L A CLOSE
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CONTENTS VOLUME 14, NO. 1
2
Index to Advertisers
3
IN THIS ISSUE
JANUARY/FEBRUARY 2012
To Transfuse or not to Transfuse, that IS the Question By Charles G. Terzian, M.D.
4
PRESIDENT’S MESSAGE
Critically Needed: Physician Engagement in 2012 By Peter J. Dehnel, M.D.
5
TCMS IN ACTION By Sue Schettle, CEO
Page 7
BLOOD MANAGEMENT
7
s
Colleague Interview Jed B. Gorlin, M.D.
11
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Introduction to Blood Management By Timothy Hannon, M.D., MBA
13
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To Predonate, or Not Predonate, That is the Question By Timothy Hannon, M.D., MBA
Page 26
15
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In Pursuit of Blood Safety: A Paradigm of Health Care Tradeoffs By Frank S. Rhame, M.D.
19
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Appropriate Utilization and the Economic Impact of Blood Product Usage By Lauren Anthony, M.D.
21
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Jehovah’s Witnesses and Transfusions: A Quick Guide with Commentary for Physicians By Gregory A. Plotnikoff, M.D., MTS, FACP
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LETTERS
Access to Psychiatrists
24
Emerging from the “Cone of Silence” A 2012 Legislative Preview
26
TCOPC Takes a Look Back at 2011
27
Advance Care Planning Materials Available in Five Languages
28
Caring Hearts for Homeless People Supply Drive/ TCMS Sponsors Forum on Mental Health
29
In Memoriam/Senior Physicians Association/
Page 32
Career Opportunities
Page 27 MetroDoctors
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New Members
32
LUMINARY OF TWIN CITIES MEDICINE
Patrick C. J. Ward, M.D. The Journal of the Twin Cities Medical Society
On the cover: Blood — indications, problems and appropriate utilization of transfusions. Articles begin on page 7.
January/February 2012
1
Doctors MetroDoctors THE JOURNAL OF THE TWIN CITIES MEDICAL SOCIETY
January/February Index to Advertisers Advanced Dermatology Care.........................25 TCMS OfďŹ cers
President: Peter J. Dehnel, M.D.
Physician Co-editor Lee H. Beecher, M.D. Physician Co-editor Peter J. Dehnel, M.D. Physician Co-editor Gregory A. Plotnikoff, M.D., MTS Physician Co-editor Marvin S. Segal, M.D. Physician Co-editor Richard R. Sturgeon, M.D. Physician Co-editor Charles G. Terzian, M.D. Managing Editor Nancy K. Bauer Assistant Editor Katie R. Snow TCMS CEO Sue A. Schettle Production Manager Sheila A. Hatcher Advertising Representative Betsy Pierre Cover Design by Outside Line Studio MetroDoctors (ISSN 1526-4262) is published bi-monthly by the Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. Periodical postage paid at St. Paul, Minnesota. Postmaster: Send address changes to MetroDoctors, Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. To promote its objectives and services, the Twin Cities Medical Society prints information in MetroDoctors regarding activities and interests of the society. Responsibility is not assumed for opinions expressed or implied in signed articles, and because of the freedom given to contributors, opinions may not necessarily reect the ofďŹ cial position of TCMS.
AmeriPride...........................................................12
President-elect: Edwin N. Bogonko, M.D.
Audiology Concepts .........................................18
Treasurer: Kenneth N. Kephart, M.D.
CrutchďŹ eld Dermatology.................................. 2
Past President: Thomas D. Siefferman, M.D.
Custom-Rx Compounding Pharmacy .......... 9
TCMS Executive Staff
The Davis Group .............. Inside Front Cover
Sue A. Schettle, Chief Executive OfďŹ cer (612) 362-3799 sschettle@metrodoctors.com Jennifer J. Anderson, Project Director (612) 362-3752 janderson@metrodoctors.com Nancy K. Bauer, Associate Director, and Managing Editor, MetroDoctors (612) 623-2893 nbauer@metrodoctors.com Andrea Farina, Executive Assistant (612) 623-2885 afarina@metrodoctors.com Barbara Greene, MPH, Community Engagement Director, Honoring Choices Minnesota (612) 623-2899 bgreene@metrodoctors.com Katie R. Snow, Project Coordinator (612) 362-3704 ksnow@metrodoctors.com For a complete list of TCMS Board of Directors go to www.metrodoctors.com.
Fairview Health Services .................................31 Healthcare Billing Resources, Inc. ...............14 Lockridge Grindal Nauen P.L.L.P. ...............22 Minnesota Epilepsy Group, P.A....................14 Minnesota Physician Services, Inc. ................... Inside Back Cover The MMIC Group .............Inside Back Cover MMIC Health IT ........... Outside Back Cover Saint Therese.......................................................22 Stillwater Medical Group................................30 Tinnitus and Hyperacusis Clinic..................18 Toshiba Business Solutions............................... 6 Uptown Dermatology & SkinSpa................17 U.S. Navy ............................................................31 Winona Health ..................................................29
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Send letters and other materials for consideration to MetroDoctors, Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. E-mail: nbauer@metrodoctors.com.
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For advertising rates and space reservations, contact: Betsy Pierre 2318 Eastwood Circle Monticello, MN 55362 phone: (763) 295-5420 fax: (763) 295-2550 e-mail: betsy@pierreproductions.com MetroDoctors reserves the right to reject any article or advertising copy not in accordance with editorial policy. Advertisements published in MetroDoctors do not imply endorsement or sponsorship by TCMS. Non-members may subscribe to MetroDoctors at a cost of $15 per year or $3 per issue, if extra copies are available. For subscription information, contact Katie Snow at (612) 362-3704.
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January/February 2012
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The Journal of the Twin Cities Medical Society
IN THIS ISSUE...
To Transfuse or not to Transfuse, that IS the Question “[Blood] is the most dangerous substance we use in medicine.” Dr. Charles B. Huggins, Nobel Prize Recipient After being exposed to blood shortages and blood borne infections as a physician in training, I became an adamant supporter of blood donations and myself a blood donor. I became an advocate for appropriate utilization of blood transfusions to the point that my colleagues criticized me about being too conservative with blood transfusions. Those were the days where a patient with an HGB< 10 almost automatically received not one but two units of blood. Then in the mid-nineties I was a trauma patient with hemorrhaging and despite my arguments about why I didn’t want to receive blood transfusions, I was transfused. Then a few years later a certified letter came in the mail that stated that I might have received infected blood. Luckily, all the testing came back negative. However, my experiences further reinforced my belief that we over utilize blood and that blood has inherent dangers that many physicians do not realize. “If stored red cells were a new biologic proposed to the F.D.A. today, they would not be approved for transfusion because of the lack of data adequately demonstrating efficacy.” Weiskopf RB, Transfusion 1998;38:517 Over the last few years I have held steadfast in belief that we over-transfuse patients and that blood transfusions are inherently dangerous. I continue to be a blood donor and encourage my colleagues to do the same. It is with enthusiasm that I and the Editorial Board welcome this edition of MetroDoctors that addresses blood management from a multitude of perspectives and has some of the leaders in blood management rendering opinions and insights. “Blood is often given without a thought as to what are the risks and what are the benefits.” Dr. Mark Olson, Director, Bloodless Medicine and Surgery Program, Sacred Heart Hospital Dr. Lauren Anthony (page 19) provides her evidence-based perspective on blood utilization with dispelling myths about the transfusion triggers. Unfortunately, all too often we end up treating a number (lab value) instead of a patient. She further elaborates on the economic impact of our transfusion decisions which need careful consideration in weighing the risk vs. benefit from not only a clinical perspective but also an economic one. By Charles G. Terzian, M.D. Member, MetroDoctors Editorial Board
MetroDoctors
The Journal of the Twin Cities Medical Society
“While blood supplies undergo rigorous testing, the risks can never be completely eliminated.” EngleWood Hospital Newsletter Dr. Jed Gorlin (page 7) talks about the inherent problems assuring the safety of the current blood supply in the U.S. and the mechanisms to make it safer. Anyone who donates blood knows about the litany of questions asked and scrutiny about the donor’s health status, lifestyle issues along with environmental and geographic exposures. Both he and Dr. Rhame (page 15) talk about the potential for transmission of infectious diseases and how difficult it is to screen blood for all potential transmissible pathogens. I have come to realize that blood transmitted disease can either be asymptomatic or deadly depending on the patient who receives the blood. “Blood transfusions may not improve outcomes in [high risk anemic] patients and can actually worsen their condition.” Strategic Blood Management I have had the pleasure of spending time with Dr. Hannon (pages 11-14) and enjoy the benefit from his wealth of knowledge and experience with all aspects of blood management. Please pay special attention to his discussions about common yet under-recognized risk inherent in blood transfusion, not the rare HIV, Hep B or C infections but the more common, TACO, TRIM and TRALI and surveillance for transfusion associated complications. “The risks of transfusions can be greater than that of anemia.” Dr. Deitch, Chairman of the Department of Surgery at New Jersey Medical School One of our editors, Dr. Plotnikoff (page 21) relates his personal experience in addressing blood management in a select religious group. He addresses the underlying rationale for not receiving blood, and the challenges both medical and legal for these patients. I anticipate that this edition will not only be enjoyable and insightful reading, but hopefully will also affect our management of anemic patients. Shifting the paradigm, from where we thought we were actually helping patients to one where we have to carefully consider all the consequences and heed caution when ordering blood transfusions. Remember “order one (not two) and then reassess” and “less is sometimes more.”
January/February 2012
3
President’s Message
Critically Needed: Physician Engagement in 2012 PETER J. DEHNEL, M.D.
F
irst of all, my very best wishes to everyone for a Happy New Year 2012. My hope is that your experience in the practice of medicine and the delivery of health care goes well, in spite of what the current outlook holds. And the current outlook is daunting: achieving “meaningful use;” transitioning to the new HIPAA 5010 electronic transaction standards; participating in one or more emerging “accountable care organization” programs; increasing emphasis on collecting data to demonstrate longer-term outcomes of care across all care settings; and the leap to ICD-10 by October 1 of 2013. This is superimposed on a financial picture that is providing less reimbursement relative to the cost of providing that care and a Medicare payment structure that is rapidly becoming unsustainable. All of this clashes with advances in new technology and pharmaceuticals and an emerging “baby boomer” population that is just entering their Medicare eligibility. Daunting indeed, and physician leadership from a broad segment of TCMS physicians is critically needed. This edition of MetroDoctors highlights the topic of blood as a critical component of health care delivery. This topic also demonstrates on a smaller scale the present day challenges and opportunities confronting all of medicine. There have been considerable advances in the understanding of blood replacement since I was in training. The surveillance for blood borne and transfusion-related pathogens is remarkable. Guidelines for use and protocols to ensure optimal component replacement have been developed and their adoption is spreading. Additional advances have been made to manage transfusion-related infections, with hepatitis C being a prime example. Known as “non-A, non-B hepatitis” until the late 1980s, viral eradication is now possible by using double- or triple-antiviral regimens, depending on which of the six strains is involved. The economic challenge here is that “triple therapy” can run $20,000 to $25,000 per month. To the affected individual it can be lifesaving, however, and spare them from developing cirrhosis or hepatocellular carcinoma. My hope is that your “New Year’s Resolution’s” list includes increased awareness and engagement in directing health care change. That is in everyone’s best interest — most importantly, our patients and their families. Many of you are already actively involved in working to direct the course of health care change at either a local, regional or even national basis. My hat is off to you and would encourage you to “keep up the good job.” For those who are not currently engaged, a few suggestions on how to become more influential in health care reform. The first step is to become more informed of the issues. Just as with our patients, the opportunity to gather information from the Internet is limitless. The second is to focus on a topic or subject area and pick one (or two) that grab your interest and “professional curiosity.” Third, find others — either individuals or organizations — who share that interest and get involved in a supporting collaborative activity. The range of potential areas or activities is substantial — something for everyone. The unique role that you can bring to an activity as a physician may mean the difference between “being stuck in neutral” or moving forward with real gains. This all begins with a decision to get involved and make a difference. As always, your participation in TCMS-related activities is genuinely appreciated and there are a number of potential options to consider in this regard. But please do not feel limited to our selected activities. The need in the broader community for physician involvement is, to use the term, “humongous.” Please register your insights, comments and criticisms — they are appreciated. Email your reaction to this, as well as other “President’s Messages,” in the form of a Letter to the Editor to our managing editor, Nancy Bauer at nbauer@ metrodoctors.com.
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January/February 2012
MetroDoctors
The Journal of the Twin Cities Medical Society
TCMS IN ACTION SUE A. SCHETTLE, CEO
TCMS Medical Forum
Thomas P. Cook Scholarship
TCMS along with the Minnesota Psychiatric Society co-sponsored the first Twin Cities Medical Society Forum on December 8, 2011. “Mental Health: Improving Access and Quality,” was moderated by Peter Dehnel, M.D. and attended by 50 physicians and providers of medical health services. See related article on page 28.
Laura Gorsuch, 3rd year medical student
Twin Cities Medical Society Board
My thanks to past presidents Peter Wilton, M.D. and Ron Hansen, M.D. for their time and energy (and leadership) serving on the Twin Cities Medical Society board of directors. Their terms ended at the end of December. I’d also like to thank Shari Ohland and Tony Orecchia, M.D. for their service and commitment to the TCMS Board. Their terms also ended in December. West Metro Medical Foundation News
West Metro Medical Foundation held their annual meeting on November 17, 2011 and voted to distribute over $18,000 in grants to community organizations and projects. E.
at the University of Minnesota and current TCMS board member, received the Thomas P. Cook Scholarship sponsored by the West Metro Medical Foundation. The award is presented by the Minnesota Medical Foundation and was acknowledged at their annual Scholarship Luncheon by TCMS Associate Director, Nancy Bauer.
Congratulations to MetroDoctors! The journal of the Twin Cities Medical Society received a bronze award for its Cover Design, “serving the faces of our community,” September/October 2010, from the Minnesota Magazine & Publishing Association.
Laura Gorsuch (right), Thomas P. Cook Scholarship winner, and TCMS Associate Director Nancy Bauer.
East Metro Medical Society Foundation News
The East Metro Medical Society Foundation awarded $38,000 in grant funds for 2012 to support locally based initiatives and organizations. The Foundation also recently finalized its five year strategic goals. The goal is to raise awareness of the East Metro Medical Society Foundation within the TCMS east metro; raise funds to increase the size of the endowment; and support Honoring Choices Minnesota. EMMS Foundation board also approved a development program that will unfold in 2012.
Duane Engstrom, M.D. and Burton S. Schwartz, M.D. were recognized for
completing their terms, serving six years on the Foundation Board of Directors.
MetroDoctors
MetroDoctors Receives Award
The Journal of the Twin Cities Medical Society
Medical Student Luncheon Program Drs. Kenneth Crabb, Lisa Mattson, and Benjamin Whitten, along with medical students John Williams and Jessica van Lengerich participated in
a luncheon program promoting medical student involvement in organized medicine on October 20. Opportunities for involvement in the AMA, MMA, and TCMS were showcased.
January/February 2012
5
Blood Management COLLEAGUE INTERVIEW
A Conversation With
Jed B. Gorlin, M.D.
J
ed Gorlin, M.D., MBA, received his medical degree from Yale University, followed by an internship and residency in pediatrics at The Children’s Hospital, Boston, MA. He continued his education as a research fellow in pediatrics at Harvard Medical School, followed by fellowships in medicine (hematology/oncology), clinical pediatric oncology, and a visiting fellowship in transfusion medicine at Puget Sound Blood Center, Seattle, WA. He is board certified in pediatrics, pediatric heme/oncology, and pathology: blood banking-transfusion medicine. In addition, Dr. Gorlin received an MBA from the Carlson School of Business at the University of Minnesota. His current position is vice president of Medical and Quality Affairs, and medical director Memorial Blood Centers of Minnesota. Questions were provided by: Lee Beecher, M.D., Peter Bornstein, M.D., Doug Burnette, M.D., Richard Lussky, M.D., Greg Plotnikoff, M.D., Richard Sturgeon, M.D., and Linda VanEtta, M.D.
Has there been progress or change in medical community behavior regarding wise/appropriate blood and blood product usage in Minnesota?
Since there is no statewide data set, does the blood bank keep any data of its own? Is there any objective data to indicate progress, such as the number of unused units?
Alas, there is no region-wide tracking system for how many and which products are used for what indications in Minnesota. We have worked actively with our hospitals to encourage signing up for the American Association of Blood Banks’(AABB) biovigilance network that will at least track and benchmark adverse reactions to transfused blood products. I can say, as medical director of HCMC, that we have worked with our transfusion committee to develop mutually agreed upon transfusion guidelines, to include those guidelines on the computer physician order entry (CPOE) and track usage. For example, plasma was often ordered even without a clear proven indication. We have reduced the use of plasma by about 1/3 which is amazing in the setting of a large trauma hospital where the recent trend has been to use it more liberally in the acute trauma setting. I do enjoy working with our hospitals to encourage wiser evidencebased use of blood. This both reduces unintended side effects and is a more cost effective use of our precious community resource, our donated blood.
Blood banks are data rich and we send out extensive measures of quality to our customers. For example, we send about a 20 page quality report quarterly to our hospital and testing customers. If we are to have blood available virtually 100 percent of the time, by definition some units outdate. In fact the vast majority of those are group AB which are compatible with only the 4 percent of the population that happens to have this blood type. Increasingly Memorial Blood Centers is having success with “Donate for your type” which encourages group O donors who are of sufficient size and hemoglobin count to donate a double red but encourages a group AB donor to donate platelets or plasma. Outdate rates overall for red cells are less than 2 percent.
You have been active in setting up blood banks in Afghanistan. What are the greatest challenges in doing so? What accomplishments have you seen? I have had the honor of serving the CDC and AABB in the PEPFAR (Presidents emergency package for AIDS relief) programs in Tanzania and
(Continued on page 8)
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The Journal of the Twin Cities Medical Society
January/February 2012
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Blood Management Colleague Interview (Continued from page 7)
Rwanda and have seen public blood supplies go from 0 publicly available units to over 100,000 annually (Tanzania). While this is a tremendous improvement, it is probably only about 3-5 units/1,000 population, far less than the ~10-20 units/1,000 population they should be drawing annually to meet true needs. In Afghanistan, a country of over 30 million people, they are drawing less than 4,000 public units and depend upon foreign nationals for the donation of any of those units. So they have a long way to go to create a sustainable national infrastructure to support blood donation and distribution. I was amazed at the contrast between their national military hospital that is quite progressive, after having years of coaching from U.S. military blood program (ASBPO) staff, and the community maternity hospitals that appear more primitive than most African hospitals I have visited. I am hoping that we can help create a train-the-trainer program internal to the country such that trained Afghani personnel may take responsibility for training the next generation of staff for their own hospitals. This is a very pressing need in that the U.S. timeline for withdrawal is coming to fruition.
Has your experience in Afghanistan provided insights into how best to set up blood banks in disaster zones? People do well what they do often. Unfortunately the fragmented medical care system in Afghanistan does not lend itself to efficient processes and many hospitals seem to create redundant systems, none of which have the critical volume to maintain competence. Specifically there are over a dozen places that collect, process and test blood in the city of Kabul alone that could be done far more efficiently if centralized. What is amazing to see first hand is how indomitable the human spirit is in that the local citizens carry out their daily lives despite the disasters continuing to happen around them.
For providing safe and timely transfusions, how prepared are U.S. hospitals and the public health system in the event of a major disaster? So the good news is there have never been any disasters that truly overwhelmed the blood supply. The sad part about disasters is that a lot of innocent people die right away, whether it was Columbine, the Oklahoma bombing or even 911. In fact, only about 600 extra units of blood were used that day, whereas the local New York Blood Center draws over 1,000 every day! Since virtually all blood centers keep 3-5 days inventory on hand, we are always prepared for a surge in use and even if the immediate supply were used, blood centers generously share with fellow blood centers to restock the shelves. The more immediate task is for public health agencies to work closely with hospital transfusion services and their blood providers to include them in the practice drills that insure that plans for emergency transfusion, distribution and administration 8
January/February 2012
of blood are in place. For example, at HCMC we work closely with the disaster planning team and participated in a mock shooter event that included sending blood from Memorial Blood Center that arrived in less than 30 minutes!
What’s on the horizon for testing blood for infectious diseases in the next five years? Memorial Blood Centers is proud to participate in many clinical trials for blood screening tests and we have helped many of the currently performed tests obtain FDA licensing. This puts us on the front line of new test development. We are currently participating in a trial to make NAT (nucleic acid test) more efficient and will be participating in two trials for new Babesia tests discussed below. That said, we think the real future is not having to have more tests but to be able to eliminate any risk of infection by treating the collected blood in ways that protect the patient even from unknown agents.
Will the tests for blood-borne pathogens become so sensitive that hardly any blood will be accepted? It does seem like every time you go to the airport there is an additional device to annoy you before you get on the plane, but in fact, with planning, we mostly all still get on the flight. By analogy, while each new test has a finite rate of false positive tests, still >99 percent of our donors pass the screening tests. Perhaps the more important question is whether it really makes sense to have to develop a new additional, and usually expensive test each time some new icky thing threatens to enter the blood supply. For example, we recently learned the XMRV is probably not linked to chronic fatigue syndrome, but in fact we were prepared to take steps to help protect the supply had it been real. Alternatively, much effort has been dedicated to finding a different strategy, one of universal inactivation of pathogens by treatment of the blood components in ways that would inactivate bacteria, viruses and parasites, usually by damaging DNA in those infections. Since red cells and platelets don’t need to divide once transfused, there is no reason not to use products that work in this way, provided that they can be proved to be completely safe for patients.
Is there pre-donation counseling in place for donors who later are told their blood is unacceptable? Many of them show up in the primary care office with a letter from the blood bank telling them their blood was not acceptable due to some positive tests (such as HTLV-I). At Memorial Blood Centers we are proud that we have a full-time donor advocate who is available to counsel donors with positive tests. As I suggested from the airport X-ray scanner analogy, most positive tests, are in fact, false positive, meaning the donor is deferred but not actually infected. This is a confusing message, which is usually the case for a rare infection like HTLV. Fortunately false positive tests occur at rates less than 0.1 percent of donations, but when you collect over 100,000 MetroDoctors
The Journal of the Twin Cities Medical Society
units a year, you can imagine those do add up. All donors sign a consent acknowledging that one possible outcome of the screening is a positive test and that if the test is confirmed to be positive (indicating it may be real and not a false positive) that we are required by law to report the positive test to the state health department.
How do blood centers advocate for the safety and health of donors? I just returned from Washington DC where I had the honor of presenting to the FDA on behalf of the American Association of Blood Banks. I am the chair of the Interorganizational Task Force to address issues of donor hemoglobin standards. The inevitable result of a whole blood donation is that we remove over 200 mg of iron with each unit. Since the total body iron stores of man are about 1 gram and many women have less than 500 mg total body iron stores, it doesn’t take many donations to lower total body iron stores. While we can increase uptake of iron from our diets, this response is limited and it often takes time for donors to fully recover their iron balance. This FDA sponsored workshop, which I was able to help organize and moderate, explored ways in which we could do an even better job of ensuring that we don’t cause excessive donor iron depletion while at the same time protecting the availability of blood for patients that need it. I look forward to innovative ways to improve donor health but maintain a steady inventory.
MetroDoctors
The Journal of the Twin Cities Medical Society
Are there any other risks to whole blood donation besides iron depletion? Donor injuries from whole blood donation generally fall into two categories, those related to a needle (arm or nerve injuries) which generally simply get better with time, or those related to volume loss and feeling faint. While fainting per se is not a problem, it certainly can be if you fall and hit part of your body against a hard object on the way down. Again, through proper prehydration and observation immediately post donation we can mitigate many of those problems. Memorial Blood Center has been active in trying to protect our most vulnerable donors, first-time low weight, especially female donors. We instituted a higher weight limit for 16-year-old donors the day they were eligible with parental permission and have since refined that to all female donors between 16-18, since they are at the highest risk of fainting. There is data from other blood centers that this strategy works. I have personally been involved in legislation to license body art parlors to ensure blood borne pathogen training and proper inspections of such establishments. It is taking until about 4/15/2012 to have a majority of those that applied for licensing to be inspected, so hopefully after that time we will no longer need to defer blood donors for one year after a body art procedure. With proper sanitary technique it is impossible to (Continued on page 10)
January/February 2012
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Blood Management Colleague Interview (Continued from page 9)
transmit any blood borne infections to patients through art so we look forward to not having to defer our increasingly “colorful” youth.
Blood donation can be life saving for persons with hemochromatosis. In the past, the cost to the patient for donating was a significant barrier for those without insurance. Are persons with hemochromatosis allowed to donate blood at no cost to them? Memorial Blood Centers was one of the first blood centers to get the FDA variance to not have to discard blood from donors with hemachromatosis who meet all other eligibility requirements for allogeneic donation. This saves over 20 units of blood/month and makes them available to patients in need. We do not charge for therapeutic phlebotomy. While we are aware that the American Red Cross has also applied for and received this variance, it is my understanding that this service is not currently available in this region. Therefore, Memorial Blood Centers is the only local blood center that is providing a way to use these medically safe units.
We know that all persons with a non-monogamous lifestyle are at risk for HIV infection yet are allowed to donate blood. What about the opposite: are gay men in monogamous long-term relationships allowed to donate blood? All blood centers are required to follow FDA guidelines which include the deferral of donors answering “yes” to a question about having ever had
The MMA will be hosting its second webinar with MN Community Measurement and the Minnesota Department of Health outlining the 2012 Statewide Quality Reporting Requirements for physician clinics. These Webinars will address the state law mandating reporting, registration, and reporting and data requirements for clinics in January 2012 and February 2012 Thursday, January 12, 2012 from 7:30 a.m.–8:30 a.m. Space is limited. Register at: www.mnmed.org/measure System Requirements PC-based attendees Required: Windows® 7, Vista, XP or 2003 Server Macintosh®-based attendees Required: Mac OS® X 10.5 or newer For questions contact Becky Schierman at MMA (612) 362-3766 or rschierman@mnmed.org
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January/February 2012
male-to male sex. The rationale for this FDA decision is the persistent disproportionate representation of new incident HIV cases among the group categorized as having had male to male sex. More information is available on their website: http://www.fda.gov/BiologicsBloodVaccines/ BloodBloodProducts/QuestionsaboutBlood/ucm108186.htm
Since Minnesota and Wisconsin are highly endemic tick-borne illness areas, could you please discuss the risk of transmission via blood transfusion of these infectious agents? Babesia, Anaplasmosis and Lyme disease are all carried by the same tiny tick whose geographic area is centered around the St. Croix River Valley. While Lyme is much more frequent than Anaplasmosis or Babesia, it has never been proven to have been spread by a blood transfusion. In contrast the rarest of the infections in Minnesotans, Babesia, is the most likely of the three to be transmitted by a transfusion. Most people who get Babesia never know it since in healthy subjects it may cause no symptoms at all. However, people who get transfused are often not healthy and an impaired immune system such as a cancer patient or an older recipient may have a harder time fighting off Babesia. Memorial Blood Centers is participating in two different clinical trials to help manufacturers create screening tests that could be used in blood centers to rapidly and cost effectively screen blood for Babesia. When and how this test would be used remains to be determined, but wide-spread use will have to wait for development, testing and FDA approval of any new assay.
Please tell us about the newer anticoagulants that have now become available, and will be increasingly used instead of Coumadin. For patients with a history of a bad blood clot or an irregular heart rhythm, Coumadin can be life saving because blood clots that travel to the brain (a stroke) or lungs and heart (pulmonary embolus) are a common cause of morbidity or mortality. While Coumadin is simple to take, a single pill daily, it is challenging because it works by blocking vitamin K dependent activation of certain blood clotting factors. It is necessary to reduce the level of active factors to <20 percent to get significant decrease risk of clotting, but if the level falls to <10 percent then the risk of bleeding goes up, so it really is sort of a hematologic tight rope walk. This is facilitated by regular and careful monitoring and adjusting doses as necessary. In contrast newer oral direct coagulation factor inhibitors do not need monitoring and are generally administered in a single fixed dose, regardless of patient size (but not renal function). The danger, however, is there simply is no rapid practical way to reverse these new medications, for example in the setting of an overdose. While many are renally excreted, meaning that they could theoretically be dealt with using dialysis, in practice, this is not easy to arrange in an actively bleeding patient.
MetroDoctors
The Journal of the Twin Cities Medical Society
Introduction to
Blood Management Scope of Blood Component Therapy
Blood products have been a vital and integral part of modern health care since the advent of the first blood bank in 1936. The foundation of the current blood banking industry was laid during WWII, when efficient methods of blood processing, handling and storage were developed to meet the huge war-time demand. Tremendous advances in blood processing technology and blood screening in the latter half of the 20th century have resulted in steady increases in blood safety and availability. The National Blood Data Resource Center estimates that each year 15 million units of whole blood are collected and processed into 24 million blood products, which are then transfused to 4.5 million medical and surgical patients.1 The development of a safe and readily available blood supply has facilitated the advent of life-saving procedures, such as trauma resuscitation, cardiac surgery, organ transplantation, and chemotherapy. None of these procedures could have come about, nor could they currently exist, without an efficient collection, distribution, and delivery system for these millions of units of blood products. Efficacy of Transfusions
While blood transfusion therapy has been in common practice since the 1940s, it wasn’t until 1999 that the first controlled clinical trial of blood transfusions was conducted. The Transfusion Requirements in Critical Care (TRICC) trial was published in the New England Journal of Medicine on February 11, 1999, and it remains a landmark study in transfusion medicine.2 In this study, 838 anemic
By Timothy Hannon, M.D., MBA
MetroDoctors
critically ill patients were prospectively randomized into one of two treatment strategies: transfuse at a hemoglobin level of 10 gm/dL, a very traditional approach to these challenging patients, or transfuse at a hemoglobin level of 7 gm/dL, which was a very radical departure from common practice in 1999. The results of this study were surprising and changed the practice of transfusion medicine because the patients who were transfused at the more liberal “trigger” of 10 gm/dL had substantially worse outcomes than those transfused at the more conservative trigger of 7 gm/dL, particularly cardiopulmonary outcomes such as pulmonary edema, ARDS and myocardial infarction. Further, hospital mortality rates were also higher in those patients transfused more liberally. The conclusion of the authors back in February of 1999 was that “a restrictive strategy of red cell transfusions is at least as effective as and possibly superior to a liberal strategy in critically ill patients, with the possible exception of patients with acute myocardial infarction or unstable angina.” Even the exception to the rule noted by the authors — those patients with acute coronary syndromes (ACS) — have now been shown to also have higher mortality rates when transfused liberally.3,4,5 The results of the TRICC trial coined the phrase “less is more for transfusions,” a concept whose evidence has grown even stronger over the past decade. Adverse Effects of Transfusions
While efficacy studies for blood transfusion are relatively few, there are a growing number of controlled studies that have demonstrated a direct relationship between the amount of blood products that patients receive and serious complication rates. These complications are largely due to the immunosuppressive effects of donor blood and include stepwise increases
The Journal of the Twin Cities Medical Society
in infection rates,6-14 ventilator support times, ICU and hospital length of stay,15-21 short-term and long-term mortality12,17,18,22,23 and cancer recurrence rates.24-27 These adverse effects become even more concerning in light of the quality management and patient safety implications of improper transfusion decisions and transfusion errors. Owing in large part to a lack of formal training in transfusion medicine for most physicians, the administration of blood products is surrounded by emotions, misconceptions, and myths. In spite of mounting evidence that demonstrates significant harm from unnecessary blood transfusions,28 there are several studies that document a generalized lack of compliance with appropriate transfusion guidelines, as well as tremendous variation in transfusion practice between different institutions and
(Continued on page 12)
January/February 2012
11
Blood Management
You will be surprised how little it costs to: • Promote Your Professional Image • Build Patient Confidence • Reduce Employee Turnover • Increase Office Efficiency
Introduction to Blood Management (Continued from page 11)
among individual physicians within the same institution.29-32 With regard to patient safety, transfusion of blood products to the wrong patient (mistransfusion) has become one of the greatest risks to transfused patients. While improved donor screening has reduced the risk of HIV transmission to less than one in a million transfusions, mistransfusion still occurs with the alarming frequency of 1:12,000-19,000 units transfused, with death occurring in 1:600,000-800,000 transfusions.33,34 From a medical-legal standpoint, the financial liability of inappropriate transfusion decisions and transfusion errors is substantial, both to the hospital and to individual physicians, and can amount to millions of dollars. Economics of Transfusions
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January/February 2012
Blood costs are increasingly on the minds of hospital administrators and have recently been in the news.35,36 Although administrators are aware that the cost to purchase blood rises 5-8 percent a year, they are often unfamiliar with the total cost of blood transfusion. The total cost of transfusion includes the cost of storing, testing, dispensing and administering blood products within the hospital. Blood is a very resource intensive product, consuming large amounts of med tech and nursing labor, as well as significant amounts of supplies and allocated overhead.37 One activity based accounting study looking at cancer patients concluded that the cost to purchase blood represents only 19 percent of transfusion-related costs, and that the total cost to transfuse a unit of blood (in 2009 dollars) was from $850-$1,404.38 A recent study used an even more detailed accounting method in a review of the cost of surgical blood transfusions. This study concluded that blood purchase costs represent only 21-28 percent of transfusion-related costs, and that the cost to transfuse a single unit of blood was from $726-$1,183.39 While these costs are considerable, an additional accounting for the cost of transfusion-related adverse events can more than double the final cost to $2,100- $3,200 per unit.40 These costly transfusion-related adverse events include stepwise increases in infection rates, ventilator support times, ICU and
hospital length of stay, short-term and longterm mortality and cancer recurrence rates.41 It should be evident from the previous discussion that the total cost of transfusing patients is substantially more than just the cost to buy it. The cost of purchasing blood products is merely the tip of the iceberg of total blood costs, when accounting for transfusion-related labor, supplies, overhead and potential adverse effects. The Rise of Blood Management Programs
Blood is a precious and vital resource that is increasingly scarce and increasingly expensive. Current evidence supports a more conservative and thoughtful approach to blood component therapy based upon a shifting risk and benefit profile. However, physicians can be slow in adapting evidence-based practices and hospitals often fail to provide adequate blood utilization oversight and education. For these reasons, hospitals and hospital systems are increasingly looking to blood management programs as a vehicle to improve safety, quality and stewardship. The goal of blood management is to ensure the safe and efficient use of the many resources involved in the complex process of blood component therapy. These resources extend well beyond blood products and include nursing time, technician time, medical supplies, medical devices, laboratory tests, pharmaceuticals, hospital beds and health care dollars. The cornerstones of blood management programs are the implementation of evidence-based transfusion guidelines to reduce variability in transfusion practice, and the employment of multidisciplinary teams to study, implement and monitor blood management best practices in high risk patient populations. Our experience with comprehensive blood management programs has demonstrated sustainable reductions in the use of blood products by 20 percent or greater. This reduction reflects a more efficient utilization of blood and its associated resources, along with improvements in patient safety and the quality of care. References available upon request.
Timothy Hannon, M.D., MBA, President & CEO, Strategic Healthcare Group LLC.
MetroDoctors
The Journal of the Twin Cities Medical Society
To Predonate, or Not Predonate, That is the Question
T
he November 2, 2011 Journal of the American Medical Association included a clinical crossroads case study on autologous predonation.(1) The scenario was a relatively healthy, non-anemic woman (“Mrs. C”) who was scheduled for elective knee replacement surgery and was asking for advice on blood avoidance options. Her specific concerns were voiced as: “Personally, I do not want anyone else’s blood. I believe I should give my own blood for safety reasons. I read the paper a lot and watch the news, and you hear so much about infectious diseases. That’s my concern; I have never had an infectious disease in my life and at this age, I don’t think I want to get one.”(1) From her standpoint, she logically inquired about options such as predonating her own blood prior to surgery or using a directed donor. I am sure that this is still a common question from patients, and I view it as a great opportunity to provide patient education and an informed consent discussion for transfusion. Mrs. C is right to be concerned about the risks of transfusion, but she is right for the wrong reason. While the general public is concerned about the risk of transmittable disease such as HIV and hepatitis, these risks have been reduced to less than 1:1,000,000 through the use of donor deferrals and donor testing. While the blood industry remains vigilant for the next emerging threat such as Chagas Disease and Babesiosis, the clear and present danger are the non-infectious serious hazards of transfusions, which occur with a frequency that is 10x-100x times more frequent than viral transmission. The most significant of these adverse events are mistransfusion due to clerical errors, transfusion related acute lung By Timothy Hannon, M.D., MBA
MetroDoctors
injury (TRALI), transfusion associated circulatory overload (TACO), and transfusion related immunomodulation (TRIM).(2, 3) There is also growing concern about the adverse effects of blood related to its storage.(4) Patients and providers are often unaware of these non-infectious hazards, and that lack of awareness can lead to
blood management. While predonation was a great option in the early 1990s, the risk-benefit ratio has evolved to the point that predonation now offers little safety benefits over allogeneic blood. The risk of transmissible disease has dropped significantly, blood storage issues are universal and non-infectious risks such as cleri-
W
hile predonation was a great option in the early 1990s, the risk-benefit ratio has evolved to the point that predonation now offers little safety benefits over allogeneic blood. inappropriate risk-benefit treatment decisions and improper informed consent. The second issue is Mrs. C’s concern to reduce her need for a blood transfusion. Mrs. C should be reassured that she is at low risk for transfusion given her ample hemoglobin and expected blood loss. Pierson published an algorithm for orthopedic blood conservation based upon the expected blood loss from a procedure and the preoperative hemoglobin.(5) For a unilateral primary knee replacement, the expected blood loss would be 4.8 gm/dL, which includes an extra 1 gm/dL safety factor. Given her starting hemoglobin of 15.1 and expected nadir hemoglobin of 10.3 gm/dL, it is highly unlikely she would need a transfusion, at least if evidence-based transfusion guidelines were used. If Mrs. C was undergoing a revision or bilateral joint replacement, or if she was significantly anemic preoperatively, I would then counsel her on the best available options for
The Journal of the Twin Cities Medical Society
cal errors and TACO can occur just as readily with autologous blood as with allogeneic. In fact, the anemia of predonation moves patients closer to a transfusion trigger and some physicians use more liberal transfusion triggers for predonated blood in spite of recommendations against this practice.(6, 7) Coupled with the fact that patients are typically not given sufficient time to restore red blood cell mass after donating, predonation is no longer a recommended blood conservation approach in orthopedic surgery.(8) Current blood management recommendations for orthopedic surgery include preoperative anemia management protocols, intraoperative use of meticulous hemostasis, regional anesthesia, topical hemostatics, minimization of surgical drains, and the use of autotransfusion in selected cases.(8) The use of antifibrinolytics such as tranexamic acid also (Continued on page 14)
January/February 2012
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Blood Management â&#x2122;Ś Insurance/Patient Billing and Collection â&#x2122;Ś Accounts Receivable Management â&#x2122;Ś Accounts Payable/General Ledger â&#x2122;Ś Payroll/Fringe Benefit Management â&#x2122;Ś Experienced in over 30 Medical Specialties â&#x2122;Ś Qualified and Experienced Staff â&#x2122;Ś Owned and Managed by Experienced Healthcare Practice Management Professionals +HDOWKFDUH %LOOLQJ 5HVRXUFHV ,QF +LJKZD\ 6XLWH (DJDQ 01
To Predonate or Not Predonate (Continued from page 13)
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Timothy Hannon, M.D., MBA, President & CEO, Strategic Healthcare Group LLC. This article and others appear on his blog site www. thebloodytruth.com.
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seems promising.(9) Coupled with conservative transfusion practice driven by evidence-based guidelines, transfusion in joint replacement can be avoided in the vast majority of cases. The overall strategy has become maintenance of the patientâ&#x20AC;&#x2122;s own red cell mass, or as Woody Allen quipped, â&#x20AC;&#x153;the best place for blood is in our veins.â&#x20AC;? Perhaps the most important modiďŹ able risk factor for transfusion is what hospital door Mrs. C walks through on the morning of surgery. Transfusion practice is notoriously variable in the U.S., and can vary tremendously from hospital to hospital and among surgeons within the same hospital.(10) Asking her surgeon about available blood management options and his or her transfusion rate should be questions at the top of her list.
References: 1. Uhl, L. A 68-Year-Old Woman Contemplating Autologous Blood Donation Before Elective Surgery. JAMA 2011;306(17):1902-1910. 2. Boucher BA, Hannon TJ. Blood management: a primer for clinicians. Pharmacotherapy, 2007;27(10):1394-1411. 3. Despotis G, Eby C, Lublin DM. A review of transfusion risks and optimal management of perioperative bleeding with cardiac surgery. Transfusion 2008;48:2S-30S. 4. Spinella PC, Doctor A, Blumberg N, Holcomb JB. Does the storage duration of blood products affect outcomes in critically ill patients? Transfusion 2011;51(8):1644â&#x20AC;&#x201C;50. 5. Pierson J, Hannon TJ, Earles DR. A blood conservation algorithm to reduce blood transfusions after total hip and knee arthroplasty. JBJS 2004;86A(7):1512-18. 6. Shander A. Surgery without blood. Crit Care Med 2003;31:S708â&#x20AC;&#x201C;14. 7. Gould SA, Forbes JM. Controversies in transfusion medicine: indications for autologous and allogeneic transfusion should be the same: pro. Transfusion 1995;35:446â&#x20AC;&#x201C;49. 8. Hannon TJ, Pierson J. Blood management. In: American Academy of Orthopaedic Surgeons Comprehensive Orthopaedic Review, Lieberman JR, editor. AAOS 2009; Rosemont, IL. 9. Alvarez JC, Santiveri FX, Ramos I, et al. Tranexamic acid reduces blood transfusion in total knee arthroplasty even when a blood conservation program is applied. Transfusion 2008;48(3):519â&#x20AC;&#x201C;25. 10. Bennett-Guerrero E, Zhao Y, Oâ&#x20AC;&#x2122;Brien SM. Variation in Use of Blood Transfusion in Coronary Artery Bypass Graft Surgery. JAMA 2010;304(14):1568-75.
MetroDoctors
The Journal of the Twin Cities Medical Society
In Pursuit of Blood Safety: A Paradigm of Health Care Tradeoffs Introduction/Organizational Involvement Blood banking superbly illustrates modern medicine’s enormous successes and painful choices. There have been giant strides toward reduction of transfusion-transmitted HIV, hepatitis C and hepatitis B. But elimination of this risk is elusive. Screening for other less prevalent pathogens is part of routine U.S. screening: West Nile Virus, syphilis and others. Consideration of other pathogens, some of which are only theoretically transfusion transmittable, is a constant for blood bankers. Decisions on whether to include laboratory assessments of donor blood are generally made with safety being the most important consideration — even though positive results are rare. In those instances, it is essentially accepted that application of this testing results in huge cost to benefit ratios, i.e. cost per prevented serious transfusion complication. “Blood bankers,” as referenced above, are in fact, a complex web of organizations, regulatory agencies, consumer groups and individuals influencing the policy and practice of transfusion. The Food and Drug Agency mandates. The DHHS Centers for Medicaid and Medicare Services (CMS) issues the Clinical Laboratory Improvement Amendments (CLIA) for clinical laboratory testing. The AABB (founded as the American Association of Blood Banks) and the College of American Pathologists (CAP) develop policies that have considerable importance. The American Red Cross and America’s Blood
By Frank S. Rhame, M.D.
MetroDoctors
testing became available. Fears about the negative effects of heat treatment prevailed. As it happened, when anti-HIV testing was applied to stored specimens in several hemophilia centers, it was established that almost all persons with severe hemophilia had become infected by 1982. But persons with milder hemophilia, who only needed occasional coagulation factor concentrate, were damaged by the decision.
Centers, the amalgamation of community blood centers, are major forces. Every sphere of modern existence seems to have its collection of “Agencies Gone Wild.” The term “blood bankers” will be used throughout this article to encompass the whole array — they do all work together, mostly in harmony. A Dilemma Blood and blood components pose a fascinating dilemma. On the one hand, one wants to treat these cells and proteins as gently as possible, lest they lose function or, if modified, become antigenic. On the other hand, many pathogens can be present in donated blood making it theoretically desirable to treat blood in such a way as to inactivate the pathogens. There was a very difficult decision about heat treatment of coagulation factor concentrate between 1982, when it became clear that much of it was contaminated with the agent of AIDS, and 1985 when anti-HIV
The Journal of the Twin Cities Medical Society
Early Thinking/Testing In retrospect, since blood is in close proximity to all our cells, it is obvious that blood can contain pathogens. What might not have been so obvious is that a few pathogens can set up an asymptomatic, chronic carrier state in us. The high burden pathogens are all viruses and two, for no apparent reason, are hepatitis viruses (although hepatitis B and hepatitis C are as dissimilar in all other respects as I can imagine). Lack of symptoms is key here: blood bankers apply donor screening to eliminate risk associated with symptomatic disease. Blood associated transmission of hepatitis was recognized in the late 1800s from vaccines containing serum or lymph node material. Baruch Bloomberg won the Nobel prize for discovering Australia Antigen in the 1960s ultimately permitting the introduction of HBsAg screening in the early 1970s. The cause of “non-A, non-B” post transfusion hepatitis was established in the late 1980s permitting the institution of primitive anti-HCV screening in 1990. Anti-HIV screening, as noted above became
(Continued on page 16)
January/February 2012
15
Blood Management In Pursuit of Blood Safety (Continued from page 15)
available in early 1985. These three steps are the giant steps in blood safety although none eliminate the respective risks.
HIV Consideration of HIV screening provides an example of the risk-benefit dilemma. There is a “window” between the onset of infectiousness and the appearance of anti-HIV antibody. Donor history, which remains a very important component of blood safety,
Table: Pathogens of interest in blood safety with administrative status and detection techniques in use currently for blood screening.
Category
Pathogen
Technique(s)
FDA Mandated
HIV 1 and 2
Anti-HIV 1/2, p24 antigen, pooled NAT
Hepatitis B
HBsAg, anti-HBc (NAT testing available but not usually done)
Hepatitis C
Anti-HBC, pooled NAT
Syphilis
Non-treponemal antibody
HTLV 1 and 2
Anti-HTLV 1/2
CAP Mandated
Bacterial contamination of platelet units
Culture/ O2 measurement/EIA for Gram+/Gram - organisms
Voluntary
West Nile Virus
Pooled NAT (Individual during peak periods)
Trypanosoma cruzi
Serology on first time donors
CMV (special request)
Anti-CMV
Risk Reported
HHV8 Hepatitis A Hepatitis E EBV Parvovirus B19 Babesia species Ehrlichia species Anaplasma species Malaria Dengue virus
Risk Theoretical
Prion agents such as vJCV GB virus C Rabies virus Lymphocytic choriomeningitis virus Other arthropod borne viruses Leishmania species
16
January/February 2012
Donor deferral for travel or history of malaria
does not eliminate the window risk either because of lack of donor candor or unrecognized risk (i.e., unprotected heterosexual contact with a person of no recognized risk). Most infectious units from donors in the HIV risk window can be found with nucleic acid amplification testing (NAT). Because of the considerable cost of NAT testing, it is currently performed either in 6 (Roche) or 16 (Chiron/Genprobe) unit pools, typically in a multiplex assay containing HIV, HCV +/- HBV probes. But there is the very rare unit that can be detected by individual unit NAT testing but has a low enough HIV content as to be missed when diluted with other units. Because blood bankers do the same thing over and over many times (about 18,000,000 whole blood units and about two million apheresis platelet units are collected annually in the U.S.), they can calculate the cost-benefit ratio with considerable precision. Pooled unit HIV/HCV NAT testing costs about $20/unit or about $20,000,000 per NAT+/EIA negative unit. The cost is even higher in the Midwest where our prevalences for these pathogens are about a quarter of the national prevalences. Individual unit HIV testing would raise the cost substantially, but more importantly (see below) would increase false positive testing four-10 fold. According to Jed Gorlin, M.D., the director of the Memorial Blood Centers in Minnesota, NAT testing of over two million units during the last 12 years has found only about three-four NAT+/EIA negative HIV or HCV+ units. Nationally, we are down to less than a one in 2,000,000 per unit risk of HIV or HCV transmission. Current and Future Thinking/Testing Having come almost all the way to eliminating the risk of HBV, HCV, and HIV, the common causes chronic asymptomatic viremia, the attention of blood bankers have shifted to less prevalent pathogens and causes of transient viremia. The roster of pathogens is formidable (see table). Every one of these agents has its own way of getting around in the world, its own set of manifestations and an array of possible identification techniques
MetroDoctors
The Journal of the Twin Cities Medical Society
(to the amazement and joy of the infectious diseases specialist!). Each could be included in blood screening but at a cost difďŹ cult to justify. For instance, Trypanosoma cruzi serology has been done for several years at a cost of about $10/unit without one clearly prevented transmission. Costs are both economic and in donor loss from false positive tests. Because most collection agencies largely rely on repeat donors, the more times you donate, the greater the cumulative risk of a false positive donation. Strict FDA rules on donor reinstatement result in considerable donor loss over time due to false positive testing. Alternatively, several approaches to pathogen inactivation in blood components have been entertained. Most that have been included in clinical trials work by crosslinking RNA/DNA since transfused blood components, except those for hematopoietic stem cell transplantation, do not require intact nucleic acids, but most pathogens do. To date, no licensed methodologies are available.
Solvent detergent treated plasma was brieďŹ&#x201A;y marketed but cost more than double the price of untreated FFP and was associated with increased thrombotic risk, perhaps because of depletion of Protein C and S. Methylene blue treated plasma and psoralen compound treated plasma and platelets are available and in limited use in some European countries, but the FDA is requiring additional trials before licensing of the psoralen compound treatment in the U.S. Some may think that blood bankers accept high cost-beneďŹ t ratios because of the criticism associated with early HIV decisions. But there is a subtle rationale â&#x20AC;&#x201D; reduction of patient anxiety about transfusion. Today, the non-infectious hazards of transfusion (inadvertent mismatch, transfusion reaction, cardiac overload, graft versus host disease (GVHD), transfusion related acute lung injury) exceed the infectious hazards by several orders of magnitude. And the pathogens themselves are no longer frequently fatal. And all these hazards are outweighed by
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under-transfusion due to patient unwillingness to take a needed transfusion. The public wants zero risk from transfusion. Two decades ago blood bankers added all possible tests so they could say they were doing everything possible to increase blood safety. They accepted very high costs per eliminated risk. But today medical advancements in risk recognition and new testing methods make that position unmanageable. And, thus, blood safety is a paradigm of modern medicine. Blood safety is one more area where we need to apply rational standards of risk beneďŹ t. Frank S. Rhame, M.D. is adjunct professor in the Division of Infectious Diseases, Department of Medicine, University of Minnesota; research director, Clinic 42, Abbott Northwestern Hospital; and physician, Allina Medical Clinic â&#x20AC;&#x201D; The Doctors, Minneapolis, Minnesota. He has been taking care of HIV positive persons since 1981.
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MetroDoctors
The Journal of the Twin Cities Medical Society
January/February 2012
17
Jason Leyendecker, Au.D., Doctor of Audiology
Appropriate Utilization and the Economic Impact of Blood Product Usage The Issue: Overtransfusion
Explanation:
The “take-home” message in the national dialogue on patient blood management is that we tend to over-transfuse in the U.S. The new consensus is that traditional transfusion triggers are too high and that a restrictive approach is actually safer for patients. The extent of damage to red cells caused by storage is under debate; still, no one believes that stored red cells are as beneficial as fresh ones. As the risks of HIV and viral hepatitis transmission have become vanishingly small, deaths related to other infectious causes such as bacterial contamination and babesiosis have moved to the top of the list. Also moving to the top are non-infectious risks such as transfusion-related acute lung injury (TRALI) and transfusion-associated circulatory overload (TACO), now the leading causes of transfusion fatalities. In addition, the risk of transfusing blood to the wrong patient and a potentially fatal hemolytic reaction is 1 in 19,000, greater than 90 times the risk of HIV or hepatitis C transmission.1 Because over-transfusion causes real and potential harm to patients, avoiding unnecessary transfusions will improve patient outcomes with fewer resources. Clearly, this is a true “win-win” situation for patients and the medical community.
The cumulative evidence of the past 20 years is that stored blood generally doesn’t increase oxygen delivery unless a patient’s hemoglobin level is below 7 g/dl. Above that level, transfused cells improve lab numbers such as hemoglobin and oxygen saturation, but don’t release oxygen to the tissues and can worsen tissue hypoxia by occluding the microvasculature.3,4 This is a case of treating the lab value instead of the patient. Exceptions where transfused cells can benefit patients at higher hemoglobin levels include conditions where severe tissue hypoxia is present, such as sepsis, ischemia, or infarction; however, the benefit is thought to be largely outweighed by the micro-occlusive effects of the transfused cells at higher hemoglobin levels.
Transfusion Triggers: Less is More
The “disconnect” in discussions about lowering transfusion triggers is: “How can we reconcile a restrictive transfusion approach against well-established evidence that patients with anemia do worse on every possible outcome measure?” The answer from experts in patient blood management is: “Anemia is bad, but correcting anemia with banked blood at the traditional transfusion triggers causes outcomes to be even worse.”
The Patient’s Blood is a Precious Resource
The message of patient blood management is that the patient’s blood is a precious resource and that banked blood is actually a transplant that carries significant short-term, long-term, and potential unknown risks. Measures to optimize and preserve the patient’s endogenous red cell mass should be used before resorting to banked blood. Banked blood should be reserved for those who truly need it. Aryeh Shander, M.D., an anesthesiologist and pioneer in patient blood management, spoke at Allina’s Abbott-Northwestern Hospital in October 2010. In his presentation, Shander stated, “Blood is an organ, like it or not. Some of us in surgery — let’s say we’re working on the liver — would sacrifice one organ, the blood, for another which is the liver. If it were reversed, I think there would be a lot of questions. How would you like it if we would say that patients going through surgery have a 70 percent chance of developing acute renal failure? I don’t think that would be acceptable.”
By Lauren Anthony, M.D.
MetroDoctors
The Journal of the Twin Cities Medical Society
World’s Most Expensive Form of Iron
An example of unnecessary transfusion is transfusing patients who have iron-restricted hematopoiesis (iron deficiency anemia), such as new mothers who are anemic after delivery. A unit of red blood cells contains only 200-250 mg of iron, an amount that would not be sufficient to replenish the patient’s iron stores and could easily be given through oral supplements. In this generally healthy patient group with normal marrow function, adequate oral or parenteral iron will support hematopoiesis and more effectively replenish iron stores without the need for transfusion. Blood Product Stewardship
If transfusions are more toxic than previously thought, then over-transfusion is bad medicine and wastes limited resources. Blood product utilization is increasing at a rate of 2-3 percent per year in the U.S. The aging population will require more blood products from a shrinking donor pool. Although blood shortages are rare in the Twin Cities, demand may exceed supply (Continued on page 20)
January/February 2012
19
Blood Management Blood Product Usage (Continued from page 20)
s
in the future. While fresher blood may be safer, the shelf-life of blood can’t be shortened unless utilization goes down. “We Pay to Transfuse”
Mayo Clinic calculates an average unreimbursed loss of $570 for every blood product they transfuse.5 Multiplied by a year’s worth of transfused blood products, this amounts to a hemorrhage of $50 million dollars for that organization in unreimbursed costs. Hospitals in the Twin Cities are operating with proportionately similar losses. When hospitals are forced to absorb such costs for critical life-saving transfusions in an era of declining reimbursement, who can afford to pay for transfusions that don’t provide a significant patient benefit, or worse, cause harm? The Cost of a Safer Blood Supply
Although donors are not paid for their blood donation, the blood supplier charges hospitals a processing fee to cover the cost to collect and process each product. Measures to improve the safety of the blood supply, including new donor restrictions, testing for bloodborne pathogens, and leukoreduction, have resulted in significantly higher costs. For example, the cost to hospitals for a unit of red blood cells rose from an average of $85 to $178 in the five year period between 1999 and 2004.6 Between 2004 and 2006, the acquisition costs for blood products increased a further 17 percent.7 Current Average Blood Supplier Charges to Hospitals for Blood Components8
Average cost per unit
Packed RBCs
Apheresis platelets
Plasma
$210
$534
$61
The True Cost of Transfusion
A recent multi-hospital benchmarking study in surgical patients found that the above blood supplier charges account for only 20-30 percent of the total cost to transfuse a unit of packed red blood cells. The vein-to-vein transfusion processes are very complex and include: Actual cost of transfusion s "LOOD PRODUCT ACQUISITION COST s (OSPITAL BLOOD BANK SUPPLY MANAGEMENT s 0RE TRANSFUSION PROCESSES 20
January/February 2012
0ATIENT BLOOD TESTING PROCESSES TYPE AND screen, crossmatch) s 4RANSFUSION SPECIlC CONSENT s )SSUING DELIVERING COMPONENTS FROM blood bank to transfusion site s !DMINISTERING MONITORING TRANSFUSIONS s -ANAGING ACUTE TRANSFUSION REACTIONS hemovigilance s 0OST TRANSFUSION LOGISTICS s $IRECT OVERHEAD s )NDIRECT OVERHEAD When all of the transfusion related processes were added to the acquisition cost, the total cost to transfuse a unit of RBCs was calculated to be $761 ± $294. 9 The Reimbursement Gap
Mayo Clinic has calculated their total cost to transfuse an RBC unit at $1,241 vs. reimbursement of $520 (average of all payers) for a loss of $721 per RBC transfusion. Reimbursement has not kept pace with the cost of transfusion, which has steadily risen over the past two decades. Many transfusions fall under bundled DRG payments through Medicare and Medicaid, because 95 percent of transfusions are given to inpatients, and half of all red blood cells are transfused to patients over the age of 60.6 The Cost of Over-transfusion
Various studies show that 20-40 percent of transfusions are given outside of evidence-based indications, and external benchmarking studies of the Allina metro hospitals show similar rates of 20-33 percent. Since unnecessary transfusions cause real and potential harm and each transfusion consumes hundreds of dollars in unreimbursed costs, patient blood management programs are growing. Allina Hospitals and Clinics Program in Patient Blood Management
Allina Hospitals and Clinics began a systemwide blood management program in 2011 and partnered with Strategic Healthcare Group, a provider of blood management consulting services,10 for education, tools and metrics. Allina has formed a system-wide interdisciplinary Transfusion Care Council to select pilot projects and guide implementation of the program. The system council works in concert with interdisciplinary transfusion medicine committees at each hospital. The organization is currently working on six blood management implementation projects.
Patient Blood Management Implementation Projects
s s
!WARENESS AND EDUCATION %VIDENCE BASED TRANSFUSION GUIDELINES computer order entry, order sets s )ATROGENIC BLOOD LOSS s #ARDIOVASCULAR SURGERY BLOOD CONSERVATION s 0REOPERATIVE ANEMIA IDENTIlCATION AND management s 2ECOGNITION AND TREATMENT OF TRANSFUSION adverse events Allina’s blood management program aims to improve care while reducing costs, a winwin scenario that is rare in today’s increasingly complex health care environment. Lauren Anthony, M.D. is the medical director of Allina Medical Laboratories. She is a graduate of Penn State College of Medicine, completed her pathology residency training, including a flex year in family medicine, at Penn State Hershey Medical Center, and is board certified in anatomic and clinical pathology. Dr. Anthony has a strong interest in laboratory clinical effectiveness and utilization, transfusion medicine, laboratory administration, and medical education. References: 1. Uhl L. Patient blood management: a 68-year-old woman contemplating autologous blood donation before elective surgery. JAMA: the Journal of the American Medical Association. Nov 2 2011;306(17):1902-1910. 2. Mirhashemi S, Breit GA, Chavez Chavez RH, Intaglietta M. Effects of hemodilution on skin microcirculation. The American Journal of Physiology. Mar 1988;254(3 Pt 2):H411-416. 3. Zubair AC. Clinical impact of blood storage lesions. American Journal of Hematology. Feb 2010;85(2):117-122. 4. Boucher BA, Hannon TJ. Blood management: a primer for clinicians. Pharmacotherapy. Oct 2007;27(10):1394-1411. 5. Stubbs JR. Allogeneic Blood Transfusions: Why Do We Even Care? 2009; http://www.mayomedicallaboratories.com/mediax/articles/hottopics/20098a-transfuse/2009-8a-transfuse-handout.pdf. 6. Blood Services: Cost, Reimbursement and Billing. Vol 4: America’s Blood Centers; 2005. 7. Waters JH. The future of blood management. Clinics in Laboratory Medicine. Jun 2010;30(2):453-465. 8. Toner RW, Pizzi L, Leas B, Ballas SK, Quigley A, Goldfarb NI. Costs to Hospitals of Acquiring and Processing Blood in the US: A Survey of Hospital-Based Blood Banks and Transfusion Services. Applied Health Economics and Health Policy. 2011;9(1):29-37 10.2165/11530740-000000000-000000000. 9. Shander A, Hofmann A, Ozawa S, Theusinger OM, Gombotz H, Spahn DR. Activity-based costs of blood transfusions in surgical patients at four hospitals. Transfusion. Apr 2010;50(4):753-765. 10. Strategic Healthcare Group. Strategic Healthcare Group Available at: http://bloodmanagement.com/ company-information/strategic-healthcare-group.
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Jehovah’s Witnesses and Transfusions: A Quick Guide with Commentary for Physicians
J
ehovah’s Witnesses are a Christian denomination well known to many because of their belief that acceptance of a blood transfusion is a violation of God’s inerrant word found in their translation of Genesis 9:3-5, Leviticus 17: 13-14 as well as from Acts 15: 19-20, and 28-29 quoted here: “…abstain from anything contaminated by idols, from their illicit sexual union, from the meat of strangled animals, and from eating blood.” “Keep abstaining… from blood.” Health professionals need to know that Jehovah’s Witnesses believe that nothing comes before the worship of God including celebration of birthdays or religious holidays. Members do not participate in voting, singing patriotic songs, or serving in anything connected to military services. They will not salute or pledge allegiance to flags. They believe that the world has been ruled by Satan and thus they remain “separate from the world” including other Christian traditions. Known legally as the Watchtower Bible and Tract Society, this Governing Body of the faith has established over 120 Hospital Liaison Committees in the United States to support “early, open and continuing communication between patients (members) and physicians.” This is a 24-hour service that can be activated by calling Hospital Information Services at (718) 560-4300. A 29-minute video which reviews blood conservation and medical alternatives to blood transfusion is available by contacting this By Gregory A. Plotnikoff, M.D., MTS, FACP
MetroDoctors
information service at his@jw.org or by fax at (718) 560-4479. Willing acceptance of a blood transfusion by a Jehovah’s Witness member has been grounds for expulsion since 1961. Thus, per the biomedical principle of autonomy “self-rule,” even in life-or-death situations, competent adult members can refuse blood or fractionated blood transfusions. For this reason, Jehovah’s Witnesses will carry an Advance Medical Directive/Release Card stating that no blood be administered under any circumstances. The language used includes this statement, “I release physicians, anesthesiologists, and hospitals and their personnel from liability for any damages that might be caused by my refusal of blood, despite their otherwise competent care.” Unacceptable treatments include transfusions of whole blood or any of its primary components including red cells, white cells, platelets and plasma. This includes preoperative autologous blood collection for later reinfusion. Acceptable treatments include use of volume expanders, synthetic erythropoietin, topical and injectable hemostatic agents, argon beam or laser coagulators, Cell Saver technologies and even hyperbaric oxygen. Decisions left to each individual member include use of blood fractions (albumin, clotting factors, hemoglobin solutions, immunoglobulins, interleukins, interferons) or use of heart bypass, hemodialysis (if the pumps are primed with non-blood fluids) or organ transplants. For these, health professionals will need to determine in advance the member’s beliefs regarding their use. The greatest challenge comes from working with the children of Jehovah’s Witness parents. Under national and state laws, physicians define the medical best interest of the child and are legally obligated to override
The Journal of the Twin Cities Medical Society
the religious beliefs of parents if a child’s life is at risk. And at what hemoglobin level is a child’s or adolescent’s life at risk? This may be where medicine is much more of an art than a science. I will never forget the superb care of a 3-year-old girl with acute lymphocytic leukemia by St. Paul pediatric oncologist Jack Priest, M.D., back in the late 1980s. What did I see? Upon diagnosis, he worked closely with this girl’s single parent, her mother, as a partner. He affirmed the importance of her faith and beliefs and also stated his beliefs, his experience with the need for transfusion during ALL treatment, and his commitment to do everything humanly possible to avoid a transfusion. He also made clear his legal obligation to override her expressed wishes should her daughter’s life be in immediate danger such as the appearance of a fever. I met them long into the therapy. The little girl was so pale and so relatively still for her age that she seemed to be more of a doll than a living being. Her hemoglobin was unbelievably low at 2.3 when last checked in the previous week. Yet she was doing well. I was deeply moved by how Jack was able to maintain a very positive, very respectful, working relationship with her and her mother. I imagined that he lost much sleep worrying about preserving this child’s physical wellbeing and preserving the mother’s psychological and spiritual welfare. Later, this frail girl did develop a fever, clearly a life-threatening event for anyone with very low hemoglobin. Jack was prepared and within minutes obtained a court order for transfusion and she did well; as did this child’s mother. I imagine that this is because she had
(Continued on page 22)
January/February 2012
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Blood Management Jehovahâ&#x20AC;&#x2122;s Witnesses and Transfusions (Continued from page 21)
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been well prepared by Jack for this possibility. The transfusion was done against her will but she was not at risk for expulsion from her faith community that allows for this situation. I will never forget the artistry demonstrated by Jack in his care for this patient and her mother. I wrestle now with the science behind necessity of transfusions outside of acute hemorrhage. Having seen aged adults walking into my clinic with a hemoglobin of 4.0 from a slow GI bleed, I wonder how many transfusions I have ordered in the past would be considered necessary now given access to erythropoietin, inducible hypothermia, post-operative blood salvage, advanced delivery capacities for bone marrow support (including B vitamins, iron, vitamin D) and hyperbaric oxygen chambers. Clearly, ongoing research and technological development will lead to new therapeutic options and guidelines to maximize oxygen delivery and minimize oxygen consumption. We have Jehovahâ&#x20AC;&#x2122;s Witnesses to thank for encouraging advancements in blood transfusion alternatives. For further reading: Mann MC, Votto J, Kambe J, McNamee MJ. Management of the severely anemic patient who refuses transfusion: Lessons learned during the care of a Jehovahâ&#x20AC;&#x2122;s Witness. Annals of Internal Medicine. 1992;117: 1042-1048. Smith ML. Ethic perspectives on Jehovahâ&#x20AC;&#x2122;s Witnessesâ&#x20AC;&#x2122; refusal of blood. Cleveland Clinic Journal of Medicine. 1997;64(9): 475-81. Gregory A. Plotnikoff, M.D., MTS is an internist practicing at the Penny George Institute for Health and Healing. He is a graduate of Harvard Divinity School.
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January/February 2012
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LETTERS
Access to Psychiatrists
High unemployment rates and hard economic times are associated with mental and substance abuse disorders. However, even after enactment of the federal mental health insurance parity law of 2008, direct patient access to outpatient psychiatrists in Minnesota is on the decline. Some reasons are: s ,OW PRIVATE SECTOR HEALTH CARE INSURANCE payment rates for psychiatric services and high deductible insurance plans s 2ESTRICTED AND INADEQUATE MANAGED CARE provider networks, and s 0UBLIC SECTOR -EDICAID AND -EDICARE payment rates which are too low to support private outpatient office-based psychiatric practices. In response, rather than doing fee-forservice work in their offices, many former private practice psychiatrists have escaped the insurance system and are now employed. They work for MN State Operated Services, consult part-time or full-time at community mental health centers or specialized treatment programs, are faculty in the VA system, or are employed as full-time hospitalists. Those who remain in office-based independent medical practice are opting out of the Medicare program and dropping managed care provider agreements. No doubt that third party reimbursement is a powerful driver of patient access to psychiatrists and for the changing venues of psychiatrists’ professional practices. These shifts from community-based private practice are causing reliance on hospital emergency departments for psychiatric triage and evaluations, support integration of psychiatric services with primary care, and may be associated with increases in psychotropic medication prescribing by primary care providers (often nurses). Psychiatrists in MetroDoctors
public and private clinic settings are increasingly taking on supervisory and administrative roles rather than providing direct patient care. Health Care Insurance
In response to ever-rising health care insurance premiums, both employers and individuals are switching to policies with higher out-of-pocket deductibles ($1,000 to $10,000) before the patient’s insurance kicks in. The insurance company usually sets its allowable charges for units of psychiatric service below the cost of running a quality outpatient psychiatric practice. Setting payment rates for psychiatric care at low levels also directs and limits how a patient can cost account his plan deductible. Most episodes of psychiatric care in an outpatient setting are completed well before a $5,000 deductible is satisfied. But, unlike patient-controlled health care accounts such as health savings accounts (HSAs), patients on high deductible insurance plans not connected to HSAs are not allowed to tally the “retail” costs of obtaining outpatient psychiatric services. Payments for “out-of-network” psychiatrists, i.e. physicians who are not under contract with the health plan, are routinely discounted 20-40 percent — if payment is allowed at all. Yet, there is widespread difficulty finding network psychiatrists who are available to see patients in managed care networks. Network psychiatrists may be retired or dead, there are frequently waits up to two months to be seen when patients or physicians call, and often the listed psychiatrist will do “med checks” only, with very limited time to do in-person psychiatric evaluations. Recently, psychiatrists in some networks or clinic systems are available to see patients
The Journal of the Twin Cities Medical Society
who qualify for insurance coverage only if referred by a network primary care physician. The Twin Cities Medical Society wants better access to quality psychiatric services [see MetroDoctors, Nov-Dec 2011] and co-sponsored a Forum with the Minnesota Psychiatric Society on this topic. What are your experiences and advice? Reference: The American Psychiatric Association (APA) has put together a publication (pdf) to help physicians navigate the health care reform law (PPACA) called “Health Care Reform: A Primer for Psychiatrists,” with information for physicians, their patients, and the profession as a whole with articles from Psychiatric News, American Journal of Psychiatry, and Psychiatric Services. Lee H. Beecher, M.D., adjunct professor of psychiatry, University of Minnesota, www.leebeechermd.mymedfusion.com. Dr. Beecher is president, Minnesota Physician-Patient Alliance (MPPA), www.physician-patient.org.
Clarification
In the interest of full disclosure, Dr. George Dawson, Colleague Interview, Nov/Dec 2011, offered the following clarifications to his introduction. 1) He held the position of assistant professor at the University until 2010, nearly 20 years; and 2) his re-certification for the added qualifications in both addiction and geriatric psychiatry have expired, pending re-examination.
January/February 2012
23
Emerging from the “Cone of Silence” A 2012 Legislative Preview
T
he “cone of silence” that came to shape the 2011 legislative session is long behind us, but the path forward into the 2012 legislative session still brings with it a level of uncertainty spanning a number of different fronts. The greatest uncertainty arises from the question of how the United States Supreme Court will rule on the constitutionality of the Accountable Care Act. Although many expect the decision to be very narrow in focus, the political implications of the Court’s decision will be impactful and far reaching. There is uncertainty around the question of what the newly drawn legislative districts will look like in 2012. And there is considerable uncertainty about what, if anything, the Republican majorities will focus on in terms of health care, and whether the health insurance exchange will be the ultimate bellwether for the politics of the 2012 session. Undoubtedly, these issues and more will bring many questions and potential surprises during the upcoming legislative session. Active Administration
Governor Dayton’s administration has taken a very active hands-on role in moving a number of reform initiatives forward. Going back to last session, the Governor announced early in session his intent to put forward a competitive bid pilot project for the Prepaid Medical Assistance Program population in the seven county metro area. The project was included in the final budget negotiations and was projected to save $170 million dollars over the next two years. In late October, the Governor announced that HealthPartners and UCare had both won By Nathanial Mussell, JD
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January/February 2012
the competitive bid for offering the “best value” although it is yet to be determined what the bid offers by either plan included. Additionally, Medica was awarded the opportunity to participate in Hennepin County and Blue Cross Blue Shield was given the same opportunity in Ramsey County. The new contracts are scheduled to take effect on January 1, 2012. There is growing concern, particularly among metro area providers, that the competitive bid award will just result in even lower reimbursement for these patients. Although the Department of Human Services had said they would release the competitive bid award, at the time of this writing the Department had yet to do so, leaving many in the medical community in the dark about a potentially significant portion of revenue. The Administration has also been active in putting together a request for proposal around payment and delivery system reform. A number of hospital systems around the state responded to the proposal in early November to put together total cost of care payment models for state program patients. These initiatives, along with others that potentially come through the Accountable Care Act and other state health reforms will have a significant impact on health care delivery in the state going forward. Short and Sweet
Coming off the longest government shutdown in state history and a knockdown drag-em out budget battle, the 2012 legislative session is expected by many to be a significantly shorter session given the current political climate and the impending fall elections. The legislature is scheduled to resume January 24 and there is some indication that the session could be as short as 10-12 weeks.
Given the short time windows with which to pass bills, the initial focus of legislative committees is likely on the Republican’s Reform 2.0 initiative. Legislators met with business leaders throughout the state over the fall months to look at ways to further streamline government and help bring economic growth back to the private sector. From a health reform perspective, there were discussions during some of the fall meetings around changes to the data submitted to the state by the health plans. There continues to be significant debate over whether health plans should be required to submit encounter data or claims level data. Providers insist that to ensure the State is measuring health care cost and quality in the most accurate manner, data reporting needs to be done on an encounter level basis. Beyond this, it remains unclear whether health care reform will have any other larger part of Reform 2.0. Although much of the focus of the 2012 session will remain on health care reform, lawmakers received an early Christmas present in December when the November forecast showed an unexpected surplus of over $850 million dollars, due in large part to lower than expected
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spending in health care from lower enrollment in Medical Assistance. If a surplus remains following the February forecast, the monies will largely go towards the state’s cash flow account and depleted budget reserves. After that, legislators and the Governor would focus on repaying the K-12 education shift from the 2011 legislative session. Putting the budget discussions and other health reform initiatives aside, the single biggest fight during the 2012 legislative session will likely hinge around the politics of a health insurance exchange in Minnesota. Downstream from the ACA
While we continue to wait for the ultimate arbiter, the United States Supreme Court, on the constitutionality of the Accountable Care Act, Minnesota, like other states, has to move forward in its implementation of many of the provisions of the federal health reform bill, but not without a lengthy list of detractors. The politics of the ACA are playing out in full force in Minnesota over the implementation and creation of a health insurance exchange, pitting Governor Dayton’s administration and the Commerce Department against House and Senate republicans. Governor Dayton moved ahead this fall in appointing a Health Insurance Exchange Task Force through the Department of Commerce charged with putting together the framework and infrastructure of a health insurance exchange. Dayton issued an executive order in early November announcing the formation of both the Insurance Exchange task force and a larger health reform task force charged with further reforming the state’s public health care programs. Dayton’s actions were not without controversy though, as Senator David Hann (R – Eden Prairie) attempted to thwart Governor Dayton’s use of almost $25 million dollars in federal monies to implement the exchange and other federal programs. Many first-term Republican legislators remain steadfastly opposed to “ObamaCare,” a view that got many of them elected in 2010. Adding fuel to the fire for these legislators a groundswell of fervent opposition to the ACA remains in states like Ohio, where voters overwhelmingly rejected the measure by a 2-1 margin in this last November’s election, and in MetroDoctors
North Dakota, where in a special session in early November, Republican legislators voted down the development of a state based insurance exchange. The catch-22 that many legislators face on the health insurance exchange debate is that if Minnesota does not implement or have in place a structure for an insurance exchange by 2013, the state would be forced to accept the federal insurance exchange model, a position that would be even more abhorrent to many of these same legislators. As a result, legislative leadership will be forced to walk a very tight rope next session as they try to balance the policies around a state-based insurance exchange with the politics of the exchange and “ObamaCare.” Rep. Steve Gottwalt (R – St. Cloud), chairman of the House Health and Human Services Reform Committee, authored a state-based insurance exchange bill in the 2011 session, and will likely be responsible for drawing up and moving forward any exchange bill to emerge from the House in 2012. There is a far less likelihood that Rep. Gottwalt’s counterpart in the Senate, Sen. David Hann (R – Eden Prairie) will have any part in moving an insurance exchange through the Senate. With Governor Dayton and Commerce Commissioner Mike Rothman moving full speed ahead on their own with implementation of an exchange, any work done by the legislature on an exchange in 2012 is sure to create a political showdown early in session. The Republican majorities are unlikely to get any bipartisan support from House or Senate Democrats who are actively participating in the Administration’s exchange task force. Ultimately, the Republicans could be shutout from offering any input on the exchange if politics get in the way. How the entire debate plays out the first few months of the session will surely provide for entertaining political theater. New Boundaries and New Elections
One of the themes that will underlay the entire legislative session is the drawing of new legislative districts for the 2012 elections. Every 10 years the state goes through a redistricting process to adjust the legislative boundaries and congressional boundaries to reflect a shifting
The Journal of the Twin Cities Medical Society
population. Last session the House and Senate passed a redistricting bill that was later vetoed by the Governor, forcing the issue onto the courts, as has been the pattern with redistricting changes in Minnesota going back to the early 20th century. A five judge redistricting panel convened over the fall to obtain input from interested stakeholders across the state. The panel will release the newly drawn legislative maps on February 24, 2012. The uncertainty surrounding what could potentially be drastically different legislative boundaries for a number of legislators, particularly those in the outer suburbs of the Twin Cities, will likely influence how aggressive legislators want to be during the legislative session. Most legislators, even those whose district is not changing dramatically, will have one foot out the door most of the session as they look to the summer and fall months and what will again likely be a divisive campaign season. Nathaniel Mussell, JD, Government Affairs, Lockridge Grindal Nauen.
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TCOPC Takes a Look Back at 2011 IT’S HARD TO BELIEVE THAT THE Twin Cities Obesity Prevention Coalition (TCOPC) has just wrapped up its first year of work! As we kick off 2012, it seems fitting to look back and highlight the accomplishments of this great group of individuals who have brought so much energy and support to the goal of creating healthier communities. November 2010 marked the first coalition meeting of the group. Introductions were made, initial conversations were begun, a coalition name was voted on and approved, and by February 2011, we had a logo that clearly identified our effort. We selected four communities in the metro area to partner with and began conversations with city leaders and key community influencers about what a healthy community resolution should look like and what factors needed consideration when creating a resolution for their city. By June, the coalition was growing in size with each monthly meeting. We began brainstorming what a sample healthy community resolution should look like and continued through the summer refining the document to be a comprehensive, low-cost and no-cost resolution that cities would be eager to pass and implement. In August, the Twin Cities Medical Society and the TCOPC hosted six international emerging public health leaders from around the world. The topic of the open dialog centered on public health issues in the U.S., with a focus on the work of the Twin Cities Obesity Prevention Coalition. We were honored to host this event and look forward to continuing our international public health conversation with our international partners. By September, the coalition, through one-on-one meetings, identified an additional eight metro communities as being locations that could benefit from the passage and implementation of a resolution. Existing relationships and networks have been crucial in approaching elected officials, and without such a strong coalition, this part of the work would be extremely difficult!
Needless to say, physician advocacy is crucial when public health is at stake. Physician members of the Twin Cities Medical Society have made it clear that the obesity epidemic is an issue they are eager to engage in. In September, TCOPC physicians attended a communication training session intended to share communication fundamentals they can apply when educating community leaders and the public on the benefits and value of obesity prevention strategies and passage of a healthy community resolution. A physician communications toolkit has been developed which includes talking points, Q & A, and Minnesota specific facts and figures relating to obesity and the costs we face as a state. Over the past year, the coalition was also able to highlight our work at events such as Minneapolis Community and Technical College’s Student Wellfest, the National Safe Routes to School conference, the 2011 Diabetes Expo and the Making It Better conference. December’s coalition meeting provided an opportunity to hear from a public health advocate from California who is working with cities to become Healthy Eating Active Living communities by passing city resolutions with polices geared to advancing healthy eating and active living practices for all residents. Without the coalition members, the accomplishments made in 2011 would not have been possible. I would like to thank everyone for their time, participation, thoughts and ideas and for being committed to advancing the goals of the Twin Cities Obesity Prevention Coalition.
By Jennifer Anderson, Project Coordinator
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January/February 2012
MetroDoctors
The Journal of the Twin Cities Medical Society
Advance Care Planning Materials Available in Five Languages
H
onoring Choices Minnesota patient education materials can be viewed and purchased on our website, www.metrodoctors.com. There are six pieces available in English, Hmong, Russian, Somali and Spanish with options to purchase a sub-license to add your organization’s logo or to obtain electronic files. The content of these materials was licensed from Gundersen Lutheran and edited collaboratively with patient education experts from several metro area hospitals and health care systems. The text has been re-worded and re-organized creating a more user-friendly layout, which is color coded and formatted for 8.5 by 11 inch paper for easy printing from any printer.
Patient Education Materials Available: s !DVANCE #ARE 0LANNING 'LOSSARY s !DVANCE #ARE 0LANNING 'UIDE s (EALTH #ARE !GENT s #02 &ACT 3HEET s (ELP 7ITH "REATHING &ACT 3HEET s 4UBE &EEDING &ACT 3HEET
Pricing — translated materials (Sold in Bundles of 25)
Quantity (in Bundles) Price per Bundle 1 – 5……………………..$4.28 6 – 10……………………$3.75 11 – 15…………………..$3.37 16 – 100…………………$2.95
Pricing — English materials (Sold in Bundles of 25)
Quantity (in Bundles) Price per Bundle 1 – 5……………………..$4.05 6 – 10……………………$3.56 11 – 15…………………..$3.20 16 – 100…………………$2.79
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January/February 2012
27
Caring Hearts for Homeless People 20th Annual Supply Drive â&#x20AC;&#x201D; February 2012
C
aring Hearts for Homeless People is an annual collection drive for health and hygiene supplies and over-the-counter medications for homeless adults and children. Donated items are sorted and distributed to the homeless directly through the following programs: Health Care for the Homeless, Listening House of St. Paul, and SafeZone Resource Center. Please consider placing a collection box at your ofďŹ ce and encouraging staff to donate.
Many clinics and hospitals are involved in this drive year after year. At the end of the month,
donations can be brought to either Saint Paul (St. Josephâ&#x20AC;&#x2122;s Hospital) or Minneapolis (Twin Cities Medical Society ofďŹ ce). Please contact Katie Snow, EMMS Foundation, at (612) 362-3704 or KSnow@metrodoctors.com if your organization would like to participate. The Caring Hearts drive is sponsored by HealthEast Care System and East Metro Medical Society Foundation.
TCMS Sponsors Forum on Mental Health
O
n December 8, 2011, TCMS kicked off its advocacy forum spotlighting the topic of mental health. Co-sponsored by the Minnesota Psychiatric Society, the forum featured a panel discussion on Mental Health: Improving Access and Quality, drawing over 50 attendees. Participants included: s 3UE !BDERHOLDEN EXECUTIVE DIRECTOR .Ational Alliance on Mental Illness s 4IMOTHY (ERNANDEZ - $ FAMILY PHYSIcian, Family Health Services Minnesota s *O!NNE (OFFMAN - $ PEDIATRICIAN 3OUTH Lake Pediatrics s *ONATHAN *ENSEN - $ PSYCHIATRIST 5NIversity of Minnesota s -AUREEN / #ONNELL ASSISTANT COMMISsioner, Minnesota Department of Human Services s *OHN :AKELJ PROJECT MANAGER 0SYCHIATRIC Consultation, Minnesota Department of Human Services Leading off the discussion, Sue Abderholden asked the audience to call out â&#x20AC;&#x153;slangâ&#x20AC;? terms used to describe persons with mental illness â&#x20AC;&#x201D; nuts, crazy, stupid, etc. Then she asked the group to describe slang names for people with heart disease, and then cancer. None were voiced. The stigma of mental illness is devastating. She called for more treatment opportunities, more collaborative care; the need for reimbursement of communitybased services and bringing the services to where children and families are. She concluded with the need for more intensive community services. Dr. Timothy Hernandez spoke about his 28
January/February 2012
family medicine practice and how they have inproposal process (RFP) for collaborative consultacorporated the DIAMOND project, utilizing tive services. a model of care managers and direct access to And, lastly, Assistant Commissioner psychiatric consultation. He noted that the payOâ&#x20AC;&#x2122;Connell empowered the audience to deliver ment re-design is paying dividends. the message to legislators and policy makers that Dr. JoAnne Hoffman described the chalâ&#x20AC;&#x153;treatment is effective and recovery happens.â&#x20AC;? She lenges she, as a pediatrician, experiences when went on to describe a number of DHS initiatives an overly anxious patient and family needs her currently underway, including: 10x10 â&#x20AC;&#x201D; increascare, and she is ill equipped to respond. Mental ing the average life span of schizophrenics by 10 health is more art than science â&#x20AC;&#x201D; no protocol years; Minnesota Kids, and ABCD â&#x20AC;&#x201D; Asssuring ďŹ ts all. She advocated for a system of improved Better Child Development. There is not a lack of communication of best practices and models of initiatives â&#x20AC;&#x201D; the challenge is educating providers care. and the public about the availability of services. â&#x20AC;&#x153;Build a â&#x20AC;&#x2DC;health homeâ&#x20AC;&#x2122; model and they will An engaging question and answer session come.â&#x20AC;? Dr. Jon Jensenâ&#x20AC;&#x2122;s message described a colensued with several suggestions offered for furlaborative health care model previously developed ther collaborative discussions around advocacy, outcomes, coordination and integration of serby Dr. Arne Anderson at Childrenâ&#x20AC;&#x2122;s Hospital in south Minneapolis. Under Dr. Jensenâ&#x20AC;&#x2122;s direction, vices. TCMS staff has committed to convene key mental health services provided by Northpoint stakeholders to continue to explore these issues. Clinic are being offered at Harrison School as a Stay tuned for the next Forum. Details to part of their school-based health program. come. Bridging the gaps between primary care and specialty care is the goal of the Collaborative Psychiatric Consultation Service developed by the Department of Human Services as described by John Zakelj, program manager. It calls for protocols to guide medication and therapy services; authorization requirements for psychotropic Psychiatrist Renee Koronkowski, M.D. addresses a question to medications; and to develop a the Forum panelists. MetroDoctors
The Journal of the Twin Cities Medical Society
In Memoriam EUGENE L. BAUER, M.D., passed away on November 25, 2011 at the age of 96. Dr. Bauer served in the U.S. Army, 99th Infantry as a Battalion Surgeon during World War II. Dr. Bauer attended the University of Illinois College of Medicine graduating in 1942. He then opened an ENT medical practice in St. Paul after two fellowships at the Mayo Clinic. Dr. Bauer has been a member since 1947. DONALD R. DAGGETT, M.D., age 89, passed away on October 23, 2011. Dr. Daggett attended the University of Minnesota Medical School. He was a successful psychiatrist known for his generosity and wry sense of humor. Dr. Daggett has been a member since 1953. JAMES J. PATTEE, M.D., born October 24, 1924 passed away on October 26, 2011. Dr. Pattee graduated from Creighton University in 1953 and completed his internship at St. Josephâ&#x20AC;&#x2122;s Hospital. He served as medical director for North Ridge Care Center and is a former board member of the Geriatric Society and past president of the American Medical Directors Association. Dr. Pattee was also professor emeritus, Department of Family Practice and Community Health at the University of Minnesota. Dr. Pattee has been a member since 1955.
Senior Physicians Association
T
he Senior Physicians Association held their his term and look forward to working with Dr. fall luncheon on October 27, 2011, with a Anderson in the upcoming year. great turnout of members and their spouses. The The Senior Physicians Association meets event was held at the Interlachen Country Club three times a year, and has one summer event. featuring Minnesota Commissioner of Health The SPA is open to Twin Cities Medical Society Edward Ehlinger, M.D., MSPH as the guest Members age 65 and over. If you are interested speaker. Dr. Ehlinger spoke on the Health of the in joining please contact Andrea Farina at (612) State. The presentation was highly informative. 623-2885 or afarina@metrodoctors.com. There were many questions asked by the members resulting in engaging dialogue between the Commissioner and the members. The group also recognized Richard Pfohl, M.D. as the associationâ&#x20AC;&#x2122;s outgoing president and welcomed Richard Anderson, M.D. as the incoming president of the Senior Physicians Association for 2012. We are very appreciative of the From left: Richard Anderson, M.D., Commissioner Edward work Dr. Pfohl has done during Ehlinger, M.D., MSPH, and Richard Pfohl, M.D.
LUIS ALBERTO VILLAR, M.D., age 62, passed away on November 11, 2011. Dr. Villar began studying medicine at the Universidad de Valladolid in Spain while playing professional soccer before coming to the United States in 1975. Dr. Villar did a fellowship in infectious diseases at the University of Iowa after two residencies in Pennsylvania and Ohio. He joined Dr. Gary Kravitz at St. Paul Infectious Disease Associates in 1987 and held a position as an epidemiologist for HealthEast. Dr. Villar has been a member since 1988. WEN Y. YUE, M.D., passed away on October 19, 2011 at the age of 92. Dr. Yue came to Minnesota in 1948 starting his residency at the Glen Lake Sanitarium. He became an anesthesiologist and practiced at the Veterans Hospital retiring in 1994. In addition, he taught at the University of Minnesota and had a private practice for acupuncture. Dr. Yue has been a member since 1955. MetroDoctors
The Journal of the Twin Cities Medical Society
CAREER OPPORTUNITIES
See Additional Career Opportunities on page 30.
W
Boating, Beethoven, Bluffs and more! www.winonahealth.org
Join our progressive healthcare team, full-time physician opportunities available in these areas: t Emergency Medicine t Family Medicine t Hospital Medicine
t Internal Medicine t Orthopedics
t Pediatrics t Urgent Care
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Contact Cathy Fangman t cfangman@winonahealth.org .BOLBUP "WF t Winona, MN 55987 t 800.944.3960, ext. 4301 t winonahealth.org January/February 2012
29
New Members Lori R. Arnesen, M.D. Dermatology Consultants, P.A. Dermatology Laurel E. Cederburg, M.D. HealthPartners – Como Clinic Pediatrics Josser E. Delgado Almandoz, M.D. Consulting Radiology, Ltd. Radiology Edward John English, M.D. Minnesota Healthcare Network Family Medicine John T. Filipovich, M.D. St. John’s Hospital Family Medicine, Emergency Medicine Ethan M. Fruechte, M.D. North Memorial Heart and Vascular Institute Cardiology, Cardiac Electrophysiology John C. Kluznik, M.D. Minneapolis Clinic Assoc. in Psychiatry Psychiatry Michael S. Madsen, M.D. Midwest Medical Examiner’s Office Anatomic Pathology Jason P. Raasch, M.D. Midwest Immunology Clinic Allergy and Immunology Ayesha Rashid, MB, BS St. Paul Infectious Disease Associates Internal Medicine, Infectious Diseases Molly E. Raske, M.D. St. Paul Radiology Radiology Ratma A. Reda, M.D., Ph.D. Edina, MN Psychiatry Silvia D. Romero, M.D. Ramsey County Mental Health Center Minnesota Integrative Psychology & Psychiatry Psychiatry
Thinesh Sivapatham, M.D. St. Paul Radiology Radiology
Heidi L. Thorson, M.D. Minnesota Perinatal Physicians Obstetrics/Gynecology, Genetics
Angela W. Tai, M.D. St. Paul Radiology Radiology
Cory A. Wulf, M.D. Twin Cities Orthopedics Orthopedic Surgery
CAREER OPPORTUNITIES
See Additional Career Opportunities on page 31.
Internal Medicine? Family Medicine?
Yup.
NEW clinic in Mahtomedi, MN? Internal and Family Medicine Opportunities Stillwater Medical Group is an 90+ provider multi-specialty group practice affiliated with Lakeview Hospital. For more than 50 years we have been providing comprehensive healthcare services with locations in the St. Croix Valley, just east of the Twin Cities metro area.
Internal and Family Medicine Physician Opportunities: Stillwater Medical Group has exciting new Internal and Family Medicine Physician opportunities at our NEW Mahtomedi, MN clinic opening Fall 2012! Additional opportunities also available in Stillwater, MN. Mahtomedi, MN? (Ma-toe-me-dye) So what if you can’t pronounce it? We can help with that.Mahtomedi is located in Washington County, on the east shore of White Bear Lake. Residents appreciate the community’s small town charm, lakeside flavor, and close proximity to the Twin Cities Metropolitan Area. In addition, the Mahtomedi School District and other area colleges offer excellence in education.
For further information please contact: Patti Lewis, Director Human Resources 1500 Curve Crest Blvd, Stillwater MN (651) 275-3304, plewis@lakeview.org stillwatermedicalgroup.com
We’ll make it all better.
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January/February 2012
MetroDoctors
The Journal of the Twin Cities Medical Society
CAREER OPPORTUNITIES
Please also visit www.metrodoctors.com for Career Opportunities.
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With just one click you will ďŹ nd information on the latest TCMS news, events and legislative issues; Board and committee actions; past issues of MetroDoctors; and new career opportunities!
MetroDoctors
The Journal of the Twin Cities Medical Society
January/February 2012
31
LUMINARY of Twin Cities Medicine By Marvin S. Segal, M.D.
PATRICK C. J. WARD, M.D. [It was dusk in Donegal, a village of 600 souls. The Irish lad trudged quickly home to practice the piano lesson he’d just taken. His home practice session was nearly silent, save for the muffled tapping of the boy’s fingers on a simulated cardboard keyboard and the soft humming of the lad himself. There was no piano in that modest Irish home.] In 1959 at the National University of Ireland, Dr. Patrick C. J. Ward received his medical diploma with honors. There followed, in Chicago, Boston and our U of M, post graduate training in Anatomic Pathology and Clinical Laboratory Medicine with an emphasis on Hematology — all three disciplines in which he holds board certification. After U.S. Air Force medical duty, Dr. Ward became the Chief of Pathology and Laboratories at the Minneapolis Mount Sinai Hospital — a position he held for 16+ years. While there, he engaged a parallel career in academics, attaining the rank of Professor which was swiftly followed by the awarding of an Endowed Chair of Pathology at the U of M. [A few years later, on an impulse and still in Europe, the youthful chap who one day would become a physician and who craved to actually have a piano of his own, commissioned the small tattoo of a grand piano to be placed on his anterior chest — so he would never forget its importance and his wish to one day own such a musical instrument.] While at Mount Sinai and the U, Dr. Ward created a comprehensive course in Laboratory Medicine along with colleagues Drs. Charles Horwitz and Desmond Burke. The course, designed to teach which lab tests would provide the most efficiency and value in a given clinical setting, soon became so popular with students that a lottery became necessary to determine which of them could attend during the three offerings each year. Numerous distinguished teaching awards were jointly presented to those three educators as a result of their diligent and practical efforts. [The 60-year-old tattoo remains. Few people who have not paid Patrick’s 25 cent “viewing charge” have ever seen it. And not enough people have been privileged to experience his accomplished musical talents on his very own beloved concert grand
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January/February 2012
keyboard. The prize he sought as a youth was his … and would be forever.] Dr. Ward served as chief of pathology at the U of North Dakota and U of M Duluth — the latter, a position he‘s held for a quarter of a century. His remarkable creativity had switched from clinical medicine to Molecular Pathology, but dedication to his students continued as he has been serially honored as Basic Science Teacher of the Year and with national Distinguished Teaching Awards from the American Society of Clinical Pathology. Sandwiched between his 47 published papers, nine book chapters, four text/atlas authorships and national editorial responsibilities has been Pat’s love of fishing in Galway Bay, puffing on cigars, driving his Hummer II, playing poker and further improving his accomplished piano techniques. He is a respected microphotographer, a sought-after visiting professor and has been further honored as a Fellow of Faculty of Pathology in the Royal College of Physicians of Ireland. [It’s evident that our Luminary has demonstrated the same resolve throughout his life as that exhibited when a very young person — diligence, perseverance and brilliant creativity. Thousands of young physicians have learned “at his knee.” Long after Pat’s upcoming official retirement, the echo of his rich Irish brogue and his conveyed wisdom will continue to benefit their work. And … he’ll still be writing (a new definitive Blood Atlas) and enthralling his fortunate grandchildren with that beautiful music.] This last page series is intended to honor esteemed colleagues who have contributed significantly to Twin Cities medicine. Please forward names of physicians you would like considered for this recognition to Nancy Bauer, managing editor, nbauer@metrodoctors.com.
MetroDoctors
The Journal of the Twin Cities Medical Society
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