, KY 40701 (606) 528-8144  Deepa Nedhiry, M.D.  Steve Morton, M.D.  James M. Thompson, M.D.  Byron Thomas Westerfield, M.D.  Sarah Cecil, ARNP SAINT JOSEPH MARTIN Joint Commission Accredited 11203 Main Street Martin, KY 41649 (606) 285-3690  vijay Ammisetty, M.D. SAINT JOSEPH MOUNT STERLING Joint Commission Accredited 227 Falcon Drive Mt. Sterling, KY 40353 (859) 497-6013  Worawute Supaongprapa, M.D. STS. MARY & ELIZABETH HOSPITAL AASM accredited 4402 Churchman Avenue, Plaza 1 Louisville, KY 40215 (502) 361-6555 LEXINGTON CLINIC SLEEP CENTER AASM accredited 1221 South Broadway Lexington, KY 40504 (859) 258 4NAP (4627) LexingtonClinic.com/sleep  Wayne B. Colin, MD, DMD, Otolaryngology  John F. Dineen, MD, FCCP Internal Medicine, Sleep Medicine  Craig A. Knox, MD, Neurology OWENSBORO ADVANCED SLEEP CENTER AASM Accredited 1126 Triplett Street Owensboro, KY 42303 (270) 687-9000 www.sleepcycle.org or www.drvora.com  Dr. Robert Pope, MD, FCCP, FAASM Pulmonary Medicine

SpeCiAl SeCTioN  Sleep MediCiNe

A Scientific Approach to predisposing, precipitating, and perpetuating Causes of Sleep disorders Lexington Clinic Sleep Center Achieves Five Year Accreditation from AASM By Gil Dunn

John F. Dineen, MD, FCCP, believes that patients want to choose their healthcare providers based on the quality of care provided

John F. Dineen, MD, FCCp

and their access to it. “The highest quality of care is what we provide at the Lexington Clinic,” says Dineen, “not just in our Sleep Center, but throughout every department.”

Dineen is double board-certified in Internal Medicine/Pulmonary Diseases and in Sleep Medicine. He has been a member of Lexington Clinic since 1983 and director of the clinic’s Sleep Center since 2008.

Dineen proudly states that in August 2012, the American Academy of Sleep Medicine (AASM) re-accredited the Lexington Clinic Sleep Center for five years, a testimony he says that, “we adhere to the nationally recognized guidelines that are on the cuttingedge of sleep medicine, and we have the documentation to prove it.”

The staff of the Sleep Center deserves the recognition, says Dineen. All sleep techs are certified for the interpretations of polysomnographs, and he credits partners Craig Knox, MD, PhD, Neurology, and Wayne Colin, MD, DMD, Otolaryngology/ENT, plus the dedicated staff, for ensuring the center’s policies and procedures for patient care, comfort, and safety are upheld.

Attention to details and dedication to high standards of quality are at the core of the success of the Lexington Clinic Sleep Center. “Medicine is moving where industry has been for a long time, putting quality and safety control measures in place across the spectrum of healthcare,” says Dineen.

“We have technology and equipment that

we, the physicians and staff, must use to interpret the results accurately, for optimum patient care.”

Sleep medicine is developing a scientific basis for diagnosing and treating sleep disorders, just as the specialty has gained recognition and integration into general internal medicine. “The role that good sleep plays in our overall health has come to the forefront, and the development of treatments stem from understanding the patho-physiology

The role ThAT good Sleep plAyS iN our overAll heAlTh hAS CoMe To The forefroNT. – dr. JohN diNeeN of the disorders,” says Dineen.

Dineen cites narcolepsy, excessive daytime sleepiness, and inappropriate periods of uncontrolled sleep, as an example. “We know it is a neurological disease due to a deficiency of hypocretin in the brain. We have identified the neurotransmitters that play a significant role in the manifestation of narcolepsy. We don’t yet have a replace-

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24 M.D. UpDate

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LEVERAGE

ment for the hypocretin, but we can treat the patient with alerting agents. Perhaps, one day we’ll find the replacement therapy,” he says.

Other common sleep disorders such as obstructive sleep apnea (OSA), central apnea, and restless leg syndrome have benefitted from scientific methods that have led to measureable outcomebased treatment.

“There has not been enough scientific understanding of insomnia, but it’s coming,” says Dineen.

Home-based sleep studies are an example of science still in the observation stage, says Dineen, who nevertheless sees some benefit to home-based studies. “The home-based studies are less expensive but they are not as reliable as the overnight, observed, multi-channel polysomnograph, which we employ as the gold standard.”

A positive result for OSA from a home study in which the patient has a history of sleep disorder can confirm a diagnosis, but a negative result does not necessarily mean OSA does not exist. “It’s entirely possible that, without observation, the patient wasn’t properly wearing the device or simply wasn’t asleep,” Dineen states.

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predisposition, precipitation, & perpetuation

“The most common elements in sleep disorders are predisposition, precipitation, and perpetuation,” says Dineen. Patients can be predisposed to sleep disorders due to facial or genetic abnormality. A precipitating event such as obesity or smoking can be the catalyst, as well as the perpetuating cause of the affliction. Significant weight loss can eliminate both the precipitating and perpetuating causes, but “we don’t have a pill or a mask that causes weight loss, only a lifestyle change can cure that,” says Dineen. ◆

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SpeCiAl SeCTioN  Sleep MediCiNe

intellectual Curiosity

Brain Waves Lead Neurologist to Sleep Medicine By JeNNifer S. NeWToN

Consciousness. Myriad philosophers, theologians, and scientists have sought to define this concept for centuries, and it was an intellectual interest in consciousness and brain waves that led neurologist Satish Rao, MD, with Floyd Memorial Medical Group – Neurology, to the study of sleep medicine. Despite all the advancements of 21st century medicine

anniversary with Floyd Memorial, Rao is part of a multidisciplinary team at Floyd Memorial’s Sleep Disorders Center that also includes two pulmonologists, Azmi Draw, MD, and Nuzhat Hasan, MD. Rao asserts that the multidisciplinary aspect is essential to comprehensive care. Each of the physicians sees patients in their own clinic and refers patients to their colleagues as necessary. The Sleep Disorders Center itself has four beds in its Floyd Memorial Hospital location and two beds in a Corydon, Indiana, diagnostic center.

reM behavior Disorder

The center offers a full range of sleep services. Obstructive sleep apnea (OSA), restless leg syndrome, and REM behavior disorders (RBD) are the most common diagnoses Rao sees. RBD is a condition where people Dr. Satish rao, neurologist with the Floyd Memorial Sleep act out their dreams. and technology, according Disorders Center, believes sleep “When you go into to Rao, the best tool for will become a big focus of healthy dreaming sleep at night, measuring consciousness lifestyle initiatives in the future. all your skeletal muscles is the 80-year-old EEG. are paralyzed,” says Rao, “Even radiology scans do not replace the with the exception of the extraocular temporal millisecond resolution of brain muscles and diaphragm. However, in the waves,” he says. While brain waves can- case of some neurodegenerative disorders, not reveal the exact subject of a person’s such as Parkinson’s disease, Lewy body thoughts, they can indicate states such as disease, and Multisystem Atrophy, “that the eye movements of reading, drowsiness, normal paralysis is lost and [patients] start dreaming, seizure, or slow-wave sleep. acting out their dreams.” Identified as a A native Louisvillian, Rao received his biomarker for these diseases, Rao cites a medical degree and a master’s in neurosci- case series out of the Mayo Clinic, which ence from U of L. He pursued postgradu- says RBD can precede a neurodegeneraate training in neurology, epilepsy, EEG, tive disorder by up to 50 years, as shown and sleep medicine at the Mayo Clinic in in one patient. With a 60% transformaRochester, Minnesota. tion rate, the clinical challenge becomes: Having just celebrated his one-year how do you counsel a young RBD patient 26 M.D. UpDate

about their likelihood of developing Parkinson’s or a related disorder?

Identifying and treating OSa

Rao estimates that an average 12 to 15 million Americans have OSA but about 70% are undiagnosed. Although awareness is on the rise, so is the prevalence of OSA, which is increasing at 1% a year, attributable to an increase in obesity and the aging population. Rao recommends the STOPBANG or STOP questionnaires as easy-touse tools for identifying potential OSA. In addition, Rao suggests physicians consider sleep apnea as a cause or link in a young person with hard to control hypertension, low testosterone with unknown cause, and nocturia or urinating at night with normal prostate exam. “[OSA] puts its little fingers into almost every organ system,” says Rao, and can cause mood, metabolic, sexual, and

Sleep iS NoT A pASSive proCeSS. iT’S NoT your BrAiN JuST reSTiNg. WhAT hAppeNS NeuroCheMiCAlly iS AN ACTive proCeSS. iT’S liKe A highly orCheSTrATed SyMphoNy goiNg oN iN The BrAiN. – dr. SATiSh rAo memory symptoms.

In addition to continuous positive airway pressure (CPAP), other treatments include surgeries such as uvulopalatopharyngoplasty (UPPP) and maxillomandibular advancement (MMA). While, MMA has reported success rates of 70% to 80%, Rao

prefers the 100% effective, non-invasive CPAP to major craniofacial surgery. Palatal implants and oral appliances offer alternative treatments for those with mild OSA. One promising treatment currently in clinical trials is the hypoglossal nerve stimulator (HGNS), which acts like a pacemaker with a battery pack implanted in the chest wall. The surgeon connects electrodes to cranial nerve 12, which controls the tongue. When turned on at night, the HGNS stimulates the tongue to protrude upon breathing in, opening up the airway. â—†

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Kentucky ear, Nose, and throat Joins Lexington Clinic

lEXinGTOn On August 27, 2012, the Lexington Clinic announced the association of Kentucky Ear, Nose, and Throat as part of their strategic alliance to further enhance healthcare service delivery to patients.

Kentucky Ear, Nose, and Throat is an Otolaryngology physician group practice comprised of its founder Keith Alexander, MD; Gregory Osetinsky, MD; Kenneth “Tad” Hughes, MD; Alberto Laureano, MD; and Ray Van Metre, MD. The practice also includes Sharon Howard, APRN; five doctors of audiology and a total of 55 employees. Kentucky Ear, Nose, and Throat provides a wide range of services, including pediatric otolaryngology, adult otolaryngology, allergies, sinus disease, hearing loss, voice disorders, and head and neck tumors.

“We are pleased to become an associate practice of Lexington Clinic. By combining our efforts, we are better positioned to meet and exceed the challenges of a changing healthcare system and to provide the best care for our patients,” said Gregory Osetinsky, MD, president of Kentucky Ear, Nose, and Throat.

This association is expected to take effect on December 31, 2012 at which time Kentucky Ear, Nose, and Throat physicians will become members of Lexington Clinic’s Associate Physician Network.

baptist Healthcare announces rebranding, New addition

lOuiSVillE On September 5, 2012, Baptist Healthcare System, Inc. officials announced the rebranding of its health system to Baptist Health. The rebranding comes as the statewide system acquires an additional hospital, Pattie A. Clay Regional Medical Center in Richmond.

“We have for many years been much more than a system of hospitals, and the new name reflects the broad scope of services that Baptist provides throughout the state,” said Tommy J. Smith, Baptist Health president and CEO. “The addition of Pattie A. Clay Regional Medical Center means that we will be able to make our care more convenient to a greater number of Kentucky residents.”

The new brand is effective immediately, but changes on signs, the corporate website and each entity’s website will be made over the next few years.

The hospital acquisition comes as a result of a growing relationship with Pattie A. Clay and Baptist Health. In 2010, Pattie A. Clay Regional Medical Center and Baptist-owned Central Baptist Hospital entered a three-year management agreement which developed into ownership.

Central baptist Hospital to Manage russell County Hospital

RuSSEll SPRinGS Central Baptist Hospital in Lexington, Ky., has entered into an

agreement to manage Russell County Hospital in Russell Springs, Ky., effective immediately.

The three-year agreement creates an opportunity to provide greater accessibility to a wider robert L. ramey range of health services in Russell County, while exploring ways to reduce costs and maintain affordability of services. The management agreement will allow creation of a broader continuum of care, including enhanced alignment of physicians and hospital services.

The county-owned hospital has 25 critical-access beds, approximately 170 employees and 23 practicing physicians.

“Bringing together Russell County Hospital and Central Baptist Hospital provides us with an opportunity to create a comprehensive and high-quality health care system in Russell County that will be of great value to our patients, our employees and our community,” said Chris McQueary, Chairman of the Russell County Hospital Board of Directors. “This strategic partnership will allow us to work more closely with a leading health care system to provide high levels of care in the most cost-effective way.”

As part of the management agreement, McQueary announced the appointment of Robert L. Ramey as the Chief Executive Officer of Russell County Hospital, also effective immediately. Ramey has served in several

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capacities during his 17-year tenure at Central Baptist Hospital, most recently as administrator of Baptist-Physicians’ Surgery Center.

Neurological surgery group joins baptist Surgical associates

lOuiSVillE Steven Reiss, MD, FACS, is a 1982 graduate of Tulane University School of Medicine in New Orleans, La. He completed his general surgery internship at University of Louisville Hospital in 1983 and his neurological surgery residency there in 1989.

Wayne G. Villanueva, MD, FACS, is a 1989 graduate of the Columbia University College of Physicians and Surgeons in New York, N.Y. He completed his general surgery internship at the University of Cincinnati Medical Center in 1990 and his neurosurgery residency there in 1995, serving as chief resident during the last year.

Sara Seifert, PA-C, is a 2003 graduate of the Philadelphia College of Osteopathic Medicine physician assistant program.

Laura Tudor, APRN, is a 2004 graduate of the University of Louisville School of Nursing advanced practice nursing program.

tients experiencing acute failure of the cardiorespiratory system.

UK becomes only the 5th medical center in the U.S. to receive a triple designation, recognizing UK’s comprehensive ECMO treatment of neonatal, pediatric and adult patient populations.

ECMO uses an artificial lung device that provides cardiac and respiratory support to patients whose heart and lungs are so severely damaged that they can no longer function. It can also serve as a bridge to transplantation, allowing patients to not only survive, but to become stronger and healthy enough to undergo the transplant surgery.

The Excellence in Life Support Award recognizes programs worldwide that distinguish themselves by having processes, procedures and systems in place that promote

excellence and exceptional care in extracorporeal membrane oxygenation. To earn the designation, programs must promote the mission, activities, and vision of ELSO; demonstrate their ability to provide outstanding patient care by using the highest quality measures, processes, and structures based upon evidence; and excel in training, education, collaboration, and communication that supports ELSO guidelines and contributes to a healing environment.

UK began using ECMO in 1994, starting with neonatal patients before branching out. In the past year, Kentucky Children’s Hospital has used ECMO to support 12 neonatal respiratory patients, six pediatric cardiac patients and two pediatric respiratory patients.

The UK adult ECMO program has supported 26 adult patients in the past year

UK becomes 5th Medical Center in U.S. to receive triple Designation for eCMO

lEXinGTOn University of Kentucky Albert B. Chandler Hospital and Kentucky Children’s Hospital have been awarded the Excellence in Life Support designation from the Extracorporeal Life Support Organization (ELSO). The award recognizes UK’s commitment to using extracorporeal membrane oxygenation (ECMO) support for inpaSepteMber 2012 29

NeWS and represents a regional referral option for patients with end-stage heart and lung disease.

UK has always strived to be on the forefront of life-saving artificial lung technology. In 2009, UK HealthCare Surgeon-in-Chief Dr. Jay Zwischenberger, in partnership with UK Artificial Organ Laboratory Director Dr. Dongfang Wang, received a patent on the double lumen cannula, a device they created which greatly improved oxygenation of the blood and expanded the potential application of ECMO.

ephraim McDowell regional Medical Center earns re-accreditation from the Joint Commission

Ephraim McDowell Regional Medical Center (EMRMC) has earned The Joint Commission’s Gold Seal of Approval™ for accreditation by demonstrating compli-

DAnVillE

ance with The Joint Commission’s national standards for health care quality and safety in hospitals. The re-accreditation award recognizes EMRMC’s dedication to continuous compliance with The Joint Commission’s state-of-the-art standards.

The Medical Center underwent a rigorous unannounced on-site survey in December. A team of Joint Commission expert surveyors re-evaluated EMRMC for compliance with standards of care specific to the needs of patients, including infection prevention and control, leadership and medication management.

“In achieving Joint Commission accreditation, Ephraim McDowell Regional Medical Center has demonstrated its commitment to the highest level of care for its patients,” says Mark Pelletier, RN, MS, executive director, Hospital Programs, Accreditation and Certification Services, The Joint Commission. “Accreditation is a

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voluntary process and I commend Ephraim McDowell for successfully undertaking this challenge to elevate its standard of care and instill confidence in the community it serves.”

The Joint Commission’s hospital standards address important functions relating to the care of patients and the management of hospitals. The standards are developed in consultation with health care experts, providers, measurement experts and patients.

U.S. News ranks baptist Hospital east #1 in Metro Louisville, #2 in Kentucky WASHinGTOn D.C. Baptist Hospital East has been ranked first in Metro Louisville and second in Kentucky in U.S. News Media & World Report’s 2012-13 Best Hospitals rankings, tying with Norton Healthcare in both categories.

Listed as the state’s top hospital is the University of Kentucky Medical Center in Lexington.

The latest rankings showcase 720 hospitals out of about 5,000 hospitals nationwide. Each is ranked among the country’s top hospitals in at least one medical specialty and/or ranked among the best hospitals in its metro area.

Baptist East was recognized for 11 medical specialties: diabetes and endocrinology, ear, nose and throat; gastroenterology; geriatrics; gynecology; heart and heart surgery; kidney disorders; neurology and neurosurgery; orthopedics, pulmonary and urology.

The complete rankings and methodology are available at http://health.usnews. com/best-hospitals. ◆

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physicians testify in Frankfort on pill Mill bill

FRAnKFORT Kentucky physicians and representatives for hospitals, nurses and pharmacists testified in Frankfort on August 15, 2012, during a hearing before the Implementation and Oversight Committee on HB 1, known as the Pill Mill Bill.

Testimony addressed various problems such as medical providers in Emergency Rooms following the regulations requiring that a doctor or nurse practitioner administering a controlled substance document a treatment plan, obtain a patient’s written informed consent and perform a KASPER inquiry prior to prescribing Schedule II and III controlled substances. Melissa Platt, MD, president of Kentucky chapter American College of Emergency Physicians said that in “an ambulance or emergency department physicians do not directly administer the medications.

Either qualified nurses or paramedics complete the physical act.”

Gregory A. Hood, MD, FACP, Governor ACP Kentucky chapter testified that the problems with HB 1 “lie not with its necessity and good intentions, but rather with the vast number of unintended consequences created along this path of good intentions.”

robert bratton, MD, Chief Medical Officer, Lexington Clinic, testifies in Frankfort on inconsistencies of Hb 1. “Neither Hb1 nor the KbML regulations address the requirements in terms of a multi-specialty group practice.”

(CeNter) Gregory a. Hood, MD, FaCp, Governor aCp Kentucky chapter. “I have personally encountered a number of examples of excessive and unnecessary consequences of these regulations.” (rIGHt) Dr Shawn Jones, president Kentucky Medical association, told committee members of the numerous inquiries, questions and complaints regarding the requirements of House bill 1.

(LeFt)

HB 1 requires the physician to perform a complete history and exam before prescribing controlled substances. In response to that requirement, Robert Bratton, Chief Medical Officer, Lexington Clinic noted that certain specialists do not perform complete histories and exams. He cites ophthalmologists as an example of a “specialist who performs a medical history relevant to the problem he/she is treating.”

Kentucky Medical Association (KMA) president Shawn Jones, MD, and KMA Executive Director Patrick Padgett addressed decriminalizing administrative, record keeping and reporting requirements of the bill; exempting Schedule IV and V for episodic pain among other issues.

Additional hearings will be heard by the committee. For more information contact the KMA, 502 426 6200. ◆

Lexington Medical Society Golf Outing

lexiNgToN The annual lexington Medical Society (lMS) golf Tournament was played under sparkling blue skies and excellent weather conditions on Wednesday August 29, 2012 at the university Club in lexington with 90 golfers participating.

The winning team in the 18 hole shamble format was eddie Burkhart, Marty Chiles and Nick landers. Second place went to the Central Baptist team of John voss, Md, rusty page Md, derrick hord and Mike rukavina, Md. other winners were closest to the pin, Bruce Broudy, Md and robin Bradley; longest drive by female, Wendy Cropper, Md. The lMS golf outing was started 23 years ago to bring physicians and community members together,” said John Collins, Md, lexington Clinic, chair of the lMS

Dr. John Collins, Ophthalmologist at Lexington Clinic takes advantage of a good lie on the fairway with the help of Dr. Jim bottiggi, also with the Lexington Clinic as ron Sanders, phD, (left) and Dr. Michael Cecil, Lexington Clinic observe the unusual shot.

(CeNter) the team of brian Dineen, John Dineen, MD, Lexington Clinic, bruce broudy, MD, Lexington Clinic & president of the Lexington Medical Society and Mike Marnhout, bluegrass Oxygen mixed youth with experience for a good showing. (bOttOM) (l-r) rusty page, MD, Lexington Surgeons, Mike rukavina, MD, Lexington Cardiology at Central baptist John Voss, MD, Ob/GYN, Women’s Care Center and Derrick Hord, physician recruiter manager at Central baptist Hospital came in 2nd place. (tOp)

golf Committee and tournament organizer. The first outing was about 40 participants. The proceeds from the tournament go to the lexington Medical Society foundation which takes requests for needy organizations with connections to the medical field.

The lMS foundation was originally organized to start the local blood bank. Now organizations such as Baby health, Nathanial Mission and more recently Surgery on Sunday are being supported. “These are outstanding examples of serving the medical needs of citizens who fall through the cracks in our health care system. doctors and nurses volunteer at these organizations to provide care at no charge or minimal charge,” said Collins.

“We hope to continue to grow the golf outing and have it for many years,” said Collins. ◆ SepteMber 2012 31

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enriching Community

latitude offers real life employment opportunities lEXinGTOn The words “employment” and “work” are consistent to all new Medicaid Waiver initiatives. For twelve years Latitude has been at the forefront in supporting the work/ employment efforts of the participants in our studio arts program. Artists in Latitude’s Studio Arts Program create employment Latitude artist tony opportunities and Dunn was featured in enrich our entire a solo exhibition, Up community via the Close and beautiful, exhibition and sale at Lexington’s of artwork.

Institute 193.

Latitude is the proud recipient of the 2012 Kentucky Arts Council- Governor’s Awards in the Arts, Community Arts Award. In the past three years Latitude artists have exhibited their artwork locally and internationally at galleries and museums from Lexington to Cincinnati, Atlanta, New York City, Moscow, London, Paris and beyond.

Collectors of Latitude artists’ work range from a French venture capitalist to the Mayor of Lexington. In addition, Latitude artists are referenced regularly in a variety of media from nationally broadcast television

32 M.D. UpDate

programs to articles and books.

To learn more about employment and advocacy opportunities at Latitude, contact Crystal Bader or Bruce Burris at (859) 8060195 or latitudearts@yahoo.com.

LIVe at bIrDLaND a New York experience

uK Singletary Center for the Arts Sat oct 20, 7:30pm.

NYC’s iconic Jazz club, Birdland, was founded in 1949 and named after its first headlining performer, Charlie Parker, aka “Bird.” Regular headliners for the landmark institution include America’s most esteemed Jazz artists: Dizzy Gillespie, Thelonius Monk, Miles Davis, John Coltrane, and Stan Getz are just a few who made Birdland their NY home.

LIVE AT BIRDLAND, directed by Tommy Igoe, recreates the ambience and experience of a night at Birdland. This dynamic new ensemble, straight from the jazz mecca of NYC, provides an unforgettable musical event that goes beyond the traditional and sets the standard for the 21st century jazz orchestra. The night will feature fresh treatments of iconic Charlie Parker compositions, as well as innovative arrangements from composers such as Chick Corea, Arturo Sandoval, Sting, Herbie Hancock, Lennon/McCartney, and Leonard Bernstein.

LIVE AT BIRDLAND will appear in concert at the UK Singletary Center for the

Arts on Saturday October 20, 2012 at 7:30 p.m. Tickets are $25 to $40 depending on seat location. For more information, call (859)-257-4929 or www.scfatickets.com. ◆

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

IT’S NOT JUST THE WAY

WE TREAT CANCER. IT’S THE WAY WE TREAT PEOPLE. A PASSION FOR MEDICINE WITH COMPASSION FOR PATIENTS. A cancer diagnosis comes with a lot of stress and anxiety.

At Baptist Health, it also comes with a superb multidisciplinary team to treat your cancer and treat you with care. They collaborate to form a plan of treatment specialized to meet your needs, all with the ultimate goal of making you well and making your cancer a thing of the past. For more information on this innovative approach, call (502) 897-8131 or visit baptisthealthky.com.

BAPTIST HOSPITAL EAST | BAPTIST HOSPITAL NORTHEAST | BAPTIST EASTPOINT BAPTIST CRESTWOOD | BAPTIST URGENT CARE | BAPTIST MEDICAL ASSOCIATES

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EffEctivEly managing your rEvEnuE cyclE is thE kEy to opErating a hEalthy practicE. With Cash Flow Options from PNC and a dedicated Healthcare Business Banking team, we can help you take advantage of everyday untapped opportunities. Like helping ensure access to credit. So you can be prepared for cash shortfalls. Or accelerate receivables to effectively manage how you receive and direct incoming payments. For uncovering opportunities to help improve your revenue cycle and to learn more about PNC Advantage for Healthcare Professionals, visit pnc.com/cfo, stop by a branch or call 1-855-PNC-4HCP. SM

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All loans are subject to credit approval and may require automatic payment deduction from a PNC Bank Business Checking account. Origination and/or other fees may apply. PNC is a registered mark of The PNC Financial Services Group, Inc. (“PNC”). Cash Flow Options is a service mark of The PNC Financial Services Group, Inc. © 2012 The PNC Financial Services Group, Inc. All rights reserved. PNC Bank, National Association. member fDic