M.D. Update Issue #85

THE BUSINESS MAGAZINE OF KENTUCKY PHYSICIANS AND HEALTHCARE PROFESSIONALS iSSue #85

Special SectioN RURAL HEALTH AND GASTROENTEROLOGY/BARIATRICS/ GENERAL SURGERY

Longevity Breeds

efficiency, expertise, & LoyaLty

Volume 5, Number 3

owensboro surgery center prides itself on 30-year tradition of putting patients first in western Kentucky

alSo iN thiS iSSue  teLeMedicine expands pHysician access  endoscopic ULtrasoUnd in georgetoWn  Bariatric sUrgery prevents co-MorBidities  Long-terM refLUx reLief WitH Linx®  diaBetes nUtrition

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Letter from the editor

road trip For those of you who follow our editorial calendar, this issue is the result of a combination of the topics we had originally slated for March and April. It encompasses Gastroenterology, General Surgery, Bariatrics, Surgery Centers, Nutrition, Rural Health, and Physician Extenders. While that sounds like a mouthful, it actually came together quite nicely, as many of the gastroenterologists and surgeons we interviewed are practicing outside of Louisville and Lexington, providing a look at services in more rural areas of the Commonwealth.

Both M.D. Update Publisher Gil Dunn and I had the opportunity to visit Owensboro Surgery Center for our cover story. The center is a great example of how an organization has adapted over a 30-year period to maintain viability and keep its physicians and patients happy. With a large Medicare population, particularly due to its ophthalmology volumes, and an increase in Medicaid patients since the expansion in January, the center also shared with us some of its challenges and strategies in a rapidly changing field.

While the Affordable Care Act and Medicaid expansion seek to provide insurance coverage for more Americans, access issues in the form of physician shortages, geography, and financial limitations still abound for Kentuckians. KMA President Fred Williams, Jr., MD, sat down with us to give an update on physician extender laws. New regulations for physician extenders do not solve the physician shortage but do provide expanded access to physicians’ expertise through extended care teams.

One health system that is making strides in connecting Kentuckians with providers is KentuckyOne Health, which has two new telemedicine programs.

Anywhere Care provides a phone or video chat consultation with a primary care practitioner 24/7 from anywhere in the state. The Community Health Based Delivery Model offers clinics in Wolfe and Powell counties that are staffed by nurse practitioners, nurses, and office staff and are connected to physicians and specialists via telemedicine.

At Georgetown Community Hospital, Justin Case, MD, and Eric Smith, DO, demonstrate the latest technology in their community in articles on endoscopic ultrasound and sleeve gastrectomy, respectively.

And, speaking of technology, Lexington physician Jason Harris, MD, is the first physician to bring the LINX® Reflux Management System to the Bluegrass, providing lasting relief to intractable GERD patients.

These are just a few examples of what’s in store in this issue. Personally, I enjoy the opportunity to leave my home office in Louisville and venture into other areas of the state to hear what’s new or, as in the case of the cover story, just what’s been going right all these years. Large or small, your community’s health care challenges and successes are shared by others across the state.

Let us tell your story.

Sincerely, Jennifer S. Newton, Editor-in-Chief Send your letters to the editor to: jnewton@md-update.com, jennewton01@gmail.com, or (502) 541-2666 mobile Gil Dunn, publisher: gdunn@md-update.com or (859) 309-0720 phone and fax 2 M.D. UpDate

Volume 5, Number 3 Issue #85 PublIshers

Gil Dunn PrInt gdunn@md-update.com Megan Campbell Smith DIgItal mcsmith@md-update.com eDItor In ChIef

Jennifer S. Newton jnewton@md-update.com graPhIC DesIgner

James Shambhu art@md-update.com

ContrIbutors:

Jan Anderson R. Jane Lockhart, ARNP Barbara Mackovic James Patrick Murphy, MD Dave Peterson Christopher J. Shaughnessy Andrea Shepherd

ContaCt us:

aDvertIsIng anD IntegrateD PhysICIan MarketIng:

Gil Dunn gdunn@md-update.com

Mentelle Media, LLC

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Contents

Issue #85

Cover story 4 heaDlInes 6 fInanCe 7 legal 9 PhysICIan vIeWPoInt 11 Cover story

16 sPeCIal seCtIon: rural health 17 sPeCIal seCtIon:

LonGevity Breeds

gastroenterology/barIatrICs/

effiCienCy, expertise, & LoyaLty

Owensboro Surgery Center prides itself on 30-year tradition of putting patients first in western Kentucky

general surgery

24 CoMPleMentary Care 27 neWs 32 events

By Jennifer s. newton photoGraphy By Gary emord-netzLey paGe 11

speCiaL seCtion  ruraL heaLth 16 InnovatIon eXPanDs aCCess: kentuCkyone health teleMeDICIne

speCiaL seCtion  GastroenteroLoGy/BariatriCs/GeneraL surGery

17 brIngIng It hoMe: Case brIngs enDsCoPIC ultrasounD to georgetoWn

18 no easy WeIgh out: barIatrIC servICes In georgetoWn

19

23

MeDICal MagnetIsM: harrIs utIlIZes lInX® for refluX

enterra® theraPy for gastroParesIs: JeWIsh hosPItal

ISSUe#85 3

headLines

Legislative success

KMA and KCNPNM reach compromise on nurse practitioner oversight of Physician Assistants sought out the help finally caught fire,” says Williams.

One particular area of opportunity for of the KMA a year ago to clarify physician After a year of patient negotiation, the assistant (PA) regulations. “The problem is team-based care and telehealth is in rural Kentucky Medical Association (KMA) and that, especially in hospital practices, they areas of the state where patients do not the Kentucky Coalition of Nurse Practitioners were interpreting the law such that every currently have good access to physicians. and Nurse Midwives (KCNPNM) reached a time a physician’s assistant wrote an order, To meet the challenge of team members compromise on the issue of physician over- before anybody would carry it out, they not physically being in one place, providers sight of nurse practitioners. The ensuing leg- wanted a co-signature. must find communicaislation was passed by the Kentucky House So it created a lot of tion tools that are comand Senate, signed by the governor, and will administrative probpliant with stringent become law this summer. lems,” said Williams.

HIPAA regulations.

According to KMA President Fred A. The result of those disWhile the new legWilliams, Jr., MD, “What this legisla- cussions is SB 41, which islation will not solve tion does is it preserves something called passed the Senate with the physician shortthe ‘collaborative agreement.’ But, after a vote of 34-2, but has age, Williams says, a nurse practitioner practices under that not yet been voted on “Working together as collaborative agreement for four years, at by the House. a team though will at that point, he or she may practice indeleast enable more peoThe bill states that pendently, meaning they don’t have to only 10 percent of a PA’s ple, particularly in rural have a collaborative agreement to prescribe orders in a 30-day periareas, to have some sort non-scheduled drugs.” The law also stipu- od need to be co-signed of access to a physician’s lates that only advanced practice registered by the supervising phyexpertise.” nurses (APRNs) focusing on primary care sician, and a PA’s orders are eligible to practice independently after do not need to be coMedical Review panels the four-year period. Those working in spe- signed before being Fred a. Williams, Jr., MD, is an endocrinologist with endocrine and cialty areas of medicine must remain under carried out. “That’s Another bill before the Diabetes associates pSC in Louisville the collaborative agreement. legislature is SB 119, going to make life a and is the 2014 KMa president.

As the first bill the governor signed this lot easier not only for which seeks to estabsession, Williams describes it as “very, very physician assistants and lish medical review pansuccessful,” and attributes the ability to nurses, but also for the doctors overseeing els. The Care First Kentucky Coalition, come to an effective compromise to nego- them,” says Williams. whose members include KMA and a broad tiations that were allowed to happen over a group of other healthcare and business year’s time, rather than at the “11th hour,” extending physician organizations, is behind the bill. Williams Coverage in the State explained, “This panel would provide an in a more relaxed atmosphere.

Another aspect of the legislation is the When it comes to physician extenders, independent, expert review of proposed establishment of a joint advisory commit- Williams and the KMA are champions of claims against health care providers to tee under the Kentucky Board of Medical team-based care. In fact, Williams says he determine whether the medical standard of care was breached.” He further stated, “Claims may still proceed to court where this LeGisLation preserves the “CoLLaBorative the panel’s opinion would be admissible.” aGreement,” But after a primary Care nurse The panel would consist of three experts, chosen by each side and one that would praCtitioner praCtiCes under that aGreement for four one be independent. Currently the bill is stuck in the House, and the coalition is undertakyears, he or she may praCtiCe independentLy. ing a public relations campaign to try and Licensure (KBML). “It enables KBML to and partner Dr. David Bybee went to (what sway House leadership.

Beyond legislation, Williams and his have more tools to oversee what sorts of was then) Alliant Health System 20 years strategic planning committee are halfway prescriptions nurse practitioners are writ- ago with a team-based care model to treat through their project. Williams predicts diabetes’ patients statewide. Telehealth was ing,” says Williams. there will be significant changes in the Less controversial than the issue of in its infancy at the time, but the physicians KMA’s future. ◆ APRN oversight, the Kentucky Academy saw its’ potential. “Now 20 years later it’s

By Jennifer s. newton

4 M.D. UpDate

headLines

Gaining Ground

The Kentucky Colon Cancer Screening Program is making strides against colon cancer By andrea shepherd, CoLon CanCer prevention proJeCt exeCutive direCtor In 2012, Kentucky launched an attack on its No. 1 cancer killer among non-smoking men and women.

That year was the first time funding was granted for the Kentucky Colon Cancer Screening Program (KCCSP), a population-based, public health initiative installed by the General Assembly in 2008 to provide colon cancer screenings for lowincome, uninsured Kentuckians ages 50-64.

The program consists of a network of state, regional, and local health professionals whose mission is to reduce new cases of colon cancer as well as the disability and death associated with colon cancer.

With $1 million from the state over two years, and a $1 million match through a public-private partnership with the Kentucky Cancer Foundation, the program officially launched in ten regions across the state encompassing 36 counties in early 2013.

The Kentucky Public Health Department manages the program, which provides a stool-based test for average risk patients and a colonoscopy for those deemed higher risk.

Since it began, more than 1,000 Kentuckians have received screenings. Of those, 151 have had pre-cancerous polyps found and removed, and eight cancers have been identified and treated.

“It’s not exaggerating to say this program saves lives,” Gov. Beshear told a crowd at a

Dr. Whitney Jones, founder of the Colon Cancer prevention project, at a press event organized by the project on March 13, 2014 at the Capitol to show support for the Kentucky Colon Cancer Screening program.

in the country, Beshear said.

He added: “Fortunately, we’re making progress.”

Beshear pointed to the fact that since 2007, Kentucky’s colon cancer incidence rate has fallen by 12 percent, and its mortal-

sinCe it BeGan, more than 1,000 KentuCKians have reCeived sCreeninGs. of those, 151 have had preCanCerous poLyps found and removed, and eiGht CanCers have Been identified and treated. press event on March 13 that was organized by the Colon Cancer Prevention Project, a non-profit working in Kentucky and surrounding communities to end colon cancer.

Kentucky has the highest incidence rate

ity rate has also fallen by 16 percent.

In an attempt to continue this reduction in cancer incidence and mortality, Beshear allocated $1 million for the KCCSP in his 2014-2016 budget, which would again

be matched through the public-private partnership with the Kentucky Cancer Foundation. After rigorous debate, funding for the KCCSP was included in the 2014 budget.

As executive director of the Colon Cancer Prevention Project Continuing, I believe this program is important to Kentuckians. It saves lives, allowing for precancerous polyps to be caught and removed before they turn into cancer. It is a wise use of money, with a 100 percent match by the Kentucky Cancer Foundation. And it is needed. Even with the Affordable Care Act, nearly 400,000Kentuckians will remain uninsured.

Tamara McNabb, who received a screening through the KCCSP, said she wants to see it continue.

“I think it’s important to keep this program around because it’s going to save lives,” McNabb said.

Whitney Jones, founder of the Colon Cancer Prevention Project and co-founder of the Kentucky Cancer Foundation, said no Kentuckian should go without proven prevention and early detection services.

“Our progress in radically improving Kentucky’s colon cancer statistics demonstrates the impact of implementing evidence-based, accessible, and pragmatic screening services,” he said. “Our broad statewide partnership’s success is a model for states battling the unacceptable colon cancer statistics. They are to be congratulated.” andrea Shepherd is the executive director of the Colon Cancer prevention project. For more information, visit www.

ColonCancerpreventionproject.org, kentuckycancerfoundation.com, or KCCSp at chfs.ky.gov/dph/ColonCancer.htm. ◆ ISSUe#85 5

finanCe

a personal Journey My father has Alzheimer’s Disease. Usually a very mild-mannered, quiet, and reserved man, in December his condition changed and he suddenly became combative, first with my 81-year-old mother and then with my younger brother. Mother was already bone-tired from being his primary caregiver for the past six years, and these episodes became the trigger for moving him to a long-term care facility. We had prepared for the eventuality that he would need some sort of assisted living. However, the family’s plan for using the facility closest to home was quickly dashed because it, like so many throughout Kentucky, is not staffed and equipped to handle residents with dementia, especially if they become combative. Any family who has been at this crossroads knows the gut-wrenching anguish that accompanies these decisions.

Advance planning lessens the burden. But let’s be honest, life gives us events that simply cannot ever be fully anticipated. I am reminded of Carl Richard’s Venn diagram containing two large overlapping circles, one is labeled “that which is important” and the other “things we can do something about;” the small center portion where they overlap is where planning needs to truly focus.

You will be glad to know that nearly all our planning clients place health care at the top of their priorities for setting spending targets; however, few are ready for the realities. Many people falsely believe that Medicare will cover their health care costs during retirement. The Employee Benefit Research Institute (ebri.org) reported in late 2013 that Medicare covers only about 62 percent of the cost of health care services (not including long-term care) for Medicare beneficiaries age 65 and older, while out-ofpocket spending accounts for 12 percent.

They went on to report that a married couple age 65, both with drug expenses in the 90th percentile throughout retirement would need $360,000 to have a 90 percent chance of having enough money to cover health care expenses (not including longterm care). It’s important for you to know that most of your patients have probably 6 M.D. UpDate

not planned for anything like this level of expense.

Moreover, while you are probably more focused on the reimbursement rate from Medicare, patients are more concerned, and

BY Scott Neal often surprised, with what it doesn’t cover.

Most people falsely believe that Medicare will pick up the tab for a stay in a long-term care facility. In fact, Medicare covers very little of those costs. It pays 100 percent of the first 20 days in a long-term care facility but only if it occurs after a qualifying three-day hospital stay. The next 80 days are partially covered, but ongoing therapy is required for the benefit to be paid. After those 100 days, Medicare does not pay for long-term care. The rules for eligibility were relaxed somewhat just this year. Prior to 2014, the standard was for therapy to “improve” the patient’s condition; now it is simply to “maintain.” So just how much does long-term care actually cost?

Genworth Financial has a very useful website that breaks down the cost of care and, as you might guess, the costs vary by locale. For Kentucky, the 2014 median annual costs are $16,510 for Adult Day Care, $39,165 for Assisted Living in a private one-bedroom, $44,616 for Home Health Aide, $73,000 for a semi-private room in a nursing home, and $80,300 for a private room. Based on my own recent search, I can say that these estimates are fairly accurate. Furthermore, these costs grow by as much as five percent per annum.

Bear in mind that these are median costs for all adults. Care for someone with dementia is considerably more expensive.

Another variable that often gets overlooked in planning is how much long-term care will be needed. The U.S. Department of Health and Human Services site provides some statistics for the type of care, duration, and percentage of people who use

long-term care services. Keep in the mind “the flaw of averages” as you read statistics.

Averages are based on large populations.

You and I and everybody else comprise a population of one, subject to “black swan” events. On average though, “someone turning 65 today has almost a 70 percent chance of needing some type of long-term care services and supports in their remaining years. Women need care longer (3.7 years) than men (2.2 years). One third of today’s 65-year-olds may never need longterm care support, but 20 percent will need it for longer than 5 years.” Interestingly, more people (65 percent) use long-term care services at home (and for longer periods) than in facilities. Many falsely believe that staying at home is cheaper. It can become more expensive and is certainly more costly if you take into account the lost productivity and travel costs for care-giving family members.

Even if you are one of those physicians who says, “I’ve got this covered,” it’s a good idea for the entire family to be prepared.

If you don’t know your parents’ plan, now is the time for “the talk.” Caregiving often extends to every family member and sometimes even to friends. I don’t have to remind you that care for dementia patients is an extremely stressful proposition and waiting for a crisis to develop before taking action only increases the stress. Eventually, the primary caregiver, which is usually the spouse, will become exhausted or simply reach the end of his or her rope. Half of all caregivers report experiencing significant psychological distress, including depression.

This obviously leads to other health issues and is all-too-often preventable. We are recommending this conversation to occur for anyone over the age of 60.

Scott Neal is the president of D. Scott Neal, Inc., a fee-only financial planning and investment advisory firm, with offices in Lexington and Louisville, where we talk about things like this. If you, or someone you know, would like to have a conversation with us, email scott@dsneal.com or call 1-800-344-9098. ◆

LeGaL

seeing the Good in iCd-10 Technical, health care-related system changes are a huge burden. Just ask the Obama Administration. The Affordable Care Act has taught us that industry-wide overhauls are difficult and time-consuming. Change can be hard, and costly, but sometimes it is necessary for the greater good. Such is the case with ICD-10 coding. Physicians may doubt the benefits of an upgraded coding system. Can improved patient care and better public health really be accomplished with different data entry?

The answer is yes. And, regardless of whether physicians agree or not, they must still jump on the ICD-10 bandwagon if they are a HIPAA covered entity (as must payers and clearinghouses). Luckily, in September 2012, the Department of Health and Human Services pushed the compliance date back to October 1, 2014. While this deadline is months away, there is much

to be done now for a successful transition.

Background

To really understand the need for a new coding system, physicians must see the

BY Christopher J. Shaughnessy bigger picture and understand the history behind the codes. In the mid1800’s, European doctors and statisticians sought to develop uniform, international classifications for causes of death to be used in death certificates and from that initiative the first draft of the code system was born.

Today, the International Classification of Diseases (ICD) is the standard diagnostic tool for epidemiology, health management,

and clinical purposes. It is used to monitor the incidence and prevalence of diseases and other health problems; classify diseases and other health problems recorded on many types of health and vital records including death certificates; and, provide the basis for the compilation of national mortality and morbidity statistics by WHO Member States. In addition, these codes help governments and private health insurers assess a value for each patient visit and determine how billions in health care costs should be allocated.

For decades, the American health care system has relied on ICD-9-CM’s threevolume set of codes. ICD-9 volumes 1 and 2 contain reporting codes for diagnoses and symptoms. Volume 3 contains codes for reporting hospital inpatient procedures.

In October, the ICD-10-CM will replace ICD-9-CM volumes 1 and 2 and ICD-

PROMISES

Made PROMISES Kept

Nearly two decades ago, we made a promise to help our members live healthier lives. Now we’ve expanded that promise to include Kentuckians throughout the commonwealth.

We invite you to become part of our growing network of healthcare providers helping us improve the health and quality of life of all Kentuckians.

Contact our Provider Contracting department at 502-585-8357 or 800-578-0775 ext. 8357.

www.passporthealthplan.com

PASS1777-3_ProviderRecruitmentAd_v2.indd 2

Passport Health Plan is the trade name for University Health Care, Inc. © 2014 copyright of University Health Care, Inc.

2/27/14 9:23 AM ISSUe#85 7

LeGaL

10-PCS (“Procedure Coding System”) will replace ICD-9-CM volume 3. ICD-10 is not completely new to all health care entities. It has been used in American hospitals since 1999 to report hospital inpatient causes of death.

The limited use of ICD-10 within our health system is idiosyncratic when compared with the rest of the developed world.

ICD-10 received WHO’s endorsement over 20 years ago, in 1990. Many countries have long past adopted the version. The United Kingdom, for example, adopted it in 1995.

the Differences

The ICD-9 manual, with its mere 13,000 codes, pales in comparison to its newer counterpart. With 68,000 codes, the ICD10 is focused on exhaustive specificity. Is a patient’s injury the result of being sucked into a jet engine? There’s a code for that.

Did a patient’s hair cause external constriction? There’s a code for that, too. The ICD-9 codes are mostly numeric with three to five digits, whereas the ICD-10 codes are alphanumeric with three to seven characters.

In addition to the far-fetched injury scenarios and its new look, ICD-10 can differentiate between the left and right sides of the body and categorize a patient’s encounter with an entity as an initial or subsequent visit.

the Opportunities

Even critics of ICD-10 can agree that ICD-9 has run its course. It is full of outdated and obsolete terms. Advanced medical technology has resulted in new procedures and assessments, but the structure of the

current coding severely limits how these can be input. Coding chapters are divided according to body systems. Many of the complex body systems are have reached their code limit so that no new codes can be listed in these chapters. Coders have tried to account for new codes in other chapters to accurately reflect advances, but the result is a piecemeal set.

The increased precision has the potential to advance the quality of care that patients receive. Physicians will be able to better track a patient’s improvements or setbacks. Having thorough historical data regarding diagnosis and treatment can lead to improved future treatment, along with reducing the patient costs associated with that treatment.

There is massive room for research improvement. The lag in technology has made it extremely difficult for researchers to compare data with other countries in recent years. The U.S. will now be able to better respond to requests for information from the WHO and track worldwide health trends and concerns.

Providers will be better able to compare performance and outcomes with their peers.

The finer details can help physicians understand and improve upon current methods and procedures. Perhaps one of the biggest advantages providers can expect to see is increased efficiency with payors. ICD-9 codes were implemented before prospective payment systems existed. Once Medicare begin relying heavily on ICD codes for reimbursement purposes, choosing the right code became critical. As providers well know, additional documentation is

almost always required to support claims and coding errors are easy to make. With ICD-10, the specificity will enable payors to better understand submissions, resulting in reduced paperwork and fewer rejected claims. More effective detection and investigation of potential fraud or abuse will also be a positive outcome.

takeaway

Covered entities cannot begin using ICD-10 before October 14, 2014 (and few would be prepared to do so). Until September 30, 2014, ICD-9 codes must continue to be used. For care occurring on or after October 14th, only ICD-10 codes will be HIPAA-compliant. Just as we waited with bated breath on October 1, 2013, to see the health care exchange roll-out, so, too, will we wait to see how covered entities handle the revamp of coding.

ICD-10 is more than just another government regulation. It is more than an IT system upgrade. It will impact everyone in the industry. It will change manual processes in practice, policy, and procedures, the way we think about patient care, and hopefully the way it is delivered. They say the devil is in the details…and there is a lot of detail with ICD-10, but physicians have to be committed to seeing the good in it.

Christopher J. Shaughnessy is an attorney at McBrayer, McGinnis, Leslie & Kirkland, pLLC. Shaughnessy concentrates his practice area in health care law and is located in the firm’s Lexington office. He can be reached at cshaughnessy@mmlk.com or at (859) 231-8780. ◆

2335 Sterlington Road, Suite 100 Lexington, Kentucky 40517 (859) 268-1040 Fax: (859) 268-6165 Email: lprober ts@barcpa.com www.barcpa.com

8 M.D. UpDate

physiCian viewpoint

is there a method to this madness?

To prescribe or not to prescribe Zohydro ER…

By James patriCK murphy, md, mm, GLms president In March 2014, Zohydro ER (hydrocodone extended-release) was introduced to the market. Never in my medical lifetime do I recall a medication stirring such angst. Worries of mass overdoses, backdoor FDA conspiracies, and blatant disregard for the public wellbeing abound. Is there method to this madness?

schedule-two drug. In summary, Zohydro ER is a long-lasting version of a widely used and effective opioid, which until now had only been available in combination with acetaminophen. So why the controversy?

aye, here’s the rub…

Zohydro ER does not have any of the new and popular tamper-resistant tech-

Some background…

Zohydro ER is a pain pill that, when taken by mouth, is released slowly over 12 hours.

The active ingredient, hydrocodone, is an opioid (i.e. narcotic) that’s been around for decades in a short-acting pill form (e.g.

Lortab, Vicodin, Norco) and has historically been combined with APAP (a.k.a. acetaminophen, Tylenol). The FDA considers hydrocodone-APAP combination pills to be relatively less addictive and designates them as a schedule-three drug. Physicians can prescribe schedule-three drugs over the phone, with up to six refills. By contrast, schedule-two drugs (e.g. morphine, oxycodone, oxymorphone), even when combined with APAP, are considered more addictive, can’t be called in, and can’t be refilled without a new hard-copy prescription.

Because it is effective for pain, relatively well tolerated, and convenient to prescribe, hydrocodone-APAP pills have become the most commonly prescribed opioid in the United States. It’s therefore not surprising that, since there’s so much in circulation, hydrocodone-APAP pills are frequently the most available opioid for abusers to abuse. Add to this the legitimate worry about acetaminophen (APAP) overuse causing liver failure, and you can understand our leaders’ concerns surrounding this pain medication.

Enter Zohydro ER, the first extendedrelease hydrocodone pill without APAP. It’s easy on the liver and lasts twelve hours; so people with around-the-clock pain may need fewer pills per day. Additionally, it’s a

James patrick Murphy, MD, MM is boardcertified in pain Management, addiction Medicine & anesthesiology. He is Medical Director of Murphy pain Center. His website is http://jamespmurphymd.com.

nologies; e.g. a matrix that won’t dissolve easily or a coating that is difficult to crush. Instead, the makers took advantage

of a delivery system (SODAS) already used successfully in a number other of extendedrelease drugs such as: Ritalin LA, Focalin XR, Luvox CR, and Avinza.

OxyContin and Opana ER are two examples of opioids that manufacturers took off the market briefly for reformulation as tamper-resistant. However, while the changes have made them more difficult to snort or inject, many addicts still find ways to abuse these drugs or have just moved on to heroin. Tamper-resistant does not mean tamper-proof.

By the way, the generic form of Opana ER (oxymorphone extendedrelease) was not reformulated and is still available without tamper-resistant technology. Also, consider that Avinza (morphine extended-release), which employs the same sustainedrelease system (SODAS) as Zohydro ER, has neither been recalled nor been required to undergo reformulation. In reality, probably 90 percent of the opioids in circulation do not have tamper-resistant formulations.

That’s why I have difficulty understanding the uproar over Zohydro ER. As a pain specialist, I welcome another effective treatment to offer chronic pain sufferers. Sure, I’d be happier if it had a hard coating or some other “deterrent” to abuse. But in reality, Zohydro ER is, for all practical purposes, neither safer nor more dangerous than many of the drugs I already prescribe with success. So far, tamper-resistant innovations have not been proven to be effective in the big scheme of things. All opioids, regardless of the formulation, must be prescribed with caution and careful monitoring.

According to the American Society of Addiction Medicine, there are four main factors that contribute to a drug being addictive: ISSUe#85 9

physiCian viewpoint

1) How much will it cost me? All things considered equal, people will choose a drug that is cheaper.

2) How fast does it get to my brain? Hydrocodone is water-soluble and actually diffuses into the brain slower than many other opioids.

3) What kind of a buzz will I get? Opioids stimulate the brain’s “reward circuit.” There is no proof that hydrocodone is any worse in this regard than other opioids.

4) How much of it can I get my hands on? People will abuse what is available to them. Since hydrocodone is the most prescribed opioid, expect it to be one of the most abused. It follows that if Zohydro ER floods the market it will be abused.

Therefore, my recommendations to physicians are:

10 M.D. UpDate

in reaLity, zohydro er is, for aLL praCtiCaL purposes, neither safer nor more danGerous than many of the druGs i aLready presCriBe with suCCess • Prescribe Zohydro ER in the lowest dose possible, for the shortest duration of time, and only if the benefits outweigh the risks.

• Monitor regularly for effectiveness, side effects, and patient compliance.

• Educate yourself and your patient.

• Follow guidelines and regulations faithfully.

By the way, that’s my advice to physicians regardless of which opioid they prescribe.

Zohydro ER may not be tamper-resis-

tant, but tamper-resistant drugs are not super heroes. Do not expect them to save us from the real villain. The real villain is not the FDA, not the drug company, not the drug, and not the patient. The villain is the disease of addiction. Focus on the disease. Prevent the disease. Treat the disease.

This Zohydro hullabaloo is a prime opportunity to shine light on the problems surrounding prescription drug abuse and addiction. Let’s take advantage of it.

And stop the madness. ◆

cover story

l to r tom

Maddox, MD roger Humphrey, MD Alan Mullins, MD, and Brad Cornell, MD

longevity Breeds efficiency, exPertise, & loyalty Perhaps one of the most impactful advancements in the field of surgery has been the advent of technology allowing so many inpatient procedures to become outpatient ones. In 1970, the first freestanding ambulatory surgery center (ASC) opened its doors in Phoenix, Arizona. It was not until 1982 that Medicare approved payment to ASCs. The following year, in December 1983, Owensboro Surgery Center opened its doors.

The Owensboro Surgery Center was founded by a group of 18 physicians and two non-physicians and began as autonomous from the Owensboro Health system. According to Tom Maddox, MD, one of the original investors who is still a partner in the center today, “We primarily started the surgery center because the hospital wanted to do a lot of procedures OWENSBORO

Owensboro Surgery Center prides itself on 30-year tradition of putting patients first in western Kentucky

By Jennifer s. newton PhotograPhy By gary emord-netzley

[as inpatients] because the reimbursement was higher, when the surgeries could be done as an outpatient.� The physicians soon decided to seek the business expertise of a management company partner, and it was in the late 1980s or early 1990s, says Maddox, that the hospital expressed interest in becoming a partner in the surgery center as well.

The resulting ownership structure became a triumvirate of physician partners, Owensboro Health, and a management company. Over the years, the management company changed hands and names several times but today is Surgical Care Affiliates (SCA).

The partnership model allows the physicians to have a limited partnership interest, while the hospital and SCA are general partners, taking the majority of the liability. Currently the center

Issue#85 11

cover story

Business office Manager Janet Clark and Administrator lyzette Galloway, rN, work in concert to ensure the surgery center’s business operations run smoothly.

l to r

to SCA’s web site, their patients pay an average of 40 percent less for identical procedures performed in hospitals nationwide.

All of the surgery center’s team members are employed by SCA. The physicians are independent of the facility but are credentialed on the center’s medical staff.

30-Year tradition

we try to take really good care of our doctors while we’re taking really good care of our Patients.

– lyzette galloway, rn, administrator

has three physician owners, although that number is in flux as physicians retire and employment statuses change. In February 2001, the center moved to its current location on the Owensboro Health Parrish Avenue campus.

SCA is a full-service management company that operates 185 surgical facilities in 34 states. Their services include a wide array of business and clinical tools and systems that have positioned SCA as an ASC industry leader. The center uses a breadth of metrics to benchmark their operating and clinical outcomes with other SCA facilities and to other centers across the country.

Collective bargaining positions and streamlined business practices mean SCA provides cost savings to the surgery center. According

ophthalmologist tom Maddox, MD, is a founding partner of owensboro surgery Center.

12 M.D. upDAte

Another original member of the Owensboro Surgery Center staff is Lyzette Galloway, RN, who began as a recovery room nurse and is now the facility’s administrator. Galloway’s multi-tasking role includes providing leadership to meet the vision and mission established by SCA and the partnership, handling licensing and regulatory issues, assuring the team and facility meet established goals, and assisting with clinical and business issues whenever help is needed.

“At SCA and at the surgery center, we put ‘Clinical First™,’” says Galloway, emphasizing the center’s focus on patient care. In addition, she says, “We try to take really good care of our doctors while we’re taking really good care of our patients.”

It’s that attitude that has physicians raving about the care their patients receive while at the center.

The majority of surgeons in Owensboro are credentialed on the center’s medical staff. Galloway estimates about 30 to 35 physicians actively use the center, with 10 to 15 utilizing it occasionally. The number of cases at the center is fluid, changing based on the season and particularly on weather conditions this past winter. The center averages 20 to 25 procedures a day and 450 to 500 a month.

Galloway is not the only staff member with longevity. “Many, many of our teammates have been with the center for greater than 10 to15 years,” she says. “That level of experience speaks for itself.”

Janet Clark, the surgery center’s business office manager, who is Galloway’s right-hand woman on all business matters, has been with the center for 28 years. Her

responsibilities include admitting, billing, collections, scheduling, accounts payable, and overseeing all financial communications and reporting between the center and SCA. The surgery center offers a broad range of surgical procedures. The three most common areas are ophthalmology, endoscopy, and general surgery. Other specialties covered include ENT, oral surgery, pediatric dentistry, gynecology, urology, orthopedics, pain management, podiatry, and plastic surgery.

The entire center’s nursing and support staff is trained to handle every procedure and every patient. “That’s one thing our surgery center really prides itself on: when everyone’s cross-trained, efficiency, customer service, and teammate satisfaction are enhanced,” says Galloway.

serving a rural population

Owensboro is the third largest city in Kentucky with a population of 58,000. The surgery center has a service area that incorporates a seven-county Kentucky Green River District and parts of southern Indiana, including Perry and Spencer counties.

Owensboro Surgery Center Medical Director and physician partner Thomas Furgason IV, MD, is an Owensboro native

and an ophthalmologist with Physicians Eye Center. Furgason went to medical school at the University of Kentucky (UK), completed his internship at The Christ Hospital in Cincinnati, Ohio, and his residency at the University of Wisconsin. Following the completion of his residency in 1998, he welcomed the opportunity to return to Owensboro to practice.

Furgason sees Owensboro as a regional medical center and a referral center for the western part of the state. “We have pretty much everything we need for the population in the surrounding area,” he says.

Given their service area, Furgason contends the surgery center has a “very high percentage of rural patients.”

General surgeon Alan Mullins, MD, is one of the few physicians in western Kentucky to have completed a head and neck oncology fellowship.

“the staff Here Makes Me look Good”

Maybe the most telling mark of the center’s success is the ease with which physicians, and staff alike, praise its efficiency, convenience, and affability.

Maddox is a native of Owensboro, who did his residency at UK and spent a couple of years as chief of ophthalmology at the naval hospital in Charleston, SC, before returning to Owensboro in 1975 to found Physicians Eye Center.

As a founding part-

General surgeon roger Humphrey, MD, says the owensboro surgery Center provides “top notch” service and “almost never runs late.”

Issue#85 13

cover story

General surgeon Brad Cornell, MD, subspecializes in vascular surgery.

the aca is going to Be the Biggest change in health care since medicare was imPlemented in 1960.

14 M.D. upDAte

ner in the Owensboro Surgery Center, Maddox’s support comes down to a simple reason: “People ask me why I use the surgery center, and I say, ‘The staff here makes me look good.’ We get compliment after compliment from patients on how well they think they are treated here.” He adds that he has always been extremely pleased with the anesthesia coverage at the center as well.

When the surgery center began, there were not many eye procedures that could be done as an outpatient. Today, ophthalmology cases make up the surgery center’s highest volume of cases. “The use of the center has evolved as technology has improved in different areas, whether it’s orthopedics, gynecology, pain control, or ENT,” he says.

Ophthalmology procedures performed at the Owensboro Surgery Center include cataracts, corneal transplants, strabismus, infants with blocked tear ducts, and retinal procedures.

Maddox estimates most surgeons in his practice do 45 to 60 cases a month at the center, plus the retinal surgeon, C. Mark Millsap, MD, who does 20 to 25 cases a month.

Retinal surgery is one of the aspects the surgery center has added over the last several years. “One of the good things about having the hospital and SCA as partners is they have always been willing to purchase whatever we really need,” says Maddox.

Alan Mullins, MD, is a general sur-

geon from Louisville, who attended medical school at University of Louisville (UofL) and did his residency at the Carolinas Medical Center in Charlotte, North Carolina. He came to Owensboro in 1996 and practices with Owensboro Health Surgical Specialists, an eight-person general surgery group that became employed by Owensboro Health last year.

Mullins is one of the few physicians in western Kentucky who has completed a fellowship in head and neck oncology surgery, which he did in 1996 at Roswell Park Cancer Institute in in Buffalo, New York.

He regularly performs endoscopy, skin excisions, breast surgery, laparoscopic surgery, and hernia repairs at the surgery center. As a “smaller, more nimble” facility, the surgery center is more flexible and personable, with good turnover and less bureaucracy than a hospital environment, he says.

“The surgery center has been a real asset to our practice,” says Mullins. “There is an important role for ambulatory surgery centers in the state.”

Roger Humphrey, MD, has been practicing general surgery for 31 years, the last 16 of those in Owensboro with Owensboro Health Surgical Specialists. Humphrey went to medical school at the University of Texas and completed his internship and residency at UofL. He has seen the community’s medical capabilities grow in his tenure there.

“There is less that patients have to leave for

as time goes on,” he says.

Humphrey, along with colleague Brad Cornell, MD, subspecializes in thoracic and vascular surgery. According to Humphrey, the practice’s volume at the surgery center has increased since it was bought by Owensboro Health last year because of a licensing category change, compelling them to move some in-office procedures to the surgery center.

Of the surgery center, Humphrey says, “The service is top notch. They almost never run late.”

It appears Medical Director Furgason’s vision for the center – “to ensure the quality of care in a more homelike environment, where people are treated in a friendly manner” – is being fulfilled. A key aspect of that quality is the staff ’s expertise, which Furgason attributes to familiarity and ongoing education. “We concentrate on doing a large volume of the same types of surgeries, so they are all familiar with exactly the way things are supposed to go,” he says. This results in an experience that is pleasant for both the physicians and the patients.

perspective on the evolution of payment models. “When I first started here 28 years ago, we had Medicare, Medicaid, and commercial insurance, no contracts, nothing like that,” she says. “Now with the ACA, we don’t just have Medicare and Medicaid, we have the exchange ... We also don’t just have Kentucky Medicare and Kentucky Medicaid, but there have also been insurances that have bought Medicare and Medicaid products.”

Clark and the staff are preparing for changes through education efforts, such as seminars and conference calls with SCA. “From what I’ve read and what I’ve heard, it’s going to be the biggest change since Medicare was implemented in 1960,” she says.

Regardless of who’s paying for the procedures, Furgason believes ambulatory surgery centers represent a growth opportunity for the future. He says, “I think they

surgery centers Provide a lower cost alternative to main hosPital ors.

An uncharted Course

By now, the uncertainty of the Affordable Care Act (ACA) is a ubiquitous refrain.

However, Furgason points to an already positive outcome of the Kentucky Medicaid expansion. “There has been a large surge of previously uninsured patients under 65, who now have insurance, who had terrible blinding eye disease … and have started coming in and getting cataracts removed.”

For example, Furgason has seen patients with mature cataracts completely covering their eye and has been able to remove them in an outpatient procedure. “We can get them seeing as well as 20/20 the next day,” he says. Furgason attributes the high percentage of severe cataracts in the area to financial and geographical access issues in western Kentucky.

Business Manager Clark confirms an influx of new Medicaid patients since January but says the center has only seen three exchange patients so far. Clark’s long history with the center gives her a unique

provide a lower cost alternative to main hospital ORs. I really think surgery centers will become more popular in an effort to maintain cost.” ◆

l to r ophthalmologists David Jones, MD, thomas Furgason IV, MD, and tom Maddox, MD, are with physicians eye Center. Jones and Maddox are founding partners of the owensboro surgery Center, and Furgason is the surgery center’s current medical director.

Issue#85 15

sPecial section  rural health

innovation expands access:

KentuckyOne develops two new possibilities for providing primary care to Kentuckians By Tim CORkRaN

Access to primary care is the key to creating a healthier Kentucky, but it remains limited at certain times and in some Commonwealth locations. KentuckyOne is hard at work piloting new ways to help ensure that all Kentuckians have that access when they need it. With 200 locations, KentuckyOne is the largest health system in KY, yet its leaders know that innovation is required to effectively meet the needs of the population. Access to primary care physicians, particularly in rural areas, has long been a problem in Kentucky, but KentuckyOne Anywhere Care, which allows virtual care delivery by phone or video web chat, and the KentuckyOne Health CommunityBased Health Delivery Model (telehealth) are making a difference.

In response to the ACA and the everchanging health care market, KentuckyOne Health is doubling down on its original commitment. Travis Burgett, director of Strategy for KentuckyOne Health, says, “We need to go back to our roots and focus on keeping the community healthy.” In order to do that, he continues, “We need a broad primary care strategy, and we are going to need to have access points in many locations.” Currently, the strategy is focused on these two innovative initiatives, both of which solve access problems in rural areas,

kentuckyone health’s anywhere care and community-Based health delivery model solve access ProBlems in rural areas, Provide convenience for the consumer, and are cost-effective for the Provider.

16 M.D. upDAte

provide convenience for the consumer, and are cost-effective for the provider. In addition to rural access issues, Anywhere Care is intended to fill the access gaps for all Kentuckians, including on nights and weekends or when getting in to a more traditional provider is just not possible.

primary Care – Anytime, Anywhere

Through Anywhere Care, Kentuckians can consult with a board-certified family practice provider without leaving home, 24 hours a day. A toll-free phone call or online request guarantees a return call or video chat within 30 minutes. Anywhere Care providers may prescribe medications, if appropriate, recommend an over-thecounter medication, or provide home care options. A follow-up report to the patient’s KentuckyOne provider is included. If needed, the KentuckyOne Anywhere Care provider will refer patients for a follow-up clinic visit or to an emergency department.

KentuckyOne is one of the first providers in the nation to try such a service. It was beta tested with their own employees last fall to great reviews, and now the service is available to any patient in Kentucky who would like to take advantage of it. Ron Waldridge, MD, a KentuckyOne Health family physician, says, “Anywhere Care is a logical extension of the care that we provide, and it complements in-person services.”

Currently, all calls are answered by remote physicians who are employed by a national firm called Carena Inc., but KentuckyOne will be using their own physicians in the future. Carena was a logical choice: having pioneered this field, they have infrastructure in place and expertise in the new modality.

Doctorless Clinics in rural Communities

The lack of physicians in many of Kentucky’s rural areas is being remedied with the use of so-called “telemedicine.”

In the KentuckyOne Health CommunityBased Health Delivery Model, primary care clinics are staffed by nurse practitioners,

nurses, and office coordinators, who utilize telemedicine technology to collaborate with remote physicians and specialists. The care providers at the clinic help insure a patient’s needs are clearly addressed by a remote physician. This way, patients get the attention and reassurance they need from trained professionals, who in turn are getting the guidance they need from licensed primary care physicians.

The first telehealth clinic was established in Powell County in 2011. The second, Saint Joseph Telehealth Primary Care Clinic – Campton, opened in August 2012 in Wolfe County. Several grants have helped establish these two clinics: a Social Innovation Fund (SIF) grant from the federal government and a Foundation for a Healthy Kentucky grant.

Refinement of the model continues as care-providers on the ground – and KentuckyOne leadership – learn more. The Campton clinic has integrated physical and behavioral health services in one location and offers all patients access to specialty consultations. A third grant, from Catholic Health Initiatives Mission and Ministry, allows Registered Nurse Transition Coaches to provide home visits for patients discharged from the facilities. These nurses also work with the Primary Care Clinic ARNPs in identifying patients at high risk for hospital readmissions and emergency department use.

Ruth W. Brinkley, chief executive officer of KentuckyOne Health, sums up the mission that is driving these innovations: “Increasing access to health care and strengthening the primary care system in the Commonwealth is an important step in our work to create a healthier Kentucky.”

Such new access points will surely be joined by others, as KentuckyOne continues to innovate. ◆

sPecial section  gastroenterology/Bariatrics/general surgery

Bringing it home

Dr. Justin Case brings the power of endoscopic ultrasound to Georgetown

By Tim CORkRaN

When Justin W. Case, MD, began to practice gastroenterology and hepatology at Georgetown Community Hospital in August 2013, he was coming home.

The Grant County native has family in Georgetown and did his undergraduate and internal medicine residency at University of Kentucky, but he did medical school and special training at the University of Cincinnati. Case did not come home alone, however. He brought to Georgetown Community Hospital his expertise with endoscopic ultrasound, a technology that is dramatically increasing the amount of detail that physicians can discern in the upper digestive tract.

The hospital has one of only two such tools in the region, and in Case’s hands, it is changing how patients proceed with the news of abnormalities in their GI and biliary tracts.

Case’s practice, Gastroenterology and Hepatology of the Bluegrass, serves adult patients, most of whom arrive with “irritable bowel syndrome or gastro-intestinal complaints like peptic ulcers, abdominal pain, constipation, and diarrhea.” He also sees patients for hepatitis and chronic liver disease. Most of his patients are from the Scott and Bourbon county area, but he increasingly sees patients referred up from Lexington to take advantage of the endoscopic ultrasound.

Advanced Imaging provides a Clearer picture

Since medical school rotations, Case’s knack for gastroenterological procedures has guided his career choices. At UC he completed a “one year program on advanced training in endoscopic ultrasound, ERCP, and liminal stint placement.” This is where he first gained familiarity with the endoscopic ultrasound.

The endoscopic ultrasound tool has an ultrasound imaging tip. As Case says, “It allows us to view the GI and biliary tracts from the inside, which provides a better visualization than external ultrasound.” If

a lesion is detected, a biopsy can be pulled through this tip, also. The half hour scans provide great detail; features as small as a millimeter can be discerned. Inserted just like a standard endoscope, the endoscopic ultrasound tip is only slightly larger.

Patients might notice this, Case explains, so “Sedation is slightly heavier than normal

Justin W. Case, MD, Gastroenterology and Hepatology of the Bluegrass

GI scoping, but few patients need to be intubated.”

Bringing the endoscopic ultrasound to Georgetown will help local patients in several ways. Primarily, it is used to complement CT scans. “Sometimes people will have CT scans that will show details that they are unclear how to follow-up with; this provides a better idea of what they are dealing with,” Case says. Case’s work in pancreatic imaging – a specialty of his – will be enhanced: “Pancreatic masses and cysts, pancreatitis, and biliary obstruction (caused by stones) will be more easily diagnosed in my office,” he notes.

The potential for broad use is great.

Endoscopic ultrasound also allows for ready, detailed screening for pancreatic cancer, esophageal cancer, and gastric cancer, as well as benign tumors of the upper gastrointestinal tract. Additionally, it can be used to identify malformations and masses in the bile ducts and pancreatic ducts.

Gastroenterological and progress

Health

Case is excited to be on the forefront of gastroenterological imaging and to evangelize about the value of the endoscopic ultrasound.

He says, “It’s very helpful, not necessarily new, but becoming increasingly widespread.”

He stresses, however, that colon screenings can do more to reduce GI cancers than any tool. He wants to see people increase their colon cancer awareness. He notes, “The biggest concern overall is that some patients are reluctant to get routine colonoscopies. The key is to get it done early so that you don’t find a cancer, you find a polyp. The polyp is where a cancer would come from; we want to remove it before it has the chance to become a cancer.” He reminds that routine screening should begin at 50.

As a hepatologist, he is also watching progress with hepatitis. Chronic viral hepatitis is becoming much more curable, especially hepatitis C. Case says that “The rate at which new medications are becoming available is making it a much more curable disease than it has been in the past.” He estimates, “By the middle of next year, over 90 percent of hepatitis C sufferers will be curable.”

Case knows he is bringing something valuable to the Bluegrass; the only other endoscopic ultrasound in the area is at UK. He says, “It’s somewhat unusual for it to be offered at a smaller hospital like this,” but as he builds his practice, word will spread of its value and local availability. Patients seeking gastroenterological and hepatological treatment in Georgetown can be glad Case returned home. ◆

1138 lexington rd, suite 140, Georgetown KY 40324 502-570-3721 www.georgetowncommunityhospital.com

Issue#85 17

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18 M.D. upDAte

sPecial section  gastroenterology/Bariatrics/general surgery

no easy weigh out

Bariatric surgery can prevent co-morbidities of obesity such as diabetes and heart disease By Jim kElSEy A student is behind in his studies and facing a tough exam. The choices? Study all night and give a best effort. Or cheat. Most would agree, cheating, though risky, is the easy way out.

Bariatric surgery has, at times, had a similar perception: potentially risky AND the easy way out.

Both, says Eric F. Smith, DO, Bluegrass Bariatric Surgical Associates, PLLC, are incorrect.

“It’s a misconception that patients are taking the easy way out,” he says. “We do a lot of counseling with the patients to find out how much support they have from their peers, their family, and their family physician … These are patients who have tried multiple times to lose weight without success, and it’s not for a lack of trying.”

“Many people still do not realize that obesity is classified as a disease state, most by recently the American Medical Association,” says Lisa West-Smith, PhD, LCSW, executive director of Bariatric Services at Georgetown Community Hospital in Georgetown, Kentucky, which has been a Bariatric Surgery Center of Excellence since 2006 with G. Derek Weiss, MD, FACS, FASMBS, serving as medical director. West-Smith also oversees the psychological screening process.

Genetic, metabolic, and environmental factors cause and perpetuate the disease of obesity.

“While behaviors can exacerbate or improve the condition, the surgical procedures themselves can help address the genetic and metabolic factors that diet and exercise don’t treat effectively. The success rate for bariatric procedures is dramatically higher than diet and behavior modification and exercise alone,” she says.

Smith asserts that bariatric surgery takes hard work and dedication. “We by no means advertise bariatric surgery as a quick fix or a magic bullet or say ‘We do this

surgery and you can eat however you want, behave however you want, and you’re going to do great.’ In fact, we’re very adamant that that’s the opposite,” he says.

Those values of hard work and dedication helped lead Smith to Bluegrass Bariatric ‘obesity is classified as a disease,” says lisa West-smith, phD, lCsW, executive director of Bariatric services at Georgetown Community Hospital BeloW “Bariatric patients are not taking the easy way out,” says eric F. smith, Do, Bluegrass Bariatric surgical Associates. leFt

Surgical Associates in November of 2013.

A certified Center of Excellence Bariatric Surgeon, he brought with him a wealth of experience, including nearly 1,000 minimally invasive weight loss surgeries and over 240 robotic procedures.

That experience has included a shift in the type of procedures he performs most frequently and, gradually, a more widespread understanding of the relatively minimal risk of bariatric procedures for most patients.

safety + High level results

“People look at bariatric surgery as elective surgery, and I can see where they’re coming from,” says Smith. “But I tell patients, if you come to me and you have colon cancer, you’re never going to question the risks that go along with surgery because you know if you don’t treat that cancer what’s going to happen to you.” Smith is quick to note he is not trying to compare morbid obesity and cancer but that studies show morbid obesity does shorten lifespan.

Bariatric surgery, in effect, then becomes a manner for treating obesity co-morbidities such as diabetes and heart disease. Benefits in physical appearance are secondary. The patient’s overall improved health – both mentally and physically – is the true benefit. And it’s a benefit that is becoming more commonplace for bariatric patients thanks to Laparoscopic Vertical Sleeve Gastrectomy. This procedure, Smith says, essentially offers the safety of the popular Lap-Band® with the high level results of the gastric bypass.

“The majority of our procedures – probably about 85 to 90 percent – of what we do from a bariatric surgery standpoint are Sleeve Gastrectomy,” Smith says. “When we look at bariatric surgery we look at excess weight loss, which is the difference between their ideal body weight and their current weight.

Sleeve Gastrectomy achieves roughly a 75 percent excess weight loss, on average, in about two years.”

That rate is comparable to gastric bypass without the nutritional problems patients can encounter after bypass.

Lap bands were popular with patients because they were the least risky procedure. “But unfortunately the average excess weight loss with the band at two years is anywhere from 25 to 30 percent less than what the average patient could achieve with a sleeve,” says Smith.

Before and After

Equally as important as the procedure itself Issue#85 19

sPecial section  gastroenterology/Bariatrics/general surgery

are the steps leading up to and following the procedure.

Bluegrass Bariatric Surgical Associates patients at Georgetown Community Hospital undergo a careful screening process that includes not only physical exams, but also psychological. Nutrition and behavioral health specialists and the patient’s primary care physician are all involved in the screening process, with the goal being to identify what led to the problem of obesity in the first place.

“There is no one standardized protocol for pre-surgical psychological evaluation that is shared nationally,” says West-Smith.

Protocols should be based on empirical and clinical evidence, be conducted by licensed mental health providers with knowledge and experience in bariatric behavioral health and meet the specific needs of patients and programs.

The Georgetown assessment protocol includes medical record review, a structured clinical interview and various test-

ing instruments to determine the patient’s overall level of functioning psychiatrically, p s yc h o s o c i a l l y, and behaviorally.

Lifetime history and current psychiatric status; weight, diet, and exercise history including any eating pathology; substance abuse or dependence; psychosocial functioning; ability to provide informed consent; prior history; and current motivation to adhere to dietary and lifestyle recommendations are among the essential factors that should be carefully considered in the screening process. “We’re trying to educate and really partner with the patient to determine their overall level of functioning and get them optimized presurgically,” West-Smith says.

Broader Applications

The positive results of bariatric surgery

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not only in terms of weight loss, but also the treatment and resolution of diabetes and other co-morbidities, lead Smith to believe that Sleeve Gastrectomy might have even broader applications in the near future. Could bariatric surgery become an earlier treatment option for those who have not reached morbid obesity levels or are in the moderate levels of treatment for diabetes? Smith thinks so. “Patients don’t die from being overweight,” he says. “They die from the co-morbidities that go along with being overweight – the uncontrolled diabetes, the uncontrolled heart disease, and on and on.”

According to Smith, less than two percent of patients who qualify for bariatric surgery actually seek it out. “Waiting until a patient is immobile, can’t get out of bed, or is on 20 medications… those patients are candidates for surgery well before that,” he says.

Bariatric surgical procedures might not be the easy way out, but they do not have to be a last resort either. Understanding the patient’s unique challenges, motivations, and goals can help determine if and when bariatric surgery is right for them. The results are well worth it.

“You simply take someone’s life and you allow them to start being able to play with their kids. You allow them to be able to get on the floor and be active with their children or grandchildren,” Smith says.

“Sometimes patient’s goals are simply to feel comfortable when they go to a movie theater or to feel comfortable when they get on an airplane. That’s the immediate impact, and it’s obviously rewarding.” ◆

BARIATRIC CENTER

Georgetown Community Hospital F E E - O N LY F I N A N C I A L P L A N N I N G

Lexington | Louisville | Cincinnati 800.344.9098

20 M.D. upDAte

|

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www.georgetownbariatrics.com 502-570-3717 or 1-888-868-0008

sPecial section  gastroenterology/Bariatrics/general surgery

medical magnetism

LINX® brings permanent reflux relief to the Bluegrass By tim corkran Jason Harris, MD, of Bluegrass Surgical Group, is a self-proclaimed “lover of all things techy,” and by staying at the cutting edge of laparoscopic and gastrointestinal surgery, he is bringing a revolutionary advancement in GERD treatment to the Bluegrass. While advancements in robotic surgery and single incision surgery intrigue him, Harris’ biggest interest currently is the laparoscopically implanted LINX® Reflux Management System.

LINX uses a band of rare earth magnets around the base of the esophagus to restore the body’s natural barrier to reflux, and it stands to bring much needed long-term relief to reflux sufferers for whom conventional medications have not helped. Harris explains, “Traditional non-surgical GERD treatments fail to provide many patients with relief. Twenty to 30 percent of patients on proton pump inhibitors (PPI) report an inadequate symptom response despite twice a day therapy.” In addition to poor symptom response, many patients may also have anxiety over PPI use due to cost or concerns over side effects or cost of long term medication use. Conversely, concern over the irreversibility and side effects of surgical therapy may dissuade patients from pursuing a laparoscopic Nissen fundoplication (traditional GERD surgery). The LINX device was created in response to this “therapy gap,” providing patients with a suitable alternative to both the long term use of PPIs and conventional surgery for GERD.

Career Convergence Breeds Innovation

Harris is the only Kentucky surgeon trained and credentialed on implanting the LINX system, and that status arose through a fortuitous convergence of career choices.

Harris came up in the golden age of minimally invasive surgery. He says, “My interest in technology coincided nicely with the timing of my fellowship in minimally invasive surgery. Laparoscopic surgery was gaining momentum and becoming the standard for more and more procedures, and surgical

technology was evolving so fast around that time.”

Intrigued by the technological advances in the field, 10 years ago he attended a fellowship on minimally invasive surgery at the University of Chicago. There he met program director Santiago Horgan, who, as Harris says, was “doing some very cut-

would stay in touch as their careers evolved.

Harris’ path led him to Bluegrass Surgical Group, where he has focused on GERD issues. He is the primary foregut and laparoscopic surgeon there, and he says he has “built my career in no small part on conventional anti-reflux surgery.”

Horgan moved on to UC San Diego and got involved with the initial development of LINX surgery here in the US. Harris notes Horgan “has since become a leader in the LINX technology.”

A few years ago, Horgan invited Harris to San Diego to train him on the LINX implantation procedure, and Harris took to the procedure quickly. His decision to bring the service to Lexington was an easy one, as he immediately recognized its potential.

Arch-like Architecture

Jason Harris, MD, of Bluegrass surgical Group, is the only Kentucky surgeon trained and credentialed on implanting the lINX system.

ting edge things with respect to minimally invasive and robotic surgery.” Horgan was also a leader in development of surgical remedies for GERD and part of the FDA trial to bring lap band surgery to the US. Following the fellowship, the two surgeons

The LINX system consists of 10 to 20 wire-linked, pea-sized magnets, depending on the diameter of the patient’s esophagus. There is one to two mm of space between segments, so, the band can expand on the wire as food passes through the esophagus. It’s a simple, elegant structure, which as Harris says, “is really based on Roman arch architecture – it supports itself.”

LINX is a Torax Medical product that achieved FDA approval in 2012. Eighteen hundred have been implanted worldwide,

lINX uses a band of rare earth magnets around the base of the esophagus to restore the body’s natural barrier to reflux.

Issue#85 21

sPecial section  gastroenterology/Bariatrics/general surgery

750 or so in the US. The magnets have a high degree of rare earth elements, so their magnetism is enduring; one implant should last the remainder of a patient’s life. It is laparoscopically implanted with four to five incisions in the upper part of the abdomen.

Harris finds it a relatively routine procedure and notes that it has “an excellent safety profile and typically is inserted as an outpatient procedure.”

FDA indication for LINX is for patients

with intractable reflux who, despite medication, continue to exhibit symptoms. The procedure is also considered for GERD sufferers who have prohibitive medication side effects or simply are uncomfortable with long term medications. LINX is currently not recommended for patients who have had previous surgery in the area, large hiatal hernias, have BMI above 35, or experience esophageal dysmotility. Harris estimates 50 to 60 percent of his anti-reflux patients

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would be considered candidates, and the first Lexington patient set is planned to receive the implant in the later part of April.

Like many new technologies, some insurance carriers are reluctant to approve the LINX procedure. But, Harris notes, “In the last two months, Medicare created a code for the implantation of the LINX device, allowing hospitals and surgery centers reimbursement for the implant. This is usually the first step before more widespread coverage of the procedure.”

simple, Accessible, and ready to proliferate

Harris expects LINX to proliferate rapidly.

He is already seeing patient-driven interest increase. The key to the success of LINX is its simplicity, both in function and implantation. Harris says, “The procedure has very uniform, well-described steps. The placement of the device is very specific, and the sizing of the device is very specific based on the size of the esophagus. It is going to take away a lot of the current outcome challenges of traditional anti-reflux surgery.”

Harris is particularly pleased to see his technological fascination intersect with his surgical expertise in reflux. And it pleases him that the technology is so accessible.

He concludes, “With the safety profile associated with this surgery and mounting data showing its effectiveness, it’s my belief that there will be widespread adoption of this procedure in the near future and a better served reflux population in our Commonwealth and beyond.” ◆

®

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State Farm Mutual Automobile Insurance Company State Farm Indemnity Company, Bloomington, IL

Jason P. Harris, MD Advanced Laparoscopic and General Surgery Bluegrass Surgical Group 1401 Harrodsburg Road, Ste. B355 Lexington, KY 40504 jpharr00@yahoo.com (859) 276-5262

sPecial section  gastroenterology/Bariatrics/general surgery

enterra therapy for gastroparesis ®

Gastric electrical stimulation therapy addresses complication in diabetes population By BaRBaRa maCkOviC lOUiSvillE A new complication for the rapidly growing US diabetes population[i] may be the significantly increased risk of gastroparesis,[ii] a serious digestive disorder which is estimated to affect five to 12 percent of the diabetes population.[iii] Jewish Hospital, part of KentuckyOne Health, is the only medical center in Louisville offering Medtronic Enterra® Therapy, the first and only FDA-approved* gastric electrical stimulation therapy indicated for use in the treatment of chronic, intractable nausea and vomiting associated with gastroparesis of diabetic or unknown origin.

In patients with gastroparesis, a disorder in which food moves through the stomach more slowly than normal, the stomach muscles work poorly (or not at all), thus preventing the stomach from emptying properly.

Symptoms of gastroparesis include nausea and vomiting, and may include abdominal bloating and pain, lack of appetite, and excessive weight loss. These symptoms prevent a person from eating normally and may lead to dehydration and malnutrition.

Although there is no cure for gastroparesis,

gastroParesis is difficult to manage, and given the enormity of the diaBetes ePidemic Particularly in kentucky, additional theraPeutic oPtions to manage the symPtoms associated with this disorder are critical. – thomas aBell, md

therapies like Medtronic Enterra Therapy may improve symptoms of chronic nausea and vomiting when conventional drug thera-

thomas Abell, MD, is the director of the Jewish Hospital GI Motility Clinic and the Arthur M. schoen, MD, chair in Gastroenterology at the university of louisville.

pies are not effective or tolerated.

“Medtronic Enterra Therapy is an important part of the treatment landscape for my patients with gastroparesis,” said Thomas Abell, MD, director of the Jewish Hospital GI Motility Clinic and the Arthur M. Schoen, MD, chair in Gastroenterology at the University of Louisville. “Gastroparesis is difficult to manage, and given the enormity of the diabetes epidemic particularly in Kentucky, additional therapeutic options to manage the symptoms associated with this disorder are critical.”

Jewish Hospital implanted its 100th temporary gastric electrical stimulation therapy device in December 2013. The temporary device is implanted first to be sure the therapy is effective before a permanent device is placed.

Susan Herrick, 49, of Simpsonville, Kentucky, received the 100th temporary implant and was able to receive a permanent

device in mid-December. Before receiving gastric electrical stimulation therapy, she experienced cyclic vomiting syndrome, gastroparesis, diarrhea, and abnormal weight loss. She was so ill she had to have a port inserted for IV fluids.

Medtronic Enterra Therapy involves surgeons implanting a neurostimulator under the skin, usually in the lower abdominal region, along with two insulated leads, which are implanted in the stomach wall muscle and connect to the neurostimulator.

The neurostimulator sends mild electrical pulses through the leads to stimulate the smooth muscles of the lower stomach, which may help control the chronic nausea and vomiting caused by gastroparesis.

Enterra Therapy has risks similar to any surgical procedure, including swelling, bruising, bleeding, and infection. In addition to risks related to a surgical procedure, adverse events related to the Enterra Therapy system may include infection, pain at the implant site, lead penetration, bowel obstruction or perforation, lead entanglement or erosion, irritation/inflammation over the implant site, and device mechanical or electrical problems. Any of these situations may require additional surgery or cause return of symptoms.

For important safety information, please visit http://www.medtronic.com/ Enterra-safety. Additional information on Medtronic Enterra Therapy is available at www.enterratherapy.com. references:

[i] “american diabetes association. diabetes rates increase significantly among american youth.” link: http://www.diabetes.org/for-media/2012/scisessions-search.html accessed: april 1, 2013. [ii] Jung h-k et al; the incidence, Prevalence, and outcomes of Patients with gastroparesis in olmsted county, minnesota, from 1996 to 2006. gastroenterology; apr 2009; 136 (4): 1225-1233. [iii] camilleri m, Bharucha a, farrugia g. epidemiology, mechanisms and management of diabetic gastroparesis. clin gastroenterol hepatol. January 2011 ; 9(1): 5–e7. ◆ Issue#85 23

comPlementary care

calories in. calories out.

Baptist Health Louisville’s new medically supervised weight loss program

By R. JaNE lOCkhaRT, aRNP

While it seems simple enough, losing weight – and keeping it off – is a challenge. Everyone is looking for the magic pill – the silver bullet – that will make the pounds magically melt away. Instead, the question, “So how’s the diet going?” may prompt the disheartening reply that you are five pounds up from last time.

The dreaded diet may work temporarily, but is rarely (if ever) a long-term fix.

Instead, a medically supervised weight loss program that seeks to educate, give one-onone support, and promote lifestyle change works best. People eventually have to live in a world that includes all the food groups, plus other “dangers,” such as sugar and carbohydrates.

The best course toward lifelong weight loss starts with getting to know the person, learning his or her individual needs, stressors, and past issues. The program’s emphasis is not only on what you put in your mouth, but working on what’s in your head that leads you to overeat, or be drawn to unhealthy foods.

A program is built that fits the person’s lifestyle, including how to handle situations that can derail his or her transition. We accept this fact. Life is going to happen. lOUiSvillE

a common sense aPProach to eating that is Positive, uPBeat, and caring sets the Program aPart from others, helPing clients to negotiate eating Pitfalls and get to the root cause of their overeating.

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There will be birthday parties, vacations, and girls’ night out. The goal is to teach clients how to navigate tempting, tough, and joyous times without it crashing their new way of life.

To get a good read on where to start, the client rests in a Basic Metabolic Rate

(BMR) machine, which gives the total calories burned at rest, with activity of daily life and in 30 minutes of moderate activity. This information is used to determine the number of calories required to achieve appropriate weight loss, one to two pounds a week, that stay off . . . for life!

As a nurse practitioner who leads the medically supervised weight loss program at Baptist Health Louisville, I speak to clients from my personal experience, as well as my training.

All clients attend an orientation group meeting and then six weeks of one-onone sessions with the nurse practitioner.

The first one-on-one meeting includes a complete physical, review of lab work, and the Basic Metabolic Rate report. Appetite suppressants are discussed and prescribed if necessary.

Each appointment, thereafter, is

designed to equip the client with some basic tools: different aspects of nutrition, food label reading, and menu building. After the first six weeks, clients meet with the nurse practitioner every other week until they reach their weight loss goal.

Besides meeting their ultimate weightloss goal, clients often discover a number of side benefits, including being able to discontinue medications for high blood pressure, cholesterol, and other conditions associated with obesity.

The medically supervised program works hand-in-hand with the weight-loss surgery program operated out of the same office and directed by surgeon John Oldham, MD. Oldham’s pre- and post-surgery clients find the program helpful in either getting on track or staying on track with their weight loss goals, although the program can work for anyone who desires a sensible approach to losing pounds. An annual consultation can be scheduled to give clients a refresher, or course correction as needed.

A common sense approach to eating that is positive, upbeat, and caring sets the program apart from others, helping clients to negotiate eating pitfalls and get to the root cause of their overeating.

R. Jane Lockhart is a nurse practitioner with 10 years’ experience. She leads the medically supervised weight loss program at Baptist Health Louisville. ◆

comPlementary care

combating type 2 diabetes

The ymCa offers diabetes education and prevention programs

By DavE PETERSON

The YMCA of Central Kentucky is working hard to educate people about their risk for pre-diabetes and type 2 diabetes, as well as preventative steps they can take today to reduce the chances of developing the disease.

In the United States alone, 26 million people suffer from diabetes and 79 million people have pre-diabetes. These statistics are alarming, and the impact on the cost of health care and the overall well-being of our communities makes preventing the number of new cases of type 2 diabetes more important than ever before.

The nation’s struggle with obesity and type 2 diabetes is no surprise, but the number of people with pre-diabetes is a growing issue, especially when only 11 percent realize they have the condition. Pre-diabetes is a condition in which individuals have blood glucose levels that are higher than normal, but not high enough to be classified as diabetes. Often a preventable condition, people with pre-diabetes can reduce their risk for developing type 2 diabetes by adopting behavior changes that include eating healthier and increasing physical activity.

People with pre-diabetes are at risk for not

as a leading voice on imProving the nation’s health and well-Being, the ymca of central kentucky encourages all adults to learn their vulneraBility for tyPe 2 diaBetes By taking a risk assessment at www.diaBetes.org/risktest

only developing type 2 diabetes, but also cardiovascular disease, stroke, and other conditions.

As a leading voice on improving the nation’s health and well-being, the YMCA of Central Kentucky encourages all adults to learn their vulnerability for type 2 diabetes by taking a risk assessment at www.diabetes. org/risktest. Several factors that could put a person at risk for type 2 diabetes include family history, age, weight, and activity level, among others.

As director of Community Health for the YMCA of Central Kentucky, we understand learning your risk for pre-diabetes and making lifestyles changes is easy to say, but oftentimes hard to do. The good news is that people don’t have to do this alone – the Y can help through our comprehensive diabetes prevention program, as well as our personal wellness coaching.

Diabetes disproportionately strikes African Americans as well as Hispanic and Latino populations. In fact, diabetes diagnoses are 77 percent higher for African Americans and 66 percent higher for Latinos.

Some basic lifestyle changes that contribute to weight loss and an increased focus on healthy living can decrease the risk for type 2 diabetes. Among these are:

• Eat fruits and vegetables every day and choose fish, lean meats, and poultry without skin.

• Aim for whole grains with every meal.

• Be moderately active at least 30 minutes per day five days a week.

• Choose water to drink instead of beverages with added sugar.

• Speak to your doctor about your diabetes risk factors, especially if you have a family history of the disease or are overweight.

Investing in your health today can pay off tomorrow. On average, expenses for a person with diabetes are $13,700 per year, more than twice the cost of a person without diabetes. In 2012, the total cost of diagnosed diabetes was $245 million.

Frankly, we cannot afford for this epidemic to not be addressed on a national and local level, and I am proud that the Y offers a solution that meets the needs of our community.

Dave peterson, director of Community Health, oversees YMCA programs for chronic disease prevention and management including the YMCA’s Diabetes prevention program and lIVestroNG at the YMCA cancer survivorship program. In addition, peterson serves as a YMCA liaison for community health promotion, health equity, and public policy advocacy. He has spent 15 years working for the YMCA of Central Kentucky and holds a BA in exercise science from the university of Kentucky and a CsCs from the National strength and Conditioning Association. the YMCA of Central Kentucky offers Diabetes prevention program sessions yearround at the North lexington, Beaumont Centre, and High street branches. For information, please contact Dave peterson, Director of Community Health, at 859-2589622 dpeterson@ymcacky.org ◆

Issue#85 25

comPlementary care

how mindfulness-Based eating can help with diabetes Cultivate your Inner Gourmet By JaN aNDERSON, PSyD, lPCC

A diagnosis of diabetes can feel like a death sentence. I remember observing the faces of some of the participants in a pre-diabetes program as the nutritionist described how to gain control of their blood glucose with portion control, eating more nominallyprocessed foods, and fewer sweets, sugary beverages, and processed baked goods.

“Changing your lifestyle may feel like a lot of work, but when you consider the health consequences of diabetes, it’s worth the time and effort,” she explained.

But change, even when desired, can be stressful. Many of the participants’ comments revealed the notion that avoiding or managing diabetes translated as dieting, deprivation, and giving up the foods they enjoy.

Which explains why I’m so impressed with Mindfulness-Based Eating as a powerful antidote to the “there goes my life” reaction when confronted with a health issueinduced lifestyle change. For a client facing what may seem like an overwhelming and unwelcome shift in his or her daily routine, Mindfulness-Based Eating may just make the difference between finding a way to get blood glucose under control and feeling too unmotivated to even try.

Yes, the focus is on eating less, but paradoxically, it comes about by enjoying food more. The focus is on eating differently, but in a way that increases awareness, satisfaction, and feeling in control. Think of it as cultivating your “inner gourmet.”

In a mindfulness-based eating session, my client learns to tune in to how he or she feels physically and emotionally at any moment. That moment can be the point of power that allows him or her to make a thought-out response that feels more in

eating is an exPerience that is often laden with emotions, whether we’re aware of them or not.

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It’s powerful to give my clients an actual experience of what it feels like to eat with calmness and awareness – to eat when they are hungry and stop when they are satisfied, the experience of not judging food as “good” or “bad” but choosing to eat food that is both pleasing to them and nourishing to their bodies.

The best part is that I get to tell my clients they don’t have to eat every bite of every meal mindfully to change their relationship to food and eating. They learn that just a few bites eaten with awareness can help them get in touch with their level of hunger before they take the next bite.

Dr. Jan Anderson is a licensed professional Clinical Counselor with a Doctorate in Clinical psychology. she is in private practice in louisville, KY. Her CD Mindful eating: A Guided experience is available at www.

DrJanAnderson.com. ◆

control, rather than acting on automatic pilot from habit or impulsivity.

My observation in working with clients over the past 15 years is that in our sensoryoverloaded world it is all too easy to barely be aware of how your food tastes, whether or not you’re enjoying it, and how full you are. It’s easy to be “out to lunch” during your experience of eating - whether it’s reading, texting, driving, talking, working, watching TV, or just drifting off somewhere else in your mind. Unfortunately, this fundamental inattention to the meal often leads to eating more. The insidious part is you’re not even aware that it’s happening … until it’s too late and you’ve overeaten … again.

Sometimes mindful eating gets dumbed-down as simplistic self-help how-to’s, such as, “Just put your fork down between bites, eat slowly, and stop eating when you’re full.” Not so easy for my client to do when he or she is surrounded by highly palatable food that is plentiful, easily available … and now “forbidden.” Add to their own internal impulses and cravings the social pressures from those around them about when, what, and how much to eat … well, you get the picture. Eating is an experience that is often laden with emotions, whether we’re aware of them or not.

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Gadre named to Kentucky licensing Board for specialists in Hearing Instruments

lOUiSvillE Arun K. Gadre, MD, the Heuser Hearing Institute professor of Otology and Neurotology at the University of Louisville, has been appointed by Gov. Steve Beshear to the Kentucky Licensing Board for Specialists in Hearing Instruments. Gadre’s term began this month and runs through July 2017.

The board is the Commonwealth’s licensing body for the hearing instrument dispensing profession and makes recommendations when needed on state laws governing hearing instruments.

Gadre is board-certified in surgery and is listed among the 2014 “Best Doctors in America,” an honor accorded to only five percent of all physicians in the United States.

At UofL, Gadre also serves as the Heuser Hearing Institute endowed chair in Otology & Neurotology and director of Otology, Neurotology, and Skull Base Surgery in the division of Otolaryngology-Head and Neck Surgery at the Hiram C. Polk Jr., MD, Department of Surgery at UofL. He practices with University of Louisville PhysiciansEar, Nose & Throat and has been on the faculty at UofL since 2006.

Gadre focuses on translational research.

He is interested in research in minimally invasive otologic surgery and in cochlear implantation. He has studied the pathophysiology of otosclerosis, in which abnormal bone growth in the middle ear causes hearing loss; and Meniere’s disease, a disorder of the inner ear that can cause dizziness, tinnitus, ear pain, or hearing loss. He also recently found a new etiology for vertigo, which he presented in Antalya, Turkey, at the 29th Meeting of the Politzer Society, the international society for otologic surgery

seND Your NeWs IteMs to M.D upDAte > news@md-update.com

and science. He was also appointed international neurotology board examiner at King Saud University in Riyadh, Kingdom of Saudi Arabia.

His clinical specialties are in otlogy, neurotology, and skull base surgery, including surgery for acoustic neuroma, a benign tumor found on the eighth cranial nerve leading from the brain to the inner ear that can affect hearing and balance. He also performs cochlear and bone-anchored hearing aid implants, other ear surgeries and surgery of the facial nerves. Other specialties include management of vertigo and treatment of maxillofacial trauma.

Gadre earned his medical degree from Lokmanya Tilak Municipal Medical College and General Hospital in Bombay, India, and completed an ear-nose-throat residency and a head and neck surgery fellowship at Bombay’s Tata Memorial Cancer Hospital. After arriving in the United States, he completed a residency in otolaryngology-head and neck surgery at the University of California-Davis Medical Center in Sacramento. He completed otology research fellowships at the House Ear Institute, Los Angeles, and was the Eleanor Naylor Dana Laser Research Fellow at the Lahey Clinic, Burlington, Mass. He completed an accredited otology and neurotology fellowship at New York University Medical Center and Tisch Hospital. He moved to Louisville from the University of Texas Health Science Center at Houston, and was formerly director of otology at the University of Texas Health Science Center at San Antonio and the University of Texas Medical Branch at Galveston.

oncofertility specialist Joins uK HealthCare team

lEXiNGTON UK Women’s Health Obstetrics & Gynecology has added an oncofertility specialist to its team. Dr. Leslie A. Appiah joins UK HealthCare as a board-certified gynecologist with expertise in oncofertility and fellowship training in pediatric and adolescent gynecology. Appiah brings five years of experience from Cincinnati Children’s Hospital Medical Center, where she served

as director of oncofertility and fellowship director of pediatric and adolescent gynecology.

Appiah will serve as director of oncofertility at UK. She will work closely with subspecialists in reproductive endocrinology and infertility, the Markey Cancer Center, and Kentucky Children’s Hospital. Appiah and her team will collaborate to preserve the fertility and reproductive health of pediatric, adolescent, and adult cancer and blood disorder patients of all genders.

Appiah attended medical school at the University of Texas Southwestern Medical Center at Dallas. She completed her residency in OB-GYN at Sinai Hospital of Baltimore and a clinical fellowship in pediatric and adolescent gynecology at Texas Children’s Hospital. She has received several teaching awards including the Johns Hopkins Excellence in Teaching Award.

Appiah’s interests include fertility preservation, minimally invasive surgery, congenital anomalies of the reproductive tract, hormone replacement therapy, and endometriosis.

Noonan Named ‘Gifted educator’ for 2014

Dr. Jacqueline (Jackie) Noonan, long-time faculty member at the University of Kentucky College of Medicine and former chair of the Department of Pediatrics, has been named the “Gifted Educator” for 2014 by the American College of Cardiology.

The award recognizes someone who has demonstrated innovative, outstanding teaching characteristics that contribute significantly to the field of cardiovascular medicine.

“This honor is well-deserved and places Dr. Noonan in rare company. She has represented the University of Kentucky admirably for more than 50 years — not just in her capacity as a teacher and mentor, but as a strong advocate for Kentuckians with

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uK Chief of Adolescent Medicine publishes Books Covering Broad spectrum of teen Health topics

Dr. Jacqueline Noonan, left, with another long-time member of the uk cardiology faculty, Dr. Nancy Flowers.

congenital heart disease,” said Dr. Doug Schneider, chief of the Division of Pediatric Cardiology at UK. Noonan came to UK’s newly established College of Medicine in 1961. In 1963, she began publishing papers about children with a rare type of heart defect and distinct physical characteristics. The condition was eventually named Noonan Syndrome in acknowledgment of her efforts.

Currently professor emerita, Noonan has served the University of Kentucky in numerous capacities, including as a member of the University Senate and the Admissions Committee for the College of Medicine.

She serves on the editorial boards of many national and international professional journals and has hundreds of book chapters, presentations, and studies in peer-reviewed publications attributed to her. Although she officially retired in 2007, Noonan comes to work every day, continues to teach, publish, see patients, and advise junior faculty. She also continues to travel to all parts of the globe to lecture.

This is not the first time Noonan has been recognized for her work. She was given the Helen B. Fraser Award from the Kentucky Public Health Association, named one of the Best Women Doctors in America by Harper’s Bazaar, and received a Lifetime Achievement Award from The Best Doctors in America. She also received the A. Bradley Soule Award from The University of Vermont, her alma mater.

Noonan accepted her award at the ACC annual meeting March 31, in Washington, D.C. 28 M.D. upDAte

lEXiNGTON To offer comprehensive health care for teenagers, doctors are required to have a broad range of expertise on topics from nutrition to sexual health to psychological intervention. Dr. Hatim Omar, chief of the Division of Adolescent Medicine in the University of Kentucky College of Medicine’s Department of Pediatrics, is working to publish a book about all topics related to adolescent health.

Omar has served as an editor of more than 15 books about adolescent health published in the past five years. He has acted as an editor and author for books addressing obesity, chronic illness, sexual health, sports medicine, ambulatory medicine, neurodevelopmental disabilities, pharmacological treatments, and other topics specific to the adolescent population.

This month alone, Omar published four books: “Children, Violence and Bullying: International Perspectives;” “Playing with Fire: Children, Adolescents and FireSetting;” “Adolescence and Sexuality: International Perspectives;” and “School, Adolescence and Health Issues (Pediatrics, Child and Adolescent Health).”

With experience in the fields of gynecology, physiology, pediatrics, and obstetrics/ gynecology, Omar developed a passion for working with adolescents during a residency followed by a fellowship at West Virginia University. He has served as the chief of the division of adolescent medicine at UK since 1998. He has published more than 150 articles in peer reviewed journals. Currently, Omar is working on a book that provides the thoughts and voices of real teenagers from his practice. Omar hopes to publish the book later in 2014.

UK’s division of adolescent medicine

comprises a team of physicians, nurses, social workers, nutritionists, and psychologists who have expertise in a wide range of adolescent concerns. For more information, visit http://ukhealthcare.uky.edu/ adolescent-medicine.

uK pediatricians publish Comprehensive textbook about Newborn Kidney Disease

UK HealthCare pediatricians Dr. Aftab S. Chishti and Dr. Stefan G. Kiessling, have edited a new textbook that provides in-depth clinical instruction about the treatment of kidney and urinary tract diseases in newborns.

Published in January, “Kidney and Urinary Tract Disease in Newborns” provides doctors with comprehensive, practical knowledge for the diagnosis and treatment of kidney diseases in babies younger than a year old. The textbook includes contributions from more than 20 experts in the field of pediatric nephrology. The textbook addresses a wide range of topics, such as neonatal hypertension, cystic kidney disease, urological abnormalities, and nutrition for children with kidney disease. Each chapter starts with a clinical case example and ends with important take-home messages.

Chishti, associate professor of pediatrics, and Kiessling, chief of the division of pediatric nephrology, served as editors and contributing authors to the textbook.

Chishti said the textbook is the only professional publication on the market focusing on kidney disease in the first year of life.

The text will serve as a go-to resource for

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pediatricians interested in furthering their knowledge of kidney disease.

Hardin Memorial Hospital Joins Markey Affiliate Network

lEXiNGTON Hardin Memorial Hospital in Elizabethtown, Kentucky, is the latest medical center to join the University of Kentucky Markey Cancer Center Affiliate Network (MCCAN).

The affiliation means more cancer patients across Kentucky will be able to receive the advanced specialty and subspecialty care of the UK Markey Cancer Center, recently named the 68th National Cancer Institute-designated cancer center in the country, and the only one in Kentucky. Other benefits include access to clinical trials and advanced technology while allowing patients to stay closer to home for most treatment.

Hardin Memorial becomes the ninth hospital to join MCCAN. Other affiliates include ARH Cancer Center in Hazard, Frankfort Regional Hospital, Georgetown Community Hospital, Harrison Memorial Hospital in Cynthiana, the Norton Cancer Institute in Louisville, Our Lady of Bellefonte Hospital in Ashland, Rockcastle Regional Hospital in Mount Vernon, and St. Claire Regional Medical Center in Morehead.

A Joint Commission accredited private surgery center where our physicians perform diagnostic and surgical procedures for the treatment of pain, to include:

oldham and Baptist Health louisville recognized as Center of excellence in Bariatric surgery

Baptist Health Louisville’s Bariatric Surgery Center recently achieved re-accreditation from The American Society for Metabolic and Bariatric Surgery Bariatric Surgery Center for Excellence (ASMBS BSCOE) program. The program has been a center of excellence since 2010.

The accreditation is for a three year period.

To earn a Bariatric Surgery Center of Excellence designation, Baptist Health Louisville underwent a series of site inspections during which all aspects of the program’s surgical processes were closely exam-

ST. maTThEWS, ky

The YMCA of Central Kentucky offers Diabetes Prevention Program sessions year-round at the North Lexington, Beaumont Centre, and High Street YMCA branches.

For information, please contact Dave Peterson, Director of Community Health, at 859-258-9622 dpeterson@ymcacky.org Issue#85 29

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ined and data on health outcomes was collected. Baptist Health Louisville and other centers receiving the Bariatric Surgery Center of Excellence designation agree to continue to share information on clinical pathways, protocols and outcomes data.

“Due to the increasing prevalence of morbid obesity and the inherent risks associated with obesity, tools such as weight loss surgery can greatly improve our patient population’s health, therefore we recognize the need to implement a systematic approach to improving quality,” said John Oldham, MD, Medical Director of Baptist Health Louisville’s Bariatric Surgery program. “At Baptist Health Louisville we believe that the ASMBS Bariatric Surgery Centers of Excellence program will serve as a catalyst, driving strong programs to get even better.”

The Center of Excellence evaluation not only documents process – such as equipment, supplies, training of surgeons and staff and the availability of consultant services – but emphasizes results.

ASMBS BSCOE accreditation formally acknowledges a commitment to providing quality improvement and patient safety for bariatric surgery patients. As an accredited program, they have demonstrated that the center meets the needs of bariatric surgery patients by providing multidisciplinary, high-quality, patient-centered care.

Kentuckyone Health and Walgreens Announce Clinical Collaboration

KentuckyOne Health and Walgreens (NYSE: WAG) (Nasdaq: WAG) announced in March a clinical collaboration agreement that will provide coordinated and expanded health care services, while improving access to high-quality, convenient, and affordable care for patients in the Louisville and southern Indiana area.

KentuckyOne Health will work with Healthcare Clinics at select Walgreens to expand the level of care and handle serious, non-emergent conditions outside of the clinics’ scope of practice. The collaboration will also offer the ability to help manage the

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treatment of chronic diseases.

While Healthcare Clinics and KentuckyOne Express Care strongly encourage all patients to have a designated primary care physician and medical home for ongoing needs, the collaboration will provide patients access to quality care seven days a week. The collaboration will include direct communication between Healthcare Clinic nurse practitioners and KentuckyOne Health physicians to facilitate care coordination and sharing of patient information.

With the Affordable Care Act expected to bring millions of new patients into the healthcare system, the relationship aims to help address some of the needs and challenges facing both patients and healthcare providers.

Medical Center Jewish Northeast Makes service Changes

Louisville As part of its efforts to improve performance, KentuckyOne Health is adjusting the mix of outpatient services offered at Medical Center Jewish Northeast (MCJNE).

The center’s emergency room will close effective at 7 a.m. April 1, 2014, due to low demand for emergency services at that location.

The medical center remains open and will continue to offer a range of other services from 7 a.m. to 5 p.m. Monday through Friday.

For emergency needs, the community will continue to be served by other excellent nearby 24/7 emergency care at: • Norton Brownsboro Hospital (7 miles away) • Medical Center Jewish East (13 miles away) • Jewish Hospital Shelbyville (19 miles away) MCJNE representatives have contacted officials responsible for emergency transport and public safety about the planned closure of the emergency room. The Kentucky Transportation Cabinet also was contacted regarding related highway siglOUiSvillE

nage. Additionally, MCJNE will conduct a community outreach effort to notify area residents and former patients about the closure and provide information about nearby 24/7 emergency care through advertising, signage, and direct mail.

Medical Center Jewish Northeast remains open and continues to offer: • Primary care and specialty physician services • Premier Surgery Center • Diagnostic imaging including general X-ray, DEXA scan, fluoroscopy, CT, MRI, nuclear medicine, PET scan and ultrasound • Laboratory services • Infusion services • Frazier Rehab Institute outpatient services

louisville Hand transplant program Celebrates 15th Anniversary

The Louisville Vascularized Composite Allograft (VCA) program, a partnership of physicians, researchers and healthcare providers from Jewish Hospital, part of KentuckyOne Health; the Christine M. Kleinert Institute for Hand and Microsurgery (CMKI); the Kleinert Kutz Hand Care Center; and the University of Louisville, marked the 15th anniversary of its first and the world’s most successful hand transplant on March 20.

Matt Scott, a New Jersey native, became the first patient to undergo a hand transplant at Jewish Hospital in 1999. Scott lost his dominant left hand on December 23, 1985 in a blast from an M80 firecracker. He has remarkable function in his transplanted hand, which he uses for everyday living activities. He is the director of the EMT and paramedic school operated by Virtua Health.

The success of Scott’s transplant has impacted the future of both transplantation and reconstructive surgery around the world. Since his procedure, the Louisville VCA program has performed eight more hand transplants on seven patients, including a double hand transplant in 2010.

Donnie Rickelman, Louisville program’s seventh hand transplant recipient, joined Scott

lOUiSvillE

news

the world’s most successful hand transplant recipient Matt scott (left) with Dr. Joseph Kutz

at a celebration marking the milestone.

“We are very pleased with Scott and the good attention to his transplant,” said Joseph Kutz, MD, primary investigator and partner with Kleinert Kutz Hand Care Center. “He has proven to the world that transplantation can be successful and allow people to get back to their normal activities.”

The success of the Louisville VCA program is promising and has led to additional funding for ongoing transplantation and research. Early funding for research on composite tissue allotransplantation and immunotherapy from the Jewish Hospital & St. Mary’s Foundation, also part of KentuckyOne Health, helped to bring about the nation’s first hand transplant.

Other hand transplants were funded by the Department of Defense. In late 2012, the Jewish Hospital & St. Mary’s Foundation allocated $1.5 million for the Louisville VCA program to be used specifically to bring potential hand transplant recipients to Louisville for screening, performance of the hand transplantation surgery and patient therapy and rehabilitation after surgery.

In 2013, the Louisville VCA program was awarded $850,000 to fund a clinical trial of a new treatment that will help prevent rejection of hand transplants as part of the Armed Forces Institute of Regenerative Medicine (AFIRM) research program.

AFIRM II is a five-year, $75 million federally funded project that will focus on applying regenerative medicine to battlefield injuries.

The clinical trial will be led by primary investigator Kutz and will take place

at Jewish Hospital and Kleinert Kutz with research taking place at the CMKI and the Cardiovascular Innovation Institute, a partnership of Jewish Hospital and the University of Louisville.

The AFIRM II funding will enable Louisville VCA researchers to explore the potential for a cell-based therapy to improve the immune system’s response to a hand transplant, and ultimately lessen or eliminate the need for immune-suppressant drugs. Results of this trial will be far-reaching and benefit not only military patients, but all hand transplant recipients.

knowledge to patients with serious conditions – often saving lives in the process by finding the right diagnosis and right treatment.

uK pharmacy, Markey Announce New Center for Nanobiotechnology

lEXiNGTON The University of Kentucky College of Pharmacy and Markey Cancer Center announce the creation of the Center for Nanobiotechnology, which will be led by

uK HealthCare physicians Named to Best Doctors in America listing for 2014

lEXiNGTON More than 100 UK HealthCare physicians affiliated with University of Kentucky Albert B. Chandler Hospital, Kentucky Children’s Hospital and UK HealthCare Good Samaritan Hospital appear on the Best Doctors in America® List for 2014 -- more than any other hospital in Kentucky. Only five percent of doctors in America earn this prestigious honor, decided by impartial peer review.

The Best Doctors in America® List, assembled by Best Doctors, Inc. and audited and certified by Gallup®, results from exhaustive polling of over 45,000 physicians in the United States. Doctors in over 40 specialties and 400 subspecialties of medicine appear on this year’s List.

In a confidential review, current physician listees answer the question, “If you or a loved one needed a doctor in your specialty, to whom would you refer?” Best Doctors, Inc. evaluates the review results, and verifies all additional information to meet detailed inclusion criteria.

In bringing together the best medical minds in the world, Best Doctors works with expert physicians from its Best Doctors in America® List to help its 30 million members worldwide get the right diagnosis and right treatment.

The experts who are part of the Best Doctors in America® database provide the most advanced medical expertise and

Peixuan Guo, UK’s William S. Farish Fund Endowed Chair in Nanobiotechnology.

Nanotechnology is the development and engineering of devices so small that they are measured on a nanometer scale. Nanoscale devices can work as parts of body organs, tissues, and drug carriers to interact with biomolecules on both the surface and inside cells. Because they have access to so many areas of the body, they have the potential to detect diseases and deliver treatments in newer and more effective ways.

The newly-established center will bring together biomedical experts working in nanobiotechnology in UK’s Colleges of Pharmacy and Medicine. All faculty with research interests in nanobiotechnology, such as nanoscale biomaterials, nanobiomechanics, nanomedicine, nanodrug delivery, nanoimunology, nanophotonics, biomolecular imaging, micro- and nano-scale biosensors, biochips, and RNA nanotechnology, are invited to engage with the center. ◆

Issue#85 31

events

2014 aha heart Ball

The 26th Annual Central Kentucky Heart Ball, held on Saturday March 8 2014 at the Lexington Center, in downtown Lexington, drew record crowds and raised $265,000 to fund the mission of the American Heart Association. The evening was chaired by Darby and Charlotte Turner, and honored community leader and heart disease survivor, Warren Rosenthal. Funds raised from the evening will be used by the American Heart Association to support cardiovascular research, preventative education and advocacy efforts in Central and Eastern Kentucky.

robert salley, MD, executive Director of Cardiovascular services, saint Joseph Hospital and fiancée Kristy Johnson, rN, strike a stunning pose at the AHA Heart Ball.

scott Hickman and wife Alison Bailey, MD, Director of Cardiac rehabilitation and Wellness program at uK Gill Heart Institute are all smiles at the Heart Ball.

Brian and Karen Hill, Coo / Chief Nursing officer, Baptist Health lexington attended the Heart Ball to support the American Heart Association.

Dr. Jennifer schaeffer and Cameron schaeffer, MD, plastic surgeon specializing in pediatric urology enjoyed a moment at the Heart Ball with Dr. preston Nunnelley, Vp/Chief Medical officer Baptist Health lexington and wife lucille Nunnelley.

Mrs. Deirdre lyons, a Cor Vitae member, and Joey Maggard, director of the American Heart Association of Central Kentucky.

Charlotte turner, Dr. sylvia Cerel-suhl and Darby turner. the turners were the Heart Ball Chair Couple and Dr. Cerel-suhl is the American Heart Association past president.

Hamid Mohammadzadeh, MD, saint Joseph Cardiothoracic surgery Associates and wife sepideh pourazima support the American Heart Association because it “unites people from all walks of life against cardiovascular disease through fundraising to support research and educational services which affect all of us at some point in our life.”

32 M.D. upDAte

Frederic de Beer, MD, Dean of uK College of Medicine and wife Marcielle de Beer, phD, paused for a moment at the Heart Ball

WHAT YOU SAY ABOUT M.D. UPDATE “I read M.D. Update from cover to cover. There is always a front page article with in-depth coverage of a particular specialty in the area. But also there is comprehensive coverage of practice management topics, insurance issues, and personal finance. I especially like Scott Neal’s financial column.”

--- Ron Shashy, MD, Board Certified in Otolaryngology and Sleep Medicine Ear, Nose, and Throat Specialists, PLLC, St. Joseph East ENT Center “I felt the recent article featuring our practice in M.D. Update magazine captured the essence of our practice in past, present and future. I have received multiple positive comments in the community about the article, from physicians and patients.

“I always enjoy getting M.D. Update. It gives me the opportunity to catch up with what my colleagues in my community are doing in this ever changing environment. M.D. Update is also a nice mixture of things that are happening in the area, particularly the arts. Keep up the good work.”

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“I just wanted to thank you again for the nice spread on the Markey Cancer Center in the recent M.D. Update. I thought that it was very nicely done and I have received a number of great comments from physicians in the region.

“Thanks again for getting the word out on the great things happening at the Markey.”

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