MD-UPDATE Issue #107

THE BUSINESS MAGAZINE OF KENTUCKY PHYSICIANS AND HEALTHCARE PROFESSIONALS ISSUE #107 WWW.MD-UPDATE.COM

VOLUME 8 • #3 • April/May 2017

Two Teams. One System.

Comprehensive Care.

Baptist Health thoracic surgeons pursue minimally invasive technique and optimal patient care

SPECIAL SECTION HEART & LUNG ALSO IN THIS ISSUE • WHEN SPECIALISTS REFER TO LUNG CANCER SCREENING • STRUCTURAL HEART DISEASE PROGRAMS • HEART CARE FOR THE UNINSURED • PEDIATRIC HEART CARE

LETTER FROM THE PUBLISHER

Welcome Back, Dr. Kraut Long-time readers of MD-Update may recall that we traditionally publish our Heart & Lung, aka cardiology and pulmonology, issue in February. This year we postponed those topics until April/May because one of our featured physicians, Jonathan Kraut, MD, thoracic surgeon for Baptist Health Louisville, was on a four-month deployment with the 691st Forward Surgical Team’s (FST) Gold Hour Offset Surgical Team (GHOST) in Afghanistan. The golden hour being the first hour after a traumatic injury occurs, this meant that Kraut and fellow GHOST members were close to combat and Special Forces soldiers, operating in tents, helicopters, or huts, as needed.

Thank you for your service, Dr. Kraut. We’re glad to have you back in Kentucky, serving your patients in Louisville. See the full story on Kraut and his colleagues Robert Linker, MD, Baptist Health Louisville, and Michael Bousamra, MD, Baptist Health Floyd, in the cover story beginning on page 10.

The Bad News/Good News We’ve heard it hundreds of times that Kentucky ranks at the top or near the top in national rankings for morbidity in heart disease and lung cancer. The good news is that there’s a new generation of providers committed to changing those rankings. In addition to this issue’s cover story on thoracic surgery and lung cancer treatment at Baptist Health Louisville and Baptist Health Floyd, lung screening is being advanced by the Kentucky LEADS Collaborative team at U of L, promoting LDCT screenings to priDr. Jonathan Kraut, Afghanistan mary care physicians and now specialists.

There is a new Structural Heart Center at Jewish PHOTO PROVIDED BY BAPTIST HEALTH LOUISVILLE Hospital in Louisville, part of KentuckyOne Health, and a new Structural Heart Program at Owensboro Health in Owensboro. Prevention, treatment, and cost-savings have gained national attention at the Graves Gilbert Clinic in Bowling Green. The congenital heart program at Children’s Hospital at UK HealthCare is growing is volume and complexity. The Have a Heart Clinic in Louisville’s downtown, serving Old Town and the West End, is bringing cardiovascular care to a population that otherwise may be untreated.

I invite you to dive into this issue of MD-Update. It’s full of great stories about Kentucky and Southern Indiana doctors. What’s your story? Give us a call.

As always, all the best,

MD-UPDATE MD-Update.com Volume 8, Number 3

ISSUE #107 PUBLISHER

Gil Dunn gdunn@md-update.com EDITOR IN CHIEF

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Jan Anderson, PsyD, LPCC Sarah Hines Lisa Hinkle Ruth Mattingly Lisa Meeker Scott Neal Jenny Patterson

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CONTENTS

ISSUE #107

Baptist Health thoracic surgeons (l-r) Dr. Jonathan Kraut, Dr. Michael Bousamra, and Dr. Robert Linker are leading the way to more comprehensive, minimally invasive lung cancer care.

SPECIAL SECTION HEART & LUNG

4

HEADLINES

5

FINANCE

7

LEGAL

10 Two Teams.

13 LUNG CANCER SCREENING: KY LEADS

15 A NEW HOME FOR STRUCTURAL HEART DISEASE: JEWISH HOSPITAL

17 A CCESS IS EVERYTHING: HAVE A HEART CLINIC

One System.

Comprehensive Care.

Baptist Health thoracic surgeons pursue minimally invasive technique and optimal patient care 13 SPECIAL SECTION: HEART & LUNG 25 MENTAL WELLNESS 27 COMPLEMENTARY CARE

19 C ARING FOR THE HEARTS OF CHILDREN: UK PEDIATRICS

21 B UILDING A STRUCTURAL HEART PROGRAM: OWENSBORO HEALTH

23 P ERFECTING PREVENTION: GRAVES GILBERT CLINIC

29 NEWS 31 EVENTS ISSUE #107 3

Headlines

Dean Dorton Acquires Metro Medical Solutions, LLC

Acquisition expands healthcare services to include billing and credentialing

BY JENNY PATTERSON

vice efficiently and effecDorton tively while providing cliAllen Ford, PLLC, has ents with additional value expanded its healthcare through a broader range services in Kentucky of specialty capabilities, by acquiring Metro advice, and solutions. In Medical Solutions, LLC, addition, we want to offer a long-standing physician more opportunities for billing and credentialour employees and refering company located in ral partners who are the Louisville, Ky. The merger backbone of our business,” was effective April 1, 2017. noted January Taylor, curDavid Bundy is president and CEO of Dean January Taylor is the current president of Metro The new physician billing rent president of Metro Dorton Allen Ford, PLLC. Medical Solutions, LLC. and credentialing services Medical Solutions. “We will be combined with Dean Dorton’s existing a low cost, creating tailored solutions for each are thrilled to be a part of Dean Dorton and healthcare consulting practice and branded as individual client.” to be able to provide our current clients with a Dean Dorton Healthcare Solutions (http:// “With the incorporation of Metro Medical full scope of accounting, advisory, and medical deandortonhealthcaresolutions.com/).

Solutions, we can now offer our physician prac- billing and credentialing services.”

“The addition of Metro Medical Solutions tice clients a full suite of outsourced services, “Joining teams with Metro Medical and their team helps us to better serve our from accounting and financial outsourcing Solutions allows us to continue our firm’s long growing healthcare practice. We are enthusias- to billing and credentialing. We are now able history of providing innovative financial and tic about the high level of service and expertise to handle all back-office functions, which business strategies to help our clients succeed Metro Medical Solutions has provided its can allow physicians to focus solely on the now and in the future,” Bundy remarked. notable client base and the opportunity to demands of their clinical practice,” added Dean Dorton Healthcare Solutions expand services to our current clients, which Adam Shewmaker, director of Healthcare includes a team of more than 20 experts who includes many physician practices,” said David Consulting Services at Dean Dorton. specialize specifically in healthcare accountBundy, president and CEO of Dean Dorton.

“Our clients’ needs always come first. With ing and financial outsourcing, medical billing “Metro Medical Solutions is highly regarded the combination of developing client needs and and credentialing, revenue cycle management, in their ability to maximize reimbursement for continuous growth, it is critical for us to find compliance and risk management, technology, physician practices in a short amount of time at a way to continue providing high-quality ser- human resources, and advisory services.

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PHOTOS PROVIDED BY DEAN DORTON AND METRO MEDICAL SOLUTIONS

Finance

Remember the IRA?

BY SCOTT NEAL

I once heard about an old CPA who, after presenting a completed tax return to his client, said, “Don’t read the {expletive deleted} thing, just sign it.” Unlike that guy, before I gave up my tax practice, I would remind clients to make sure that they understood what was on the return so that it could be as complete and accurate as possible. I know that the tax code is much more complex these days, but you should read and understand your 1040.

Unless you are different than most people I know, you probably don’t volunteer to pay extra taxes. Guess what? If you haven’t kept track of your non-deductible contributions to your Individual Retirement Account (IRA), you may pay more taxes than you should when you turn 70-1/2. This column is meant to be a quick refresher on IRAs—not exhaustive by any means—but will be important to many of our readers. Bear with me for what could be very good news for some of you.

Traditional IRAs came into existence in 1974 and were initially only available to taxpayers who were not already covered by a qualified retirement plan. Contributions were originally limited to $1,500. The Economic Recovery Tax Act of 1981 lifted the qualified plan restriction, and taxpayers could contribute and take a tax deduction of up to $2,000 on their own account, plus $250 for a nonworking spouse. Deductions began to be phased out under the Tax Reform Act of 1986 for IRA contributions made by high-income taxpayers who were also covered by a retirement plan, or had a spouse covered by one. Additional changes were written into law in the late ‘90s. Income limits were raised, allowing more people to make contributions.

The Taxpayer Relief Act of 1997 introduced the ROTH IRA, a special kind of retirement account. Contributions to ROTH

IRAs are made with after-tax dollars. There is no deduction taken for the contribution and no taxes paid on the distribution, so long as all the rules have been met. However, the ability to make contributions to ROTH IRAs is phased out for higher earning taxpayers.

Deductions for Traditional IRAs are also eliminated for certain taxpayers. But anyone who has “earned” income can still make contributions to a Traditional IRA up to the limits (presently $5,500 or $6,500 for people over 50). The deduction, not the contribution, may be eliminated based on income.

Non-deductible contributions still make sense for most taxpayers.

Our recommendation is to first test to see if you can make a deductible contribution to a Traditional IRA. If so, make the contribution and get the benefit of the deduction. The phaseout of the deduction happens at different levels of income, depending on filing status (joint, single, or head of household) and whether you or your spouse are covered under a retirement plan. If you are phased out of the deduction due to the income limits, you should then test to see if you can make a ROTH contribution. If

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ISSUE #107 5

Finance

your income is also too high to make a ROTH contribution, you should still be able to make a non-deductible contribution to a Traditional IRA if you have had earned income.

Remember that distributions from Traditional IRAs are required beginning at age 70-1/2, and they are fully taxable unless you can prove that you have tax basis in the IRA. Making a non-deductible contribution to an IRA creates tax basis. These should be reported on Form 8606 of the tax return for the year in which the non-deductible contribution is made. If you skip a year of making the contribution there will be no 8606 for that year. This means that the carry forward information regarding basis is very easily overlooked in subsequent years. We have even seen taxpayers and preparers who simply fail to report the non-deductible contribution.

Non-reporting seems very logical to some people since the contribution has no present tax consequence. But who would ever think that the tax code was built on logic?

6 MD-UPDATE

The responsibility for keeping track of basis rests with the taxpayer, not the government, and not the custodian of your IRA. Herein lies a potential problem, with a corresponding opportunity to avoid paying unnecessary taxes in the future, if you act now. Let’s say you made tax-deductible IRA contributions early in your career, and non-deductible contributions for the past several years. As distributions are taken throughout retirement, a portion of each distribution is considered a non-taxable return of basis. If you cannot prove your basis, the government can claim that the entire distribution is taxable. If you think that you have this problem, now is the time to get it fixed.

If you have made a non-deductible contribution to your IRA, pull out your tax return and find the Form 8606. On line 2 of that form you should find your total basis in all Traditional IRAs. If you have not yet taken distributions from your IRA, this should be the amount of your lifetime accumulated non-de-

ductible contributions to any Traditional IRA. If it doesn’t look right, now is the time to discuss it with your tax preparer.

Scott Neal, CPA, CFP, is the president of D. Scott Neal, Inc. a fee-only financial planning and investment advisory firm. You may subscribe to his blog at www.dscottneal.com. Or simply call 1-800-344-9098 or email to scott@ dsneal.com with questions or comments.

Coming Soon... .com

Legal

Watch Out MCOs

Appealing MCO payment denials and Medicaid overpayment determinations

BY LISA HINKLE AND SARAH HINES

With reported revenues in the billions of dollars and net profits not far behind, insurance companies providing a Medicaid Managed Care product are making huge profits on Kentucky’s Medicaid business. Across the country, lawsuits are being filed that go so far as to allege that these Medicaid Managed Care Organizations (MCOs) have been unjustly enriched and have made fraudulent misrepresentations as well as negligent misrepresentations to providers and their staff. WellCare, in particular, is the subject of a new action in Florida based, in part, on its Kentucky Medicaid business. While these lawsuits create a very important way to address reimbursement issues, Kentucky providers have a new avenue to pursue claims against MCOs. In April of 2016, the Kentucky legislature directed that healthcare providers have a process by which a Medicaid MCO’s final decision denying a healthcare service or claim could be reviewed and appealed. Under the statute, providers could receive an independent, third-party review of denied Medicaid managed-care claims, as well as an administrative process for review. Prior to the new process in Senate Bill 20, the only avenue for appeal was to the MCO itself or through the Department of Insurance’s policy of reviewing claims regarding failure to make prompt payment, which was a process established by policy, not regulation.

Finally, in December 2016, the final regulations implementing the statute and providing the process for appeal were promulgated by Kentucky’s Department for Medicaid Services (DMS), making available long-awaited relief for health care providers facing denied claims from Medicaid MCOs. Kentucky’s new appeals process, codified in KRS §205.646, is similar to those found in states such as Virginia and Georgia, where some Kentucky MCOs also operate. This was at least the second attempt by the legislature to bring this appeals process to Kentucky

– the last attempt was vetoed by Governor Beshear in 2013. The new process applies to all MCOs that contracted with the state after July 1, 2016, and the emergency regulations became effective as of December 1, 2016.

With the new regulations in place, providers should have a new tool for challenging reimbursement denials and findings of overpayment by MCOs. Because the statute and regulation are somewhat ambiguous, there is some question about whether denials of payment based upon statistical sampling, among other things, are appropriately reviewed in this process. We think that they are.

Third-Party Review KRS §205.646 (2) states that “a provider who has exhausted the written internal appeals process of a Medicaid managed care organization shall be entitled to an external independent third-party review of the MCO’s final decision that denies, in whole or in part, a health care service to an enrollee or a claim for reimbursement to a provider.” The MCO must provide the decision in writing to the provider, along with a statement that the internal appeal rights have been exhausted and that the provider is entitled to an external review, along with the time period and contact address to request such a review.

The specifics of the external review process are the same in both the emergency and regular forms of 907 KAR 17:035. Upon receiving the final decision from the MCO, the provider has 60 calendar days to request third-party review. This can be done electronically, or by fax or postal mail. The request must state the reason why the provider believes the MCO’s decision is erroneous. The MCO must then notify both DMS and the Medicaid enrollee within five business days of receiving the external review request, and DMS will assign a third-party reviewer to assess the case.

Because the time frames for requesting review and appeal, particularly appeal, are short, providers need to follow the requirements very closely and have a process in place where office and billing staff calendar denials and are equipped to handle them. Additionally, it is probably important to notify beneficiaries, as well, to assure that they know what is going on with the claim. This process could potentially get tricky if the beneficiary requests an administrative hearing on the denial before the provider does. In that case, the request for external third-party review will be denied. If the enrollee requests an administrative hearing after the provider requests third-party review, the third-party review will be suspended pending the full adjudication of the enrollee’s administrative proceeding.

Administrative Hearing Once the independent third-party review has been conducted, both the provider and the MCO have the right to appeal the decision within 30 days. 907 KAR 17:040E (both emergency and regular regulations contain the same provisions) governs the appeal process after the third-party review.

The party that does not prevail in the administrative hearing will bear the costs of the hearing: a fee of $600 payable to DMS.

Accountability The basic effect of these new laws and regulations is that MCOs are now held accountable for denial of care and claims. This process gives providers a right to an administrative review and ultimately review in Franklin Circuit Court. Having the process does not immediately mean relief, but it is a step toward resolution. MCOs now must provide an external review process and have a time frame that they should follow. They no longer get the final word on the reimbursement of claims and ISSUE #107 7

Legal

determination of medical necessity, supporting documentation, requirements, and quality of care issues. The process gives power to providers essentially on the behalf of their patients so that the balance now shifts back toward quality, comprehensive care of all patients.

Overpayment Appeals

by Medicaid 901 KAR 1:671 governs the Medicaid appeals process in Kentucky for findings of overpayment by Medicaid rather than MCOs. This process applies not only to overpayments, but to any other appealable determination, such as termination or suspension of provider status, sanctions by the Department for Medicaid Services, or withholding of payments during a fraud investigation. While the process has been around for quite a while, it is complicated and has important deadlines that can be easy to miss for providers.

When deciding whether to appeal an overpayment determination, a provider should consider one important benefit—Medicaid’s

8 MD-UPDATE

recoupment process is stayed or stops! In other words, a provider does not have to pay back the amount of overpayment immediately as Medicaid usually demands. The repayment is essentially tolled until the resolution of the administrative review and hearing process.

Once the decision to appeal has been made, the provider must first complete a request for a Dispute Resolution Meeting (“DRM”) within 30 calendar days of receipt of the demand or notice from the DMS. It is crucial to note that all allegations and issues must be raised in the DRM request or DMS will deem that the issue may be waived. And, it can be quite a chore to prepare a DRM request that raises all issues in a very short time frame. The provider may also elect to submit documentation in lieu of a meeting or even ask for a telephone conference. Within 30 days of the DRM, DMS will issue a decision, which can be appealed by requesting an administrative hearing within 30 days.

If the provider is dissatisfied with the administrative result, then an appeal can be

taken to Franklin Circuit Court, which may, if asked, also order that recoupment not be instituted.

Conclusion While the appeals process for both MCO claim denials and overpayment determinations is complicated and can be lengthy, both operate to provide healthcare providers with a route to defend claims and practices against overzealous determinations on the part of DMS and MCOs. The new appeals process for MCO denials and findings of overpayment is an important tool that providers should take advantage of when economical.

Lisa English Hinkle is a member of McBrayer, McGinnis, Leslie & Kirkland, PLLC. She chairs the healthcare law practice area and works in the firm’s Lexington office.

Sarah E. Hines is an associate at McBrayer, also working in the firm’s Lexington office in healthcare law. Learn more at www.mmlk.com.

This article is intended as a summary of federal and state law and does not constitute legal advice.

Cover Story

Two Teams. One System.

Comprehensive Care.

Baptist Health thoracic surgeons pursue minimally invasive technique and optimal patient care

BY JENNIFER S. NEWTON LOUISVILLE & NEW ALBANY, IND. Often, when it

comes to heart and lung programs, it is the heart side of the equation that we hear most often about. In cardiology and cardiac surgery, new techniques and treatments with exciting possibilities abound. For pulmonology and thoracic surgery programs, their work is no less important, although perhaps more of a slow and steady mentality.

“In recent years there has not been a revolutionary advance in the treatment of lung cancer,” says Michael Bousamra, MD, thoracic surgeon with Baptist Health Floyd. “But progressive refinements have led to improved surgical outcomes, less patient morbidity, and more rapid return of function.”

However, Bousamra and his cohorts across the river at Baptist Health Louisville – Robert Linker, MD, and Jonathan Kraut, MD – have set out to establish full service thoracic surgery programs specializing in minimally invasive procedures and are implementing proven programs and techniques, as well as innovative clinical trials, to make patient care and outcomes incrementally better.

Linker, thoracic surgeon and medical director of the oncology program for Baptist Health Louisville, says, “We provide the full range of general thoracic surgical procedures with the emphasis on minimally invasive procedures. There isn’t much that we turn down or send away.”

Linker is originally from Louisville and attended medical school at the University of Louisville. He pursued his general surgery

residency at the University of Cincinnati and his thoracic surgery residency at The Medical University of South Carolina. He returned to Louisville in 1986 and began practicing heart, vascular, and general thoracic surgery. It was not until 2001 that he began to focus solely on thoracic surgery.

Thoracic surgeon Kraut is from outside Philadelphia and moved to Louisville in 2006 to join Linker in practice. He attended medical school at St. George’s University in Grenada, West Indies, and completed his general surgery residency at Christiana Care Health System in Delaware and a fellowship in heart and lung at St. Luke’s Mid America Heart Institute in Kansas City, Mo. Bousamra, who is from Michigan, attended medical school at the University of Michigan. He completed his general surgery residency at the Medical College of Virginia in Richmond and his thoracic surgery residency at Washington University in St. Louis. He came to Louisville in 1999 and spent 17 years practicing at U of L before joining Baptist Health Floyd in 2016.

At Baptist Health Floyd, Bousamra says, “We’re a full service thoracic surgery practice. We operate on all diseases of the lung, esophagus, and mediastinum.” Those diseases include lung and esophageal cancers, as well as benign diseases of esophagus such as achalasia or hiatal hernias.

Concurrent Approaches to Cancer Care In both its locations on either side of the Ohio River, in Louisville and New Albany,

1 A merican Cancer Society. (2017, January 5). Key Statistics for Lung Cancer. Retrieved from American Cancer Society: https://www.cancer.org/cancer/non-small-cell-lung-cancer/about/key-statistics.html 10 MD-UPDATE

PHOTOS BY ROBERT DENSMORE

Dr. Robert Linker is a thoracic surgeon and medical director of the oncology program for Baptist Health Louisville.

Dr. Jonathan Kraut is a thoracic surgeon with Baptist Health Louisville.

Dr. Michael Bousamra is a thoracic surgeon with Baptist Health Floyd in New Albany, Ind.

Ind., Baptist Health’s thoracic surgery programs put particular emphasis on lung and esophageal cancer treatment. Linker estimates that 70 percent of their practice is oncologic, and with good reason. In the US, one out of every four cancer deaths is attributable to lung cancer, more than breast, colon, and prostate cancers combined1. Unfortunately, Kentucky leads the way. According to the

Dr. Robert Linker presents a case at the Multidisciplinary Lung Care Conference at Baptist Health Louisville.

CDC National Program of Cancer Registries, Kentucky ranked highest in the US in lung cancer incidence and deaths from 200920132. The American Cancer Society estimates Kentucky lung cancer deaths for 2017 will reach 3,560, up from 3,300 in 2009.

That’s why these surgeons have focused their careers on tactical, evidenced-based strategies to provide better treatments and outcomes for patients, such as streamlining patient pathways and access, refining minimally invasive techniques, and providing access to better tools for screening and early detection.

Baptist Health Louisville Both Linker and Kraut were instrumental in starting the Multidisciplinary Lung Care Clinic at Baptist Health Louisville when their practice joined Baptist Health in 2008.

The clinic allows patients to see a team of providers, including Linker and Kraut, medical oncologists, radiation oncologists, a nurse navigator, and psychosocial services.

The clinic gets 12 to 15 new patients a week.

While providers see patients two days a week in the clinic, they also meet once weekly in a multidisciplinary conference to discuss cases and optimal treatment. “The multidiscipline conference and clinic is instrumental in patient care. It has been shown nationally to

provide the best outcomes for these patients,” says Kraut.

Supplementing the virtual experience provided by the clinic is the physical space afforded by the Charles and Mimi Osborn Cancer Center at Baptist Health Louisville, which opened in 2014. “We have concentrated all of our cancer programs across the Baptist campus in that one area,” says Linker.

Kraut adds, “One of the benefits of having a cancer center and a multidiscipline clinic is that you are able to provide convenient, compassionate, expedient, and comprehensive care in one facility. It allows our patients to see multiple different specialists at one time. It saves additional appointments down the road

2 U .S. Cancer Statistics Working Group. United States Cancer Statistics: 1999–2013 Incidence and Mortality Web-based Report. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention and National Cancer Institute; 2016. Available at: www.cdc.gov/uscs.

PHOTO PROVIDED BY BAPTIST HEALTH

ISSUE #107 11

Cover Story

and helps us get our patients to more definitive therapy much more quickly.”

At Baptist Health Louisville, about 60 percent of lung cancer surgeries are performed minimally invasively. Linker specializes in robotic lobectomies with the da Vinci® Surgical System. Kraut performs video-assisted thoracic surgery (VATS). Both techniques result in quicker recovery, shorter hospital stays, minimal blood loss, minimized scarring, and less pain as compared to open thoracotomy.

One way to improve outcomes is to reduce the severity of cases that appear in the thoracic surgery clinic. In July 2013, the US Preventive Services Task Force (USPSTF) issued guidelines recommending annual CT screening for individuals at high risk for lung cancer. Linker and Kraut also initiated a lowdose CT screening program. Since Medicare has approved payment for screenings, guidelines have changed. The biggest change for physicians and hospitals is that patients must undergo pre- and post-test counseling about radiation exposure. Baptist Health has a nurse practitioner that meets with patients pre-test to ensure they meet Medicare criteria and to explain the screening. After the CT scan, a radiologist and Linker examine the scan, and the patient is counseled about their result.

Bousamra is also involved in a research project – breath analysis to diagnose cancer – a project he developed while at U of L and has brought with him to Baptist Health Floyd. “A patient breathes one breath into a non-reactive plastic bag, and we pass that breath across the patented silicone microchip.

It captures a certain subset of compounds that are specific for cancer, and then we anaIn 2013, Baptist Health Louisville initiated a low-dose CT screening lyze those compounds,” says program for individuals at high risk for lung cancer following the US Preventive Services Task Force (USPSTF) guidelines. Baptist Health Bousamra, who has identified Floyd now offers low-dose CT lung cancer screening and has been four lung cancer markers. conducting clinical trials to compare the effectiveness of CT screening “We’ve embarked on a versus breath analysis in lung cancer detection. study at Floyd where we’ve Outside of cancer surgery, the surgeons done CT scans on patients and treat conditions such as pleural effusions, hiatal breath analysis studies on the same patients hernias and reflux, and chest wall problems. and found that the breath analysis study is a Linker has a special interest in thoracic outlet more accurate test for detecting lung cancer surgery. To relieve compression and brachial than is the CT scanner. It doesn’t produce as plexus, Linker uses thoracoscopy for first rib many false positives,” says Bousamra. resection, which reduces hospital stay and He has submitted an NIH grant to study recovery time over standard chest surgery. further at Floyd and Baptist Health Louisville.

Kraut specializes in chest wall reconstruction “We’re a ways away from having a breath analand trauma, where he is “using a plates and ysis test as a primary screening for lung cancer, screws rib system for rigid fixation of rib frac- but that’s the long-term goal,” he says. tures,” he says.

Whether through multidisciplinary teams and conferences, state-of-the art screening, or Baptist Health Floyd minimally invasive surgical techniques, the At Baptist Health Floyd, Bousamra has thoracic surgeons of Baptist Health demonassembled his own team. “From a surgical strate a commitment to collaborative, refined, perspective, we have a focused team that’s evidence-based care. devoted to taking care of patients with lung Linker points to one final example of teamcancer and esophageal cancer and working work as he shares the role he believes thoracic up spots in the lung. We have a tumor board surgeons will play as new medical therapies, that’s robust and meets regularly,” he says. which are showing promise in certain subgroups Like Kraut, Bousamra performs the min- of patients, continue to evolve. “With these imally invasive VATS procedure. And while minimally invasive techniques, we’re able to get there have not been revolutionary advances a significant amount of tissue for diagnosis and in thoracic surgery, he believes minimally testing. The big trend now is toward individualinvasive surgery and efforts to minimize air ized treatment. With DNA markers and newer leaks and bleeding and reduce chest tube time drugs we’re getting into specific treatments for result in better outcomes for patients. specific tumors. I think our role is going to be Medical oncology and radiation oncology, getting enough tissue to draw these tests on so along with a full complement of cancer services, patients can be treated with immunotherapy are available at the Cancer Center of Indiana, and various new drugs coming out, such as which is in very close proximity to the hospital.

Opdivo® and Keytruda®,” he concludes.

12 MD-UPDATE

PHOTOS BY BRIAN BOHANNON, COURTESY OF BAPTIST HEALTH

SPECIAL SECTION

Heart & Lung

Lung Cancer Screening – Not Just a Primary Care Responsibility

BY RUTH MATTINGLY There is a major statewide push to encourage primary care providers (PCPs) to refer eligible patients to low-dose computed tomography (LDCT) lung cancer screening. However, a pulmonologist in Lexington wants specialists to know that they, too, can refer eligible patients to this potentially life-saving screening.

Mahmoud Moammar, MD, of KentuckyOne Health Pulmonology

Associates, said his practice sees many patients with chronic obstructive pulmonary disease (COPD), a disease most frequently caused by cigarette smoking. Many of them meet all of the lung cancer screening criteria, he said, adding, “They deserve the screening.”

LDCT screening for lung cancer was recommended by the U.S. Preventive Services Task Force in December 2013, following the National Lung Screening Trial (NLST). The National Cancer Institute-sponsored study

Mahmoud Moammar, MD PHOTO BY GIL DUNN

proved that new technology could detect small tumors early enough to remove them by surgery.

Moammar said he has been referring patients to LDCT screening since 2015 when the Centers for Medicare & Medicaid Services (CMS) added it as a preventive service benefit under the Medicare program. “We do it every day,” Moammar said. “I believe in it.”

Moammar said he has had several patients whose lung cancer was caught at an early stage. “They got a cure for lung cancer; not palliative care,” he added. “It was surgery with intent to cure.”

CMS covers screening as a preventive services benefit for beneficiaries who are: • Current smokers, or those who have quit within the last 15 years, age 55-77.

• Individuals that have a tobacco smoking history of at least 30 pack-years; a pack year equals one pack per day for a year.

• Asymptomatic, with no signs or symptoms of lung cancer.

Anthony Weaver, MD, of the University of Kentucky College of Medicine, is also a major proponent of lung cancer screening.

He wants healthcare providers to view LDCT lung screening like mammography and other recommended tests ordered “as a matter of general health.” He said that Kentucky, with the nation’s highest lung cancer incidence and mortality, has a responsibility to show that LDCT screening can lower lung cancer death rates. “It is up to us,” Weaver said.

Angela Criswell of Lung Cancer Alliance, a national nonprofit advocacy group, said some specialists hesitate to refer patients because of the “asymptomatic” requirement of CMS. She said that criterion is to ensure that patients with true symptoms, such as coughing up blood and weight loss, receive diagnostic tests rather than screening. A “persistent cough” does not make a patient ineligible for screening, she said.

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Criswell pointed out that many patients with chronic conditions see specialists much more frequently than PCPs. “The specialists have strong relationships with their patients, many of whom meet high-risk criteria for lung cancer screening, and they see these patients regularly for evaluation and management of their health concerns – so they are a major referral pathway,” Criswell said.

Moammar said specialists might hesitate to refer patients to screening because they do not want to be burdened if lung cancer screening requires follow-up attention. He pointed out that most screening facilities, particularly within large health systems, have staff dedicated to ensuring follow-up of abnormal findings. “That takes the burden off their shoulders,” Moammar said.

Since early 2016, Kentucky LEADS Collaborative team at the University of Louisville has been promoting LDCT screening to PCPs through several continuing medical education offerings, including visits

Angela Criswell

to providers, presentations to medical groups, and a free interactive online course “Lung Cancer in Kentucky: Improving Patient Outcomes,” at www.LungCancerinKentucky. org. The online course familiarizes providers with screening eligibility and how to conduct CMS-required shared decision making with

patients, and it features resources for tobacco treatment and cancer survivorship.

Jesse Adams III, MD, a cardiologist with Baptist Health in Louisville, recently took the online course and called it a “succinct means of getting up to date on this important topic.”

Adams, immediate past-Governor of the Kentucky Chapter of the American College of Cardiology, said he does not yet refer patients to LDCT screening. “The course prepared me to appropriately refer patients when I choose to do so, and to provide guidance to patients who are eligible,” he said.

The free interactive course is available at www.LungCancerinKentucky.org. For more information about Kentucky LEADS Collaborative, see www.KentuckyLEADS.org

Ruth Mattingly, MPA, is co-investigator, Kentucky LEADS, and assistant director for special initiatives, Kentucky Cancer Program at University of Louisville, 501 E. Broadway, Ste. 160 Louisville, KY 40202.

She can be reached at (502) 852-4065.

WE’VE DONE THIS BEFORE♦ From health care transactions and compliance to litigation defense, Sturgill Turner’s health care team is committed to providing comprehensive legal services to health care providers, hospitals and managed care organizations.

Lexington ♦ STURGILLTURNER.LAW 14 MD-UPDATE

PHOTO PROVIDED BY KENTUCKY LEADS

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A New Home for Structural Heart Disease

Jewish Hospital opens a Structural Heart Center to advance its structural heart disease program with a team approach to minimally invasive treatment for valvular disease heart Center of Excellence. We are a regional training site for these minimally invasive technologies,” says Kendra Grubb, MD, MPH, cardiovascular surgeon and surgical director of the Structural Heart Program.

BY BOB BAKER AND JENNIFER S. NEWTON LOUISVILLE They say, “Home is where the heart

is.” Well, now the heart has a new home – at the Structural Heart Center at Jewish Hospital.

The Structural Heart Program at the University of Louisville and Jewish Hospital, part of KentuckyOne Health, was begun in 2011 by interventional cardiologists Michael Flaherty, MD, PhD, and Naresh Solankhi, MD, with cardiothoracic surgeon Matthew Williams, MD, who was director of clinical cardiac operations at the time. While other cardiac programs address coronary arteries and electrophysiology, the scope of the Structural Heart Program is defined as abnormalities of the walls, muscle, and valves of the heart.

Since its inception, the Structural Heart Program operated within the hospital but did not have a dedicated space. Now, the Structural Heart Center at Jewish Hospital will provide a central home to further distinguish the program’s services for patients.

By bringing all the services of the Structural Heart Center together into a new singular clinical space at Jewish Hospital, a prospective patient can see a multidisciplinary team of practitioners in one location, on the same day. All relevant testing such as CT scans, echocardiograms, and EKGs will be immediately available.

As Flaherty points out, “The greatest value for the patient and the providers is that in one visit there will be no unanswered questions.”

While traditional open heart surgery is and always will be an important part of a structural heart program, minimally invasive techniques are gaining ground for appropriate patients. The Structural Heart Center takes a team approach to therapies such as transcatheter aortic valve replacement (TAVR)

Building the Foundation

Dr. Michael Flaherty is an interventional cardiologist with U of L Physicians and the medical director of the Structural Heart Program at Jewish Hospital.

Dr. Kendra Grubb is a cardiovascular surgeon with U of L Physicians and the surgical director of the Structural Heart Program at Jewish Hospital.

and MitraClip® for mitral regurgitation. “Our multidisciplinary team is setting a new bar for patient care and continuing to establish Jewish Hospital as a valve and structural PHOTOS BY ROBERT BURGE

Before 2011 there was no center in Kentucky offering the TAVR procedure.

Flaherty, an interventional cardiologist with U of L Physicians, was already certified and working at U of L when he decided to go to Baltimore to pursue a fellowship in minimally invasive techniques in 2009. “The main reason I went to Johns Hopkins was to learn transcatheter aortic valve and mitral valve therapies because we didn’t have that in Louisville at the time,” he says. Flaherty is board certified in internal medicine, cardiology, and interventional cardiology and is now director of adult structural heart disease and research interventional cardiology at U of L and medical director of the Structural Heart Program at Jewish Hospital.

As Flaherty was starting the TAVR program in Louisville in 2011, 200 miles away, Grubb, a fellowship-trained cardiovascular surgeon was completing an additional fellowship year in interventional cardiology and transcatheter therapies at Columbia University in New York. In 2013, she was recruited to join U of L Physicians and the faculty at U of L in the Cardiothoracic Surgery Division and help expand the TAVR program at Jewish Hospital. Grubb has since become surgical director of the Structural Heart Program.

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such as TAVR are an absolute paradigm shift in the way healthcare professionals view the evaluation and treatment of patients with cardiac valvular disease.” Prior to FDA approval for TAVR clinical trials, patients with aortic stenosis who were too sick to have open heart surgery had no other alternative. These patients, the very sick and high risk, were the first to be entered into an FDA trial of TAVR at U of L. The first trial, which randomized patients to TAVR or standard cardiac treatment, was so successful that a trial of intermediate risk patients was immediately planned and carried out. The second study randomized patients to TAVR or conventional open heart surgery. The intermediate patient trial showed TAVR was at least as good as open heart aortic valve replacement and was minimally invasive to the patients. Patient comfort and rapid return to normal life compared to the trauma of open heart surgery cannot be over emphasized. Due to the success of the previous trials, a current study is underway on low risk patients with aortic stenosis.

The Jewish Hospital Structural Heart Team performs the entire TAVR procedure under twilight anesthesia. There is no intubation, and the patient can speak and be spoken to throughout. According to Jiapeng Huang, MD, PhD, cardiac anesthesiologist who is board certified in anesthesiology and cardiac anesthesia, “Easy anesthesia for the patient

Dr. Jiapeng Huang is a cardiac anesthesiologist with KentuckyOne Health Anesthesiology Associates and is president of the Medical Staff.

PHOTO PROVIDED BY KENTUCKYONE HEALTH 16 MD-UPDATE

The Structural Heart Program involves a team effort, not just from physicians but also from its support staff.

Pictured from left to right: Erika Keithley, BSN, RN, CCRN, nurse/valve coordinator, Sharon Vincent, MSN, RN, clinical research coordinator, Anne Marie Webb, RN, BSN, clinical research coordinator, and Genny Sanders, MSN, APRN, FNP-BC, nurse navigator.

PHOTO BY ROBERT DENSMORE

means that this is the most demanding form of cardiac anesthesia for the physician. There is no down time for the anesthesiologist.”

Minimally Invasive = Maximum Team Effort The intraoperative team consists of an interventional cardiologist, a cardiothoracic surgeon, a cardiac anesthesiologist, and an experienced team of nurses and surgical technicians.

Taking on clinical trials, such as the early TAVR trials, requires many well-trained and dedicated personnel in addition to the physicians. For the research studies, Anne Marie Webb, RN, BSN, and Sharon Vincent, MSN, RN, serve as clinical research coordinators with the assistance of Genny Sanders, MSN, APRN, FNP-BC, the nurse navigator, and Erika Keithley, BSN, RN, CCRN, the nurse/ valve coordinator. Grubb states emphatically that, “The Structural Heart Program could not exist without these nurses and coordinators.”

Both Flaherty and Grubb see great advances coming and coming soon. TAVR and MitraClip will continue to improve at the design and the implementation level. Beyond

MitraClip, which only addresses mitral regurgitation, there are already devices being evaluated for transcatheter mitral valve replacement.

Research is also developing devices for the right side of the heart, specifically the pulmonic valve. Grubb describes the tricuspid valve as the next target for minimally invasive therapies.

The program recently celebrated its 450th TAVR and now is performing more than 150 transcatheter valve therapies a year. Huang believes strongly that performing a large number of carefully monitored procedures per year is key to operative efficiency and a low complication rate.

Clearly this group of healthcare providers already functions at an exemplary level, but the opening of the Structural Heart Center at Jewish Hospital means that patients that once had no options can see a multidisciplinary team of providers in a single visit and potentially be treated with minimally invasive life-saving technology. It also means these providers are training the next set of physicians across the region and setting the stage for the next generation of leading-edge technology.

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Dr. Michael Imburgia runs diagnostic testing on a patient at the Have a Heart Clinic.

Access is Everything

Have a Heart Clinic relocates to downtown Louisville and explores a new model of care to improve access for Louisville’s uninsured

BY DONNA ISON LOUISVILLE Heart disease does not discriminate

based on sex, race, or religion. However, it seems poverty does play a role. According to a 2014 Louisville Metro Health Equity report, in parts of the West End, death by heart disease is approximately three times higher, and the average life expectancy is 68, in contrast to their more affluent counterparts in St. Matthews where it is 83. Nationally, cardiovascular disease is the number one reason for patient visits to federally-qualified, nonfor-profit clinics. A 2012 Americares study found that 40 percent of all visits were due to cardiovascular issues.

After becoming aware of these statistics and the gap in coronary care for the indigent and uninsured, Michael Imburgia, MD, FACC,

felt compelled to do something. In his words, “There is such disparity in how we care for people. And, we’re paying for it financially.

More importantly we’re paying for it ethically and morally, to go to sleep knowing that people are not being cared for.” So, in 2008, he, his wife Sandy, and Sue Dillon, FASE, RDCS, founded the Have a Heart Clinic, a cardiac care clinic dedicated to serving patients regardless of their ability to pay. Imburgia is also the medical director of the Outpatient Cardiovascular Ultrasound Lab at Baptist Health Louisville.

The name, Have a Heart, was the brainchild of his wife Sandy Imburgia, RN, who in the clinic’s earliest stages also took care of the majority of patient scheduling. Considering that many patients had only intermittent phone service, this was no easy task. And, PHOTOS PROVIDED BY HAVE A HEART CLINIC

there were other challenges inherent in assisting the indigent.

Initially, Imburgia started seeing patients one Saturday a month at the Louisville Cardiology facility in St. Matthews, but realized the location was prohibitive. “For the most underserved area of the community, it’s an hour and a half bus ride one way. We needed more times to see patients and, more importantly, we needed to be part of their community. We needed to be closer.”

So, in January, the clinic relocated to 310 East Broadway in downtown Louisville. The new ADA-compliant facility offers all aspects of cardiovascular care, including ECG and Echo stress testing, echocardiography, Holter and event monitoring, and vascular testing.

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The Have a Heart Clinic is made possible by a team of professionals who volunteer their time. Back row (l-r): Steve Driskell, Marcia McGuire, Chris May, Lorie Obst, Sue Dillon, clinic co-founder, and Sandy Imburgia, clinic co-founder. Front row (l-r): Rita Owens, Dr. Michael Imburgia, clinic co-founder, Anita Keating, and Ann Hopkins.

missing a day of work is not an option, so weekend and evening hours are a necessity.

Imburgia explains, “We have the space, so now the biggest challenge is providing more times to see patients.”

Another impediment for not-for-profit clinics lies is connecting with willing providers. Normally, they must simply work from a list of specialists. The Have a Heart Clinic is remedying this by reaching out to these clinics, as well as churches and organizations like the Sister Visitor Center, which provides emergency assistance to the poor. Imburgia’s message to clinics such as Family Health and Park DuValle is, “We want to see those patients for you and give you a place to send them.”

All of these barriers fall under the blanket of access. And, as Imburgia emphasizes, “Access is everything. The reason the United States, when ranked against every other industrialized country, ranks last in healthcare is because of access. Not because we don’t have good doctors, not because we don’t have good hospitals, but our population does not have easy access to healthcare, so our patient populations are sicker.”

Since the opening of the downtown facility, patient volume has increased 30%. Most indi18 MD-UPDATE

viduals seeking treatment are under the age of 65 making them ineligible for Medicare, and are part of the nine percent of Kentuckians who are presently uninsured.

In the future, the Have a Heart Clinic plans to become self-sustaining using a “payit-forward” model by treating patients with insurance and the ability to pay fees, and then using those funds to supply free care to qualifying persons.

Currently, the clinic is staffed entirely with volunteers. As Imburgia puts it, “There’s an army of people behind us. I come in to work like any other day. There are a lot of people behind me who made it work.” That army consists of other cardiologists, nurse practitioners, nurses, medical assistants, echo techs, interpreters, and even people who volunteer to sit at the front security desk. When asked why so many donate their time and energy, Imburgia says, “It’s the atmosphere and knowing that they’re really making a difference and impacting patient care.”

Regardless of the growth and changes, the mission of the clinic will remain the same.

“This clinic is about the quality of patient care,” Imburgia states. “We’re about taking care of patients.” He elaborates with, “I can treat your coronary disease all I want to, but

if you’re hungry, if you don’t have a place to sleep, if you’re stressed at home, then there isn’t going to be a thing I can do for your heart until all those other things are addressed.”

Another component to top quality care lies in the development of a Cardiovascular Home. Have a Heart is collaborating with Passport Health to design a team of medical professionals, including cardiologists, nurses, nutritionists, and behavioral and mental health specialists, to address the needs of the sickest patients. Passport’s Integrated Care Program Manager Jessica K. Beal, PsyD, further expounds, “Dr. Imburgia was already familiar with integrating behavioral health services into a medical practice and was a firm believer in the benefits to his patients; there are health psychologists who specialize in working in cardiology. We just helped him look at the potential patient population and assess how many types of health conditions could be impacted in a single patient by this model.”

Though Imburgia and the Have a Heart Clinic are already making an important impact on Louisville, he realizes the need is far greater. “The country has to change. We have to provide care for everybody. To anybody who ever says, ‘Who’s going to come up with the money?’ I’d respond that we spend 80 billion a year in uncompensated care, and your taxes pay 55 billion. So, you’re already spending the money. You’re paying for it.

So, we might as well keep them happier and healthier.”

310 East Broadway Louisville, KY 40202

502.245.0002 info@haveaheartclinic.org

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Caring for the Hearts of Children The pediatric cardiology and cardiothoracic surgery team at UK’s Kentucky Children’s Hospital grows in volume and complexity

BY GIL DUNN LEXINGTON The pediatric cardiology division

of UK HealthCare is led by Division Chief Douglas J. Schneider, MD. “Congenital heart disease is the most common birth defect that children are born with,” he states.

“Approximately eight out of 1,000 children are born with some form of heart defect, ranging in severity from minor to very complex.”

Congenital heart disease cuts across all geographic and socio-economic classes in Kentucky. In answer to the question of nature versus random embryonic and fetal development in congenital heart disease, Schneider says, “Yes, it’s sometimes genetic, but it’s not always clear.” And that’s where and when Schneider’s team of cardiologists, electro-physiologists and interventionalists find their work, fulfilling their mission of providing access to the highest quality of care throughout even the most remote regions of Kentucky, a goal started

by Jacqueline Noonan, MD, former chair of pediatric cardiology at UK. Schneider began his career as an engineer before attending the School of Medicine at the University of New Mexico. He says the mechanical aspects of the cardiovascular system appealed to him during his residency in internal medicine and pediatrics at UK, citing Noonan’s mentorship. Schneider did a fellowship in pediatric cardiology at University of Cincinnati Children’s Hospital followed by a fellowship in interventional pediatric cardiology at St. Christopher’s Hospital for Children in Philadelphia.

The era of surgical treatment for congenital heart disease began in the 1930s, says Schneider, when surgeons discovered that they could perform heart surgeries on infants and children to correct abnormalities. Advancements in the specialty continued through the end of the 20th century towards

Dr. Douglas J. Schneider, division chief, pediatric cardiology at UK HealthCare, Department of Pediatrics

a progression of repair and management of congenital heart defects. “In the catheterization laboratory, we can now close holes in the heart, open and even replace abnormal heart valves, and enlarge narrow or occluded blood vessels to both prolong life and greatly increase the quality of life,” says Schneider.

PHOTO BY GIL DUNN

The UK Pediatric Cardiology Team Schneider estimates that his division sees between 200 and 300 patients a week.

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grounded in general cardiology but utilize the expertise of the other team members,” he says.

Members of the UK Pediatric Cardiology team form a diverse and highly trained group.

It includes: Carol Cottrill, MD; Kristopher Cumbermack, MD; Abeer Hamdy, MD; Joshua Hayman, MD; Melissa Lefebvre, DO; Majd Makhoul, MD; Shaun Mohan, MD; Callie Rzasa, MD; Mark Vranicar, MD; Kelly Van Metre, APRN; and Laura Murphy, APRN. The pediatric cardiothoracic surgery team includes: James Quintessenza, MD (pediatric and adult congenital cardiac surgeon); Jennifer Davis, PA-C (surgery physician assistant); and Andrew Parker (pediatric perfusionist).

“I could talk for hours about our team,” says Schneider. “We go to at least 20 or more locations throughout the state to do outreach clinics.” Telemedicine is used in addition to clinical visits, using digital transfer of echocardiography for ultrasound interpretation.

“We consult with local pediatricians so that the families don’t always have to drive to Lexington from remote rural locations. That’s a very important part of what we do,” says Schneider.

Lifestyle of the Congenital Heart Patient A heart healthy lifestyle is vital to the pediatric patient as well as the adult, say Schneider, and what is considered healthy has evolved. “Through the years, we’ve told the congenital heart patient not to strenuously exercise or exert themselves. It’s clear now that regular exercise and a healthy diet are essential for these patients.” Schneider envi-

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sions developing a heart healthy program for children for his division’s patient population in conjunction with its new partnership with Cincinnati Children’s Hospital, which will help patients get the best quality care as close to home as possible.

Congenital heart patients also have different psychological challenges, similar to post traumatic stress syndrome. “Not encouraging these patients to exercise has sometimes led to obesity, depression, and a sedentary lifestyle. This is not in their best interest,” says Schneider.

Advancement in Prenatal Diagnosis Fetal echocardiograms have been one of the most significant advancements in saving the pediatric patient’s life. “It’s not uncommon for patients to come to us from obstetricians who have suspected a potential heart malformation through a fetal ultrasound,” says Schneider.

Cumbermack is the director of the pediatric and fetal echocardiography lab at UK. “Our fetal echocardiography specialists, Dr. Cumberback and Dr. Makhoul, will read the echo and prepare us and the parents, so that the baby is delivered into a situation where it will receive immediate care,” says Schneider.

Babies born with Down syndrome or DiGeorge syndrome have a higher probability of congenital heart defects, and although most congenital heart defects occur in isolation, occasionally they are associated with defects of other body organs, such as gastrointestinal malformations or skeletal abnormalities. It’s important that these patients are cared for in a multidisciplinary environment like Kentucky

Children’s Hospital, which has a full menu of expert subspecialty children’s services.

Cardiac Arrhythmia Management Mohan is the electrophysiologist of the group. He manages patients with heart rhythm abnormalities, including those that are life-threatening and those that are less dangerous such as supraventricular tachycardia (SVT). Schneider says that SVT is typically not life-threatening but can be life-altering.

“In most cases Dr. Mohan can identify the pathway causing the SVT and correct it via radiofrequency ablation or cryoablation. This allows patients to get off their medications, play sports, and choose hobbies and careers that their conditions might have otherwise prevented,” says Schneider. Dr. Mohan also manages patients with cardiac pacemakers and implantable cardiac defibrillators.

Scope of Pediatric Cardiology Fortunately, not all the patients seen in pediatric cardiology clinic have congenital heart disease. Many patients are seen for “screening” for underlying heart disease due to a symptom that might possibility represent a cardiac problem (such as passing out or palpitations) or the finding of a heart murmur by their primary care physician. Although some heart murmurs are indicative of a structural heart problem, many are “normal” heart noises heard in healthy patients with completely normal hearts. The role of the pediatric cardiologist is oftentimes to rule out or exclude an underlying cardiac condition and offer reassurance to the patient and family if there is no heart disease.

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Building a Structural Heart Program Abdelkader Almanfi, MD, joins Owensboro Health to bring leading-edge, minimally invasive treatments to the region

the cath lab and seeing patients, both in-patient and referral. Almanfi does a mix of work, OWENSBORO Many physicians can point to a including coronary artery disease management mentor or a singular event during their trainand vascular intervention, but his focus is ing that influenced their choice of specialty. on the advancements in the treatment of For Abdelkader Almanfi, MD, his reason for structural heart disease. He states, “There has choosing the field of cardiology was a simple, been a revolution in the industry over the yet global one. “Heart disease is the number past 10 years allowing us to now fix valves one cause of death, not just in the states, but with catheters when the only option was open everywhere in the world,” he says. heart surgery.” Two of the most beneficial are An interventional cardiologist with an transcatheter aortic valve replacement (TAVR) emphasis in structural cardiology, Almanfi’s and MitraClip®. passion and enthusiasm are evident when he Since being approved by the FDA five years discusses his work and the program he came ago, TAVR has become an option for patients Dr. Abdelkader Almanfi, interventional cardiologist who, either due to their age, risk factors, or to Owensboro to build. with Owensboro Health Cardiology, moved to Almanfi began his medical career at Al-Arab degree of illness, were not deemed good canOwensboro to start the Structural Heart Program at Medical University in Libya, where he graduat- Owensboro Health Regional Hospital. didates for surgery. With minimal invasiveness, ed in the top one percent TAVR allows physicians to of his class. While there, replace the damaged aorThis program requires a lot of work and cooperation from he also completed an intertic valve with a new valve hospital administration, the community, and the doctors around nal medicine residency and delivered through a catheme. That is why we have achieved success. We’re not at full post-doctoral cardiology ter from the femoral artery fellowship. His first board in the groin. In order to potential, but heading that way. Without teamwork, certification came from the qualify for TAVR, an indiwe could not have achieved that. — Dr. Abdelkader Almanfi Royal College of Physicians vidual must be diagnosed in the United Kingdom. He then traveled to disease in the heart, outside of coronary through echo findings with severe aortic stethe United States to advance his education with arteries, like valve conditions or holes in nosis and be symptomatic, as well as deemed an internship at George Washington University the heart.” The program also includes high or intermediate risk by a heart valve team in Washington, D.C., and a residency at St. interventional cardiology, which along with for surgery.

Luke’s Hospital in St. Louis. After completing the treatment of structural heart disease, Due to pending approval, Owensboro both cardiology and interventional cardiology includes coronary and vascular intervention. Health cannot currently conduct TAVR onsite. fellowships at the Texas Heart Institute in As the medical director, he realized one of In order to serve the needs of Owensboro Houston, one of the premier cardiology inno- the most crucial components in building the patients, the team endorsed an affiliation with a vations facilities in the world, Almanfi looked program was assembling a structural heart hospital in Lexington where Almanfi is able to for a void in heart care that he could fill. “The team. Therefore, Almanfi put together a offer TAVR to these patients. It is expected that reason I moved from Texas to here is that I saw dedicated group of specialists, consisting of within the next three months, Owensboro will a big need and that there was something new I himself, fellow cardiologists, cardiac surgeons, have the capability to perform the procedure at could bring to the practice, both specialty-wise valve coordinators, and imaging experts who their facility, which serves Western Kentucky, and organization-wise. That was my main regularly meet to develop plans of action and as well as Southern Indiana. motivation.” coordinate patient care.

For those too unstable for TAVR, Almanfi So, nine months ago, Almanfi founded offers balloon aortic valvuloplasty (BAV), the Structural Heart Program at Owensboro A Revolution in another minimally invasive procedure in Health, which has been growing rapidly since. Transcatheter Techniques which a balloon is inserted and opens the He defines structural heart disease as “any Currently, Almanfi divides his time between valve, allowing for blood flow.

BY DONNA ISON

PHOTOS PROVIDED BY OWENSBORO HEALTH

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MitraClip, which has been available at Owensboro Health since October 2016, is also giving patients an alternative to open heart surgery. Again, through a femoral catheter in the groin, a clip is inserted and attached to the valve allowing it to close more efficiently and reduce mitral leak. For many with mitral valve regurgitation, this provides a solution and a much quicker recovery.

Another new structural cardiac technology, which will be available at Owensboro Health in the near future, is the recently approved WATCHMAN device for patients with atrial fibrillation who have had incidents of bleeding with blood thinners. WATCHMAN is another catheter therapy with groin access to deploy this small, coil-like plug to close off the left atrial appendage and prevent clots. Most patients can then stop blood thinners forever.

In addition, because of his endovascular training, Almanfi offers treatment for both aortic abdominal and thoracic vascular aneurysms with the endovascular aneurysm repair (EVAR) and thoracic endovascular aneurysm repair (TEVAR) procedures. During these, Almanfi inserts a stent graft granting an alternative conduit for blood flow, thereby excluding the aneurysmal sac and preventing rupture.

With all of these advancements, it is no wonder the Structural Heart Program is growing so rapidly. Almanfi is grateful for the opportunity and support. “This program requires a lot of work and cooperation from hospital administration, the community, and the doctors around me. That is why we have achieved success. We’re not at full potential, but heading that way. Without teamwork, we could not have achieved that.”

Almanfi is optimistic about the future and the structural heart program’s ability to serve its patients by ensuring the most up-to-date treatments. “The hospital does a great job supporting me in attaining new technologies that were not available here before.”

On the horizon, though not yet approved by the FDA, is transcatheter mitral valve replacement (TMVR). This will be just one more tool that Almanfi and his structural heart team at Owensboro Health can utilize to improve the lives of their patients and increase the accessibility of cutting-edge care.

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Dr. Abdelkader Almanfi has been performing the MitraClip® transcatheter procedure for mitral valve regurgitation at Owensboro Health since October 2016.

PHOTOS PROVIDED BY OWENSBORO HEALTH

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Perfecting Prevention

Graves Gilbert Clinic demonstrates the value of prevention and collaboration in state-of-the-art cardiovascular care

BY JIM KELSEY

The most important

BOWLING GREEN The saying goes, “An ounce of

prevention is worth a pound of cure.” A more practical way of saying it might be, “A few minutes of conversation is worth thousands – even millions – of dollars.”

With today’s healthcare costs, any procedure, any medication, any treatment that can be avoided means tangible savings to patients and the communities in which they live and work.

Graves Gilbert Clinic in Bowling Green, Ky., prides itself on delivering high-quality, low-cost care.

“The most important intervention is the physician talking to the patient,” says Sandeep Chhabra, MD, an interventional cardiologist at Graves Gilbert. “Each patient is unique in their needs. Their treatment plan and care plan and prevention plan is individualized by a team approach.”

That team approach is optimized by the unique structure of Graves Gilbert, a physician-owned multispecialty clinic founded in 1937 by Dr. Graves and Dr. Gilbert. Graves Gilbert now includes 170 physicians covering 30 specialties. The result is that the patient has access to a wealth of resources, all in one place. Collaboration between physicians is the norm, as is a devised treatment plan which can be thoroughly communicated to the patient. An informed and engaged patient is better equipped to manage their own care, be it preventive or recovery.

The efforts of the clinic to provide their patients with preventive treatment plans resulted in a 100 percent quality score from the federal government in 2016. Nearly 400 Medicare Accountable Care Organizations (ACOs) were included in the evaluation, and only four received the 100 percent quality score. In addition to the quality of care rating, Graves Gilbert’s preventative, collaborative approach saved the government an estimated $12 million in Medicare costs in 2016.

intervention is the physician talking to the patient.

— Dr. Sandeep Chhabra

Dr. Sandeep Chhabra is an interventional cardiologist who specializes in high-risk procedures.

“Our focus on preventative population medicine is what puts us on the forefront of medicine in the 21st century,” says Chhabra, who completed his interventional cardiology training at Mt. Sinai Hospital in Manhattan before coming to Graves Gilbert in 2011.

“The integration of the primary care and the specialty care that we have allows us to become more effective in implementing the preventative strategies to improve the health of the community, as well as be able to help them in their sickness.”

Minimally Invasive Cardiovascular Procedures The cardiology team at Graves Gilbert treats a wide spectrum of patients with common presentations including blockages in the heart, arrhythmias, and peripheral vascular disease.

Chhabra specializes in high-risk procedures such as high-risk coronary interventions, high-risk valve interventions, and highrisk peripheral interventions. He has helped Graves Gilbert introduce new technology and procedures to the area. For instance, recently Chhabra has begun implanting the MRI PHOTOS BY GIL DUNN

Dr. Charles Lin, whose brother and father are also cardiologists, is dually trained in interventional cardiology and electrophysiology.

Compatible Single Chamber Pacemaker and the MRI Compatible Single Chamber ICD. Charles Lin, MD, who performs both device electrophysiology and interventional cardiology procedures, sees nearly 3,800 patients per year and specializes in complex biventricular defibrillators. He reports that over 90 percent of his biventricular defibrillator patients improve over time – drastically higher than the national data, which shows that nearly two-thirds of the procedures are not successful. He attributes his success to his unique dual training.

“I have both EP training and interventional training,” says Lin, who was born in Taiwan, grew up in Los Angeles, attended medical school in Taiwan, and then completed his residency at the University of Southern California.

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He did his fellowship at the University of Kentucky and has been at Graves Gilbert for 18 years. “A lot of interventionalists know how to do this procedure, but they don’t have the understanding of the subtle tricks and details.

The downside to not doing the procedure correctly is recurrent hospitalization.”

The elimination of such long-term, cyclical healthcare events is high priority for Graves Gilbert. It’s all about high quality, low cost, and maximum convenience for the patient.

A working relationship with the nearby hospital, and the expanded services it offers, is also to the benefit of patients. “We are fairly close knit with the medical center, and they have a very well run cardiac rehab center,” says Lin. “I take a lot of pride in that the majority of my patients have not had their second open heart surgery. That says something about the rehab center.”

The recent implementation of a transcatheter aortic valve replacement (TAVR) program, led by Jerry Roy, MD, is another example of

24 MD-UPDATE

Dr. Jerry Roy recently introduced a TAVR program at Graves Gilbert Clinic.

Graves Gilbert’s commitment to patient care.

Patients used to have to travel to Nashville or Louisville for these treatments before Roy and his team started the program in December 2016.

“We are vigilant of costs of medications and procedures and how it’s going to affect the bottom line,” Roy says, noting that they perform TAVR cases every two weeks. “TAVR is a collaborative procedure where surgeons and cardiologists are involved. It is a several week process to evaluate if they are an appropriate patient. When we first started doing the procedure it was only as a bailout for patients not eligible for surgery. This spring we will start doing some of our intermediate risk patients.

Patients are out of the hospital in two days.”

Originally from Chicago, Roy went to the Caribbean for medical school, returned to Chicago and eventually completed his training in West Virginia. He has been with Graves Gilbert for nearly two years. Already he is embracing the culture of prevention and lowering costs and patient accountability.

“Prevention is really important,” Roy says.

“We tend to see patients when things are going wrong. All physicians across the board can do a better job of prevention.”

Mental Wellness

Shut Up and Meditate

BY JAN ANDERSON, PSYD, LPCC

It was an unexpected comment from an unlikely source. I was sitting there minding my own business at the Louisville Heart Ball when one of the healthcare executives at my table made an interesting comment. “It seems that most high-performing professionals attribute their success to some type of mindfulness practice.”

I didn’t realize someone had told him I taught yoga and meditation classes for 10 years along the way to getting my doctorate and license.

It’s true – there’s a plethora of C-suite and celebrity types that swear by their meditation practice as their secret way to lead a crazy-busy life, stay focused on what’s important, and stay calm in the digital age.

The business case for mindfulness is backed up by solid research: If you’re fully present on the job, you’ll be more focused and productive, you’ll make better decisions, and you will work better with other people.

I can only say that my initial experience of meditation was more like Lily Tomlin’s musing, “What if the present moment is the worst possible place to be?”

What if the present moment is the worst possible place to be?

Who wants to be in the present moment when it’s not enjoyable, interesting, or at least hopeful? When it includes the rumination of reliving old hurts and rehearsing new fears?

As I reflect on my 20+ years of meditation practice, I’ve sometimes wondered how I kept going. Looking back now, I can tell you why: Because I wanted it so badly – I wanted a better life. I wanted better relationships. I wanted to be happier and more at peace with myself.

It’s hard to meditate when you have an

It’s hard to meditate when it means spending 20 minutes listening to the harangue of your Inner Critic.

Inner Pusher that has no use for the utter waste of time of sitting quietly for 20 minutes (aka doing nothing). Fortunately, some other part of my personality understood that meditation is more about un-doing.

It’s hard to meditate when it means spending 20 minutes listening to the harangue of your Inner Critic. “Your mind wandered … again. What’s wrong with you?”

The first time I tried meditation I gave up after the first class. I was working for a law firm during the day and going to law school at night. I thought meditation might help me concentrate so I could absorb the mountain of reading required at work and school.

My first meditation instructor told us (mistakenly) that meditation means “to not let your mind waver from one thought or image.” Of course, my mind was immediately all over the place – and it stayed that way the rest of the class. So, I promptly quit meditation and got prescription eyeglasses instead.

What I know now is that I was becoming more emotionally intelligent – in the form of self-awareness, self-empathy, and emotional regulation. I knew I’d turned a corner in making peace with my Inner Critic the day I found myself ending one of those excruciating “I can’t wait for this to be over” sittings with an out-loud exclamation, “That was a terrible meditation!” … and I was chuckling as I said it.

It took a little longer to “get it” that meditation would also help me with another

Meditation is the easiest and hardest activity there is.

It would be years before I stumbled upon bona fide meditation instruction: “It’s the nature of the mind to wander. When you notice your mind has wandered, don’t criticize yourself – Be glad you noticed and just come back – to this moment … this breath. You’re learning the art of how to be with yourself.”

ISSUE #107 25

Mental Wellness

component of emotional intelligence – relationship management. After all, what could be sillier than a whole group of people – sitting there together saying nothing – for 20 minutes? Well, guess what? If you can learn to be present and empathic with yourself … you will naturally get better at doing that with … other people.

I’ve even got my husband meditating with me every morning. He calls it “thinking.” I don’t really care what he calls it – he does a great job of being quiet and still – no fidgeting, no tension, no heavy sighs, no judgment of me for spending 10-20 minutes this way every day.

Recently I was having a hard time settling in for our morning meditation. My husband was waiting for me, but I was still dithering around in the kitchen with another cup of coffee and mindless chatter. Finally, my Inner Pusher helped me out: “Jan, shut up, sit down, and meditate.” My husband laughed, I laughed … and we began. And as it always goes with meditation, it was a better day, and I’m a better person because of it.

Caring for Patients with Alzheimer’s Disease Christopher Callahan, MD

Director, IU Center for Aging Research Center

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Dermatology, Plastic Surgery, Vascular Medicine

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Complementary Care

Your Heart and Ears Have a Lot in Common. Love Them Both!

BY LISA MEEKER People tend to take matters of the heart very seriously, and they tend to brush off hearing loss as inconsequential. But the truth is, your heart and ears have a lot more in common than most people realize.

Decades of research point to a link between cardiovascular and hearing health. Professors at Wichita State University conducted an analysis of 84 years of work from scientists worldwide on the link between cardiovascular health and the ability to hear and understand what others are saying. Their research confirmed a direct link, and also suggested that hearing loss may be an early sign of cardiovascular disease. Our entire auditory system, especially the blood vessels of the inner ear, needs an oxygen-rich nutrient supply. If the supply is diminished due to cardiovascular health problems, then hearing can be affected.

Other research suggests that hearing loss may be an early sign of cardiovascular disease in seemingly healthy middle-aged people, and even found that hearing loss is common in people in their forties.

Professors at the Medical College of Wisconsin in Milwaukee went so far as to

Our entire auditory system, especially the blood vessels of the inner ear, needs an oxygen-rich nutrient supply. if the supply is diminished due to cardiovascular health problems, then hearing can be affected.

“The inner ear is so sensitive to blood flow that it is possible that abnormalities in the cardiovascular system could be noted earlier than in other less sensitive parts of the body,” says Daena Wilds, AuD, with Bluegrass Hearing Clinic.

conclude from their studies that patients with low-frequency hearing loss should be regarded as “at risk” for cardiovascular events and appropriate referrals should be considered.

The heart-hearing link is best explained by Daena Wilds, AuD, with Bluegrass Hearing Clinic. “The inner ear is so sensitive to blood flow that it is possible that abnormalities in the cardiovascular system could be noted earlier than in other less sensitive parts of the body. The most common abnormality we see is hypertension.”

Many experts find the evidence so compelling that they suggest that the ear may be a window to the heart and encourage collaboration among hearing care providers, cardiologists, and other healthcare professionals.

Here are five random things your heart and ears have in common: 1. Someone with heart disease is at a higher risk of depression, and someone with unaddressed hearing loss is at a higher risk of depression.

PHOTO BY DAVID GREENLEE

Our trusted Doctors of Audiology have been providing superior hearing health care since 1997.

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2. E xercise is good for your heart, and exercise is good for your ears. A higher level of physical activity is associated with a lower risk of hearing loss.

3. Smoking hurts your heart, and it is bad for your ears too. Both smokers and passive smokers are more likely to suffer hearing loss.

4. Your heart and ears love omega-3 fatty acids. Studies have shown regular consumption is associated with a lower risk of hearing loss in women.

5. Obesity puts people at risk for heart disease, and it affects hearing function.

ISSUE #107 27

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Norton and Oglesby Appointed Interim Leaders for Baptist Health LOUISVILLE On March 21, 2017, Baptist Health

announced that system Chief Executive Officer Steve Hanson was leaving the organization, effective immediately. Hanson has served as CEO since March 2013.

Prior to joining Baptist Health, Hanson served as executive vice president and operations leader for the Dallas-Fort Worth region for Texas Health Resources.

The Baptist Health Board of Directors appointed Vice President and Chief Legal and Regulatory Affairs Officer Janet Norton and Chief Financial Officer Steve Oglesby to provide shared interim executive leadership for Baptist Health. Both Norton and

Janet Norton

Steve Oglesby

Oglesby are long-term Baptist leaders, Norton a 29-year employee serving as general counsel since 1999, and Oglesby, a 24-year employee recently named CFO in September 2016.

“We believe it is imperative to provide a strong transition team. We want to ensure

our continued focus on providing the highest quality of care to our patients and to continue Baptist Health’s success,” says Baptist Health Board of Directors Chairman Allen Rudd.

A nationwide search for a successor has begun.

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States Recognized by Society of Toxicology Metals Specialty Section

Bush Receives 2017 Dissertation Fellowship LEXINGTON Matthew L. Bush, MD, asso-

LOUISVILLE J. Christopher States, PhD, pro-

fessor of toxicology and associate dean for research in the U of L School of Medicine, received the Career Achievement Award from the Society of Toxicology Metals Specialty Section. The award is given in recognition of outstanding achievement as a researcher, mentor, and leader in the field of toxicology.

States received the award at the 2017 Society of Toxicology Annual Meeting and ToxExpo in Baltimore, March 12-16.

The Career Achievement Award recognizes a senior investigator who has substantially advanced the understanding of metals toxicology through scientific contributions, training, and mentorship of young scientists, leadership and service to the metals toxicology field, and

Koren Mann, PhD, associate professor of oncology at McGill University of Montreal and director of the Molecular and Regenerative Medicine Axis, Lady Davis Institute for Medical Research, and J. Christopher States, PhD

influence in regulatory and risk assessment decisions related to metals toxicology.

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ciate professor in the Division of Otology, Neurotology, and Cranial Base Surgery at the University of Kentucky College of Medicine, has been selected as a recipient of a 2017 Dissertation Fellowship from The Honor Society of Phi Kappa Phi, the nation’s oldest and most selective collegiate honor society for all disciplines. Bush is one of only 10 recipients nationwide to receive the $10,000 fellowship.

Bush is a doctoral candidate in the Department of Behavioral Science at UK. His research investigates hearing healthcare disparities in underserved rural populations with a goal to develop and implement innovative interventions that improve the diagnosis and treatment of hearing loss.

Bush has received extensive medical training at Marshall University and UK in hearing health care, ear surgery, and revolutionary technologies like cochlear implants. It was during a fellowship at OSU where he began to develop a line of research related to disparities of hearing healthcare for rural populations.

Lexington Clinic, Legends Partner for 17th Season LEXINGTON Lexington Clinic and the Lexington

Legends are proud to partner for the 17th season in 2017.

The Legends have called Central Kentucky home for 17 years now, and the Lexington Clinic Orthopedic – Sports Medicine team has been by their side every step of the way.

“The Legends have become a big part of our community here in Lexington, and we’re proud to help this wonderful team,” says Head Team Physician W. Ben Kibler, MD, FACSM. Lexington Clinic Orthopedics – Sports Medicine has served as the official team doctors for the baseball team since the team was established in 2001, and provides day-to-day care for the players and staff including injury prevention and treatment. The team doctors also work as a part of the medical staff for the entire Kansas City Royals organization.

Events

s Current board chair Jeff Koonce, market president Wesco Bank, Tony Lewgood, CEO, Shriners Hospitals for Children Medical Center – Lexington, and Allen Grimes, past chair, Dupree & Company

Corporate Council Raises Funds for New Technology at Shriners Hospitals for Children Medical Center – Lexington LEXINGTON Over 40 Central Kentucky business owners and executives

have formed a Corporate Council with the mission of advancing children’s healthcare at Shriners Hospitals for Children Medical Center – Lexington. Through direct contributions and fundraising, members of the Corporate Council enjoy a distinctive relationship with Lexington’s s Dr. Scott Riley, Karen Harbin, CEO Commonwealth Credit Union, Dr. Chip Shriners Medical Center. Under the leadership of board chairs, Alan Iwinski, chief of staff, Shriners Hospitals for Children Medical Center – Lexington Grimes and Jeff Koonce, the Corporate Council has funded over $400,000 in special projects for the Medical Center. Recently, members contributed funds to purchase a Mini C-Arm. This portable x-ray machine produces 50 percent less radiation than a regular x-ray machine.

s Trisha and Paul Lauritzen, VP, manufacturing, Big Ass Fan Solutions, and Cynthia Bohn, Equus Run Vineyards

s Claire and Dr. Ryan Muchow with Dr. Elizabeth Hubbard, Shriners Hospitals for Children Medical Center – Lexington ISSUE #107 31

Events

KPMA Conference Forging the Future in Psychiatry and Mental Health was the theme for the Kentucky Psychiatric Medical Association (KPMA) conference on March 10, 2017 at the Louisville Boat Club in Louisville, Ky. The conference covered recent advances in psychopharmacology, neuropsychiatric complications in traumatic brain injury, evidence-based strategies to build resiliency in trauma-exposed children, and an overview and panel discussion of the current challenges in treating addiction in Kentucky.

MD-Update Mental Wellness columnist Dr. Jan Anderson attended the KPMA conference along with some colleagues. Pictured from left to right: Dr. Mark Wright, Dr. Bruce Hirschfield, Dr. Rebecca Tamas, Dr. Gary Weinstein, Dr. Jan Anderson, and Dr. David Casey.

An Evening at the Cardiovascular Innovation Institute MD-Update Mental Wellness columnist Jan Anderson, PsyD, LPCC, had an evening of inspiration and education with Mark Slaughter, MD, U of L Physicians cardiovascular surgeon, who heads up a nationally award-winning research team at the Cardiovascular Innovation Institute. Says Anderson, “They’re doing groundbreaking research, and we desperately need it.” In Kentucky, cardiovascular disease accounts for almost 75 percent of all deaths.

At the Cardiovascular Innovation Institute event were: (l-r) Greg Miller, CFO of Trilogy Health Services; Randy Bufford, CEO of Trilogy Health Services; Dr. Jan Anderson; Dr. Steve Raible with Norton Hospital Cardiology; Mark Carter, CEO of Passport Health Plan; and Dr. Mark Slaughter.

Louisville Heart Ball The 25th anniversary of the Louisville Heart Ball was held in Louisville on Saturday, February 18, 2017 at the Louisville Marriott Downtown. The Heart Ball helps to advance the lifesaving mission of the American Heart Association. Contributions received support cardiovascular research, professional and community education, and advocacy efforts.

“We’re having a ball at the Heart Ball!

It’s all about building healthier lives, free of cardiovascular diseases and stroke,” says MD-Update Mental Wellness columnist Dr. Jan Anderson, pictured with her husband Bill at the Louisville Heart Ball.

“ Were you the lucky bidder? I donated one of my favorite workshops to the annual Heart Ball – ‘Mindful Eating for People Who Love Food, Wine, and Eating Out,’” says Dr. Jan Anderson.

MONDAY, JUNE 12, 2017 at The University Club of Kentucky P 859.313.1704 KentuckyOneHealth.org/sjhfgolf

32 MD-UPDATE