MN Physician December 2016 by Minnesota Physician Publishing

Vo l u m e X X X , N o . 9 D e c e m b e r 2 016

The SMART program A novel way to decrease burnout By Richa Sood, MD, and Amit Sood, MD

Balancing tensions Improved chronic disease management By Audrey Hansen, BSN, MA, PMP; Sarah Horst Evans, MA; and Claire Neely, MD

he Triple Aim of better care, better health, and lower cost challenges clinicians and care systems to constantly improve. Pursuing these aims often uncovers underlying tensions; seemingly opposing forces that complicate how best to accomplish these goals, too often leaving care systems frustrated with their ability to improve

outcomes, and physicians and others feeling blamed for slowing progress. The Institute for Clinical Systems Improvement (ICSI) has experienced first hand how these tensions manifest themselves. Over the last several

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ealth care professions are currently experiencing an epidemic level of burnout with over 50 percent of physicians reporting at least one burnout symptom. Burnout is associated with absenteeism, turnover, early retirement, increased rate of medical errors, and a decrease in patient satisfaction. Organizational level interventions to decrease and optimize physician workload, while helpful, are not always feasible or effective. Several interventions to enhance individual stress management skills have been tested with modest efficacy. A novel resiliency enhancement intervention, the Stress Management and Resiliency Training (SMART) program, that is anchored in neuroscience and designed as a scalable program with high effect size, offers a potential solution. Combining SMART with organizational approaches may offer an effective long-term strategy to decrease health care provider stress and burnout. This article provides the rationale, evidence of efficacy, and features of the SMART program.

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Rapid Response | Critical Care Life Link III is a great Midwest model of nine hospital systems cooperatively delivering the goals of the Triple Aim. These hospital systems are member-owners of Life Link III:

Life Link III operates six helicopter bases that include Alexandria, Blaine, Cloquet, Hibbing, and Willmar, Minnesota, and Rice Lake Wisconsin. The companyâ&#x20AC;&#x2122;s helicopter and airplane services provide on-scene emergency response and inter-facility transport for patients requiring critical care. Life Link IIIâ&#x20AC;&#x2122;s transportation services are accredited by CAMTS (Commission on Accreditation of Medical Transportation Services), ensuring the highest standards of quality and safety are met.

800-328-1377 www.lifelinkiii.com

MINNESOTA PHYSICIAN DECEMBER 2016

www.lifelinkiii.com

DECEMBER 2016 • VOLUME XXX, NUMBER 9

COVER FEATURES Balancing tensions Improved chronic disease management

The SMART program A novel way to decrease burnout

By Audrey Hansen, BSN, MA, PMP; Sarah Horst Evans, MA; and Claire Neely, MD

By Richa Sood, MD, and Amit Sood, MD

DEPARTMENTS CAPSULES

MEDICAL FACILITY DESIGN

MEDICUS

INTERVIEW

Lean process analysis in clinic design Efficiency equals profitability

Caring for the critically ill

Robert Shapiro, MD Hennepin County Medical Center

RESEARCH

Addressing health disparities The role of demographic research

By Dylan Galos, MS, and Dimpho Orionzi

By Daniel J. Abeln, MArch, MBA, and Chad Frost, BSME, BSEM

ORGANIZED MEDICINE

Joining a professional organization What are the benefits?

By Nick Hernandez, MBA, FACHE

PROFESSIONAL UPDATE: NEUROLOGY

MEDICAL EDUCATION

Cervical total disc replacement Better outcomes and cost savings

The changing state of health care Training future leaders

By Charles R. Watts, MD, PhD

By Susan E. McClernon, PhD, FACHE

SPECIAL FOCUS: SENIOR AND LONG-TERM CARE Montessori Inspired Lifestyle 20 A new paradigm for dementia care

Early detection of Alzheimer’s 22 Having a diagnosis matters

By Cameron J. Camp, PhD

By Michael H. Rosenbloom, MD; Deb McKinley, MPH; and Michelle Barclay, MA

www.mppub.com

PUBLISHER Mike Starnes | mstarnes@mppub.com EDITOR Lisa McGowan | lmcgowan@mppub.com ASSOCIATE EDITOR Richard Ericson | rericson@mppub.com ADVERTISING DIRECTOR Dale Decker | ddecker@mppub.com ART DIRECTOR Sunshine Sevigny | sunny@mppub.com OFFICE ADMINISTRATOR Amanda Marlow | amarlow@mppub.com Minnesota Physician is published once a month by Minnesota Physician Publishing, Inc. Our address is 2812 East 26th Street, Minneapolis, MN 55406; phone 612.728.8600; fax 612.728.8601; email mpp@ mppub.com. We welcome the submission of manuscripts and letters for possible publication. All views and opinions expressed by authors of published articles are solely those of the authors and do not necessarily represent or express the views of Minnesota Physician Publishing, Inc. or this publication. The contents herein are believed accurate but are not intended to replace medical, legal, tax, business, or other professional advice and counsel. No part of the publication may be reprinted or reproduced without written permission of the publisher. Annual subscriptions (12 copies) are $48.00/ Individual copies are $5.00.

DECEMBER 2016 MINNESOTA PHYSICIAN

CAPSULES

Drugs Given in Medical Settings Greatly Affect Rising Costs The Minnesota Department of Health (MDH) and the PRIME Institute at the University of Minnesota have partnered on a new analysis that shows that drugs given in medical settings—such as treatments for cancer, multiple sclerosis, rheumatoid arthritis, and autoimmune disease—are having a substantial impact on rising drug costs. They analyzed claims data from 2009 to 2013 and discovered that the spending growth for drugs given in medical settings was almost three times more than the spending growth for drugs from pharmacies—35.5 percent and 13.5 percent. “Minnesota is one of the first states in the nation to show how drugs delivered in medical care settings are increasingly important—and not well understood—drivers of health care costs,” said Ed Ehlinger, MD, Minnesota commissioner of health. “We are hopeful that this first analysis from

a planned series of publications will help insurers and policy makers find solutions for managing unsustainable trends.” The analysis showed that Minnesotans had an average of 15 prescription claims a year that average out to about $90 each. Retail and other types of pharmacies filled about 80 percent of drug claims, while the remaining approximately 20 percent were given in medical settings. Total drug spending for Minnesotans with health insurance was a total of $7.4 billion in 2013, growing 20.6 percent since 2009— twice the rate of inflation. “Employers are very concerned about the pressure that both the unjustifiable cost and rate of increase in price and use of ‘specialty drugs’ have on their ability to provide affordable benefits to their employees and family members,” said Carolyn Pare, president and CEO of Minnesota Health Action Group. “We need to know that patients are getting the right drug, at the right time, in the right place.” Drugs given in medical settings only

MINNESOTA PHYSICIAN DECEMBER 2016

accounted for about 20 percent of all drug claims from 2013, but accounted for more than half of the spending growth from 2009 to 2013. The average cost for drugs at pharmacies increased about 6.4 percent, due in part to new, lower cost generic drugs. In contrast, the average cost for drugs given in medical settings increased 36.8 percent. “The faster growth for drugs in medical settings is largely due to high drug prices and faster cost growth than for drugs delivered by retail pharmacies,” said Stefan Gildemeister, state health economist. “However, these medications are often newer, innovative drugs that are given by injection and do not have lower cost generic alternatives.”

MHA to Continue Patient Safety Improvements The Minnesota Hospital Association (MHA) has been selected by The Centers for Medicare and Medicaid Services (CMS) as one of 16

organizations across the U.S. to receive a Hospital Improvement Innovation Network contract to continue efforts to reduce preventable hospital-acquired conditions and readmissions in the Medicare program. MHA will receive $4.25 million each year for the next two years to continue the statewide quality improvement work that began in 2011 with the Partnership Hospital Engagement Network, which sought to reduce patient harm from hospital-acquired conditions in 10 focus areas. Through 2019, the Hospital Improvement Innovation Networks will work to achieve a 20 percent decrease in overall patient harm and a 12 percent reduction in 30-day hospital readmissions as a population-based measure from the 2014 baseline. They will also be required to address a wide variety of topics, including adverse drug events, central-line associated urinary tract infections, catheter-associated urinary tract infections, clostridium-difficile infections, injuries from falls and immobility, pressure ulcers,

sepsis and septic shock, surgical site infections, venous thromboembolism, and ventilator-associated events. CMS will monitor and evaluate the activities of the networks to ensure that they are generating results and improving patient safety. “We have made significant progress in keeping patients safe—an estimated 2.1 million fewer patients harmed, 87,000 lives, and nearly $20 billion in cost-savings from 2010 to 2014—and we are focused on accelerating improvement efforts,” said Patrick Conway, MD, acting principal deputy administrator and chief medical officer at CMS. “The work of the Hospital Improvement Innovation Networks will allow us to continue to improve health care safety across the nation and reduce readmissions at a national scale—keeping people as safe and healthy as possible.”

Study Connects First-Time Kidney Stone Patients, Chronic Kidney Disease A study at Mayo Clinic has found a connection between patients with firsttime kidney stone formers and chronic kidney disease, showing a persistent decline in kidney functioning after a first case of kidney stones. Researchers assessed a group of 384 individuals three months after their first case of kidney stones to study the effect of kidney stones on kidney function. Compared to a control group, those who had kidney stones maintained higher levels of the blood marker cystatin C and urine protein. Both are connected with higher risk of chronic kidney disease. “Even after adjusting for other risk factors, including urine chemistries, hypertension, and obesity, we still found that those with a kidney stone episode had subsequent abnormal kidney function,” said Andrew Rule, MD, a lead author of the study. “This helps us better understand the long-term implications of kidney stones beyond recovery time.” Kidney stones affect about 7 percent of adults in the U.S., and that rate has been rising. Previous studies have shown a long-term risk of chronic kidney disease in individuals who have had kidney stones, but kidney function

immediately after a first-time kidney stone event had not yet been assessed. “This research shows that the implications of kidney stones may go beyond the discomfort they are so often associated with,” said Rule. “Prevention of kidney stones may be beneficial for a person’s overall kidney health.” The authors note that further study is needed to determine whether these early kidney function findings in stone formers contribute to the longterm risk of chronic kidney disease and end-stage renal disease.

Ridgeview Medical Center Buys Minnesota Valley Health Center Ridgeview Medical Center is purchasing the Minnesota Valley Health Center (MVHC) building and grounds effective Jan. 1, 2017. The City of Le Sueur is the current owner after the Le Sueur City Council unanimously approved a lease agreement approving the deal on Nov. 14. MVHC signed an affiliation agreement with Ridgeview earlier this year and boards and leadership of the organizations have been meeting for months to finalize the details. It will become a wholly owned subsidiary of Ridgeview and will be renamed the Ridgeview Le Sueur Medical Center. Mayo Clinic Health System subleases a clinic space on the property, and will continue to do so through the lease end date of Aug. 30, 2018. Landlord responsibilities will transfer to Ridgeview. In addition, Ridgeview will take over the operation of the Le Sueur ambulance service, which is currently volunteer-run. “This is an exciting time for all of us,” said Pam Williams, president and CEO of MVHC. “MVHC and Ridgeview share a common vision to provide accessible, local, and high quality patient-centered care. With this agreement and support from the City of Le Sueur, we are committing to keeping health care services in Le Sueur and doing what is best for our patients, community members, staff, and our organizations.” Previously, MVHC was affiliated with Duluth-based Essentia Health Capsules to page 6 DECEMBER 2016 MINNESOTA PHYSICIAN

Capsules from page 5

from 2009 through spring of 2015 when they came to a mutual dissolution agreement.

Hospitals Continue to See Declines in Uncompensated Care Costs Uncompensated care at Minnesota hospitals has dropped 16.7 percent since the implementation of the Affordable Care Act (ACA) in 2013, according to a new analysis by the Minnesota Department of Health. Uncompensated care has two components—charity care, or care that hospitals provide without expecting payment, and bad debt, or payment that hospitals expect for care provided, but do not receive. Bad debt increased in 2014 (the first year of the ACA) but declined in 2015. From 2014 to 2015, bad debt dropped by $18.5 million (a 10.2 percent decline) and charity care dropped by $18.7 million (a 15 percent decline). That overall 12 percent

decline over one year brought uncompensated care down to levels similar to those in 2008. The primary factor in spending for both components is lack of insurance coverage. However, bad debt is also accumulated by people with insurance coverage who struggle with cost sharing, such as through high deductible policies. Overall uncompensated care costs decreased for both insured and uninsured patients in 2015, from $129 million to $118 million and from $192 million to $149 million respectively. “While we still have significant challenges to ensure that all Minnesotans have access to high-quality health care at affordable rates, this drop in charity care and bad debt is a positive sign that reflects our progress in reducing the number of Minnesotans going without coverage,” said Ed Ehlinger, MD, Minnesota commissioner of health. “We need to continue our work in addressing the underlying causes of high health care costs through smart reforms, and at the same time we need to sharpen our focus on keeping people healthy.”

MINNESOTA PHYSICIAN DECEMBER 2016

Most hospitals saw a decline in uncompensated care costs, with 97 reporting decreases, however 34 saw an increase. Hennepin County Medical Center was the largest provider of uncompensated care, followed by the two Mayo Clinic hospitals in Olmsted County.

Firstlight to Expand Mora Campus FirstLight Health System has begun work on a $40 million expansion of its hospital campus in Mora. Preconstruction and site work, including moving power lines, installing fiber optics, and removing houses, is being completed this fall. The health care system will officially break ground on the four-phase project this spring. The first phase includes moving rehabilitation services to the building’s southwest side and adding a second floor to house 23 new inpatient and birthing rooms. The second phase involves moving the existing emergency department and helipad to the

northeast corner of campus and remodeling the existing lab, imaging, materials management, and information technology areas. In phase three, a new community pharmacy will be constructed, as well as a new public dining and common area. It also includes a new centralized entrance from State Hwy. 65, a relocation of the eye clinic from downtown, and changing the current birthing center to infusion rooms for better patient privacy. The final phase will optimize parking areas and patient drop-off and pick-up areas. The project will take about two years to complete and result in about 200,000 finished square feet, compared to FirstLight’s current 130,000 finished square feet. It aims to address necessary growth and upgrades. FirstLight notes that over the past seven years, emergency department visits have increased 11.3 percent and rehabilitation visits have increased by 87 percent. In addition, the construction will allow inpatient rooms to be remodeled for new technology and plumbing, which they have not been since the 1970s.

MEDICUS PATRICK J. FLYNN, MD, oncologist/hematologist and director of research at Minnesota Oncology and Hematology, PA, has received the 2016 Charles Bolles Bolles-Rogers Award from the Twin Cities Medical Society Foundation Board. Candidates are nominated by their colleagues for achievement or leadership in medicine, contributions to clinical care, teaching and/ or research. Flynn is also the medical director of the Patrick J. Flynn, Autologous Bone Marrow and Stem Cell Transplant MD Center at Abbott Northwestern Hospital and is a clinical professor at the University of Minnesota. In addition, he has served for 30 years as the principal investigator at the Metro-Minnesota Community Clinical Oncology Program. He earned his medical degree at the University of Minnesota Medical School. ANNE EDWARDS, MD, has been named senior vice president, primary care and subspecialty pediatrics at the American Academy of Pediatrics (AAP), a role in which she will lead pediatric practice-related initiatives and programs for AAP members. Previously, Edwards worked with Park Nicollet Health Services where she practiced general pediatrics and served as chair of pediatrics and co-chair of children’s health initiatives Anne Edwards, at HealthPartners. She has also held several leadership MD positions with the AAP, most recently serving as co-chair of the Task Force on Pediatric Practice Change and chair of the Committee on State Government Affairs. She also served as president of the Minnesota Chapter of the AAP from 2006 to 2010. Edwards earned her medical degree and completed her pediatric residency at the University of Minnesota. FAWN ATCHISON, MD, PHD, chief of staff at Cuyuna

Regional Medical Center, has been inducted into the Academy of Science and Engineering at the University of Minnesota–Duluth’s Swenson College of Science and Engineering, which was established in 2002 to recognize distinguished alumni and friends of the College who have distinguished themselves through commitment and leadership in their chosen profession. Fawn Atchison, She is an anesthesiologist and serves on Cuyuna MD, PhD Regional Medical Center’s board of directors, where she is also medical director of education. Atchison earned her combined medical degree and PhD through the medical scientist training program at Duke University Medical Center. She then completed a fellowship in cardiovascular anesthesiology and her graduate medical training in the anesthesiology residency program at Mayo Clinic in Rochester, where she was elected as chief resident by her faculty and peers in 2008. DAVID ABELSON, MD, ha s been na med a s t he

next president of the Institute for Clinical Systems Improvement (ICSI) board of directors. Previously, he served with Park Nicollet Health Services for more than 30 years, where he held several leadership positions. Most recently, he served as president and CEO of Park Nicollet and executive vice president of HealthPartners before retiring in 2014. He was also a member of the David Abelson, Governor’s Task Force on Medical Education in the MD State of Minnesota in 2014. Abelson has been on the boards of VigiLanz Corporation; HealthPartners, including Quality and Transformation committees, Regions Hospital, and HealthPartners Institute of Research and Education; Park Nicollet Health Services; and the Minnesota Hospital Association. He was in private practice at Internal Medicine Physicians PA and received his medical degree from the University of Minnesota. DECEMBER 2016 MINNESOTA PHYSICIAN

INTERVIEW

Caring for the critically ill

ROBERT SHAPIRO, MD Hennepin County Medical Center Dr. Shapiro is a member of the Division of Pulmonary and Critical Care in the Department of Medicine at Hennepin County Medical Center. He is the program director for the Critical Care Fellowship at Hennepin County Medical Center and co-director of the Medical Intensive Care Unit, Hennepin County Medical Center. He is also an assistant professor at the University of Minnesota.

Critical care medicine is a relatively new specialty. What can you tell us about how it began and why? Critical care medicine as a field developed gradually along with the ability to keep people alive by supporting multiple organ systems, which required continuous monitoring and specialized, highly skilled medical care. The first ICUs in the U.S. appeared in the late 1950s. As technology became more specialized and complex, a new group of physicians emerged composed largely of specialists in internal medicine, surgery, and anesthesiology with an interest and the expertise to provide care in this complex environment. I believe the first critical care training program was started in the early 1960s.

physician communication, family meetings, shared decision making, and palliative care involvement in the ICU, we still have a way to go.

Please tell us about the fellowship program you direct at HCMC. The Critical Care Medicine Fellowship at HCMC is a two-year fellowship that provides advanced clinical training for those planning to practice critical care medicine as their primary specialty. The fellowship includes rotations at four leading health care systems in the Twin Cities: HCMC, Abbott Northwestern, Methodist, and Fairviewâ&#x20AC;&#x201C;University. We accept two fellows per year. Fellows have ample opportunity to acquire and improve procedural skills, manage critically ill patients, and develop leadership abilities. Our program includes trauma situations, advanced disease states, pre- and post-transplant, neuro-critical care, extracorporeal life support, and advanced cardiac-intensive opportunities. Training at public, private, and university hospitals ensures exposure to a broad spectrum of patients and pathology; HCMC rotations provide a diverse, multi-cultural environment and perspective on patient care. In their second year, fellows are actively involved in ICU quality improvement and original research.

Finally, it has become clear that survivors of critical illness often are left with major physical and psychological disability. Despite this recognition, what we can do as intensivists to improve outcomes and quality of life in survivors of critical illness remains unclear. And structured, funded programs to deal with these problems after discharge from the ICU need to be developed.

Delirium is extremely common in the ICU and has been linked to longer ICU stays and mortality. While the ICU community has become better at recognizing and naming delirium, we are still left wanting for effective prevention and treatment. It remains unclear how much delirium can be minimized/prevented by changing our practices in the ICU, but it seems likely that aggressive physical therapy, less sedation with the most appropriate sedatives, more interaction with people, and improved sleep quality could all play a role.

What kinds of interactions do you have with other medical specialties? In order to provide the best care of the critically ill patient, the intensivist must interact frequently with other specialties. Support of multiple organ systems, diagnosis and treatment of infections, management of surgical problems that result in critical illness or arise during the ICU stay, interpretation of advanced diagnostic imaging and diagnosis, and management of life-threatening toxicology problems require consultation and input from multiple medical and/ or surgical specialties. While input from a variety of specialties is often required, the critical care physician remains the primary physician responsible for the What are the biggest challenges that critical care patientâ&#x20AC;&#x2122;s care. It is the responsibility of the intensivist faces as a specialty? Burnout of ICU caregivers (both physicians and to ensure effective and frequent communication with nurses) is increasingly being recognized as a major consultants, and coordinate and implement their problem. A recent article by the Critical Care Societies multiple recommendations when appropriate. Collaborative reviews the symptoms, prevalence, risk factors for, and consequences of burnout syndrome. A critical care physician must regularly make very They report that up to 45 percent of critical care rapid life-and-death decisions. How do you use the physicians have symptoms of severe burnout differential diagnosis process in these cases? Without question there are times where rapid syndrome, and that critical care physicians have the highest prevalence of burnout when compared to decision-making is required in the ICU. Fortunately, other types of physicians. The review also discusses the differential diagnosis in these situations is interventions to prevent burnout, and in my opinion often relatively small, and the extensive monitoring is a must read for physicians and trainees in critical and bedside diagnostic modalities immediately care medicine. available in the ICU allow us to make appropriate We have progressed as a specialty to a point where and timely interventions. For example, take the we are much better at keeping people alive than we are patient who becomes acutely hypotensive on the at getting them better. We still expend an inordinate ventilator. The major differential diagnoses in this amount of our medical resources in the last months of situation that might require urgent intervention are life, and much of this occurs in the ICU. While there tension pneumothorax, gas-trapping/auto-PEEP, has been progress over the last decade on improving pulmonary embolism, acute left ventricular failure,

MINNESOTA PHYSICIAN DECEMBER 2016

Gun violence is a growing public health concern. What can you add to this discussion from your work in critical care medicine? We do not care for many victims of gun violence in the MICU, but I spoke to one of our surgical intensivists, Dr. Chad Richardson, who said that HCMC has seen an increase in penetrating trauma (which includes shootings and stabbings) in 2016 over 2015. We should do everything we can as individuals and as a society to prevent gun violence and its attendant morbidity and mortality.

sedatives), attention to fluid balance, and is very low. In these situations, palliative care avoiding unnecessary procedures and their and at times an ethics consultation can be attendant complications come to mind as helpful. things that could be avoided. For outpatients it is not enough exercise, What are some examples of how precision preventive medical and mental health care, medicine impacts your specialty? The ICU has yet to really feel the impact poor patient compliance with that care, along with too much tobacco, alcohol, recreational of precision medicine but the potential in this area is tremendous. Take for example the use drugs, and obesity. of corticosteroids for ARDS. While a large randomized controlled trial was unable to show a benefit, there is a definite sense that We are much better at there are some patients who benefit. As with keeping people alive than a lot of our potential interventions, the trick we are at getting them better. is to be able to sort out which patients would benefit from a therapy, which is what precision medicine promises. In the meantime, we still have to rely on randomized controlled trials Critical care physicians face many and the experienced intensivist to determine complicated social and ethical issues. which patients might benefit from a given Please tell us about some of these issues. Much of the critical illness we see at therapy or intervention.

By the time you see a patient in the ICU, they are seriously ill. What are the most common things you see that could be avoided? In already hospitalized patients, progression of disease or unanticipated complications can progress to critical illness even when care is meticulous. Nevertheless, careful use and monitoring of dangerous drugs (insulin, anticoagulants, narcotics, and

HCMC is caused or exacerbated by social ills: homelessness, poverty, chemical dependency, and mental illness. While we often can get people through their acute illness, the lack of societal resources to address the underlying issues can be extremely frustrating. Many of our patients lack family or other surrogate decision makers. This can pose real ethical dilemmas for the critical care team trying to determine the most appropriate plan of care when the likelihood of an acceptable outcome

and hypovolemic shock. A brief physical exam, assessment of ventilator mechanics and limited bedside cardiac ultrasound evaluation performed by the intensivist (all of which can be done in a matter of minutes) will usually lead to the appropriate diagnosis and timely intervention.

What does the future hold for critical care medicine? With an aging population and an everincreasing ability to intervene in lifethreatening illness, I suspect critical care medicine will continue to grow. Given the shortage of critical care trained physicians, there will likely be increased use of advanced practice providers in the ICU, with the intensivist acting in a more supervisory role.

DECEMBER 2016 MINNESOTA PHYSICIAN

Balancing tensions from cover

years, practice facilitators from ICSI teamed with clinics throughout Minnesota on a number of special projects, all targeted to improve clinical care for patients with chronic disease. As we partnered with these clinics, we identified five recurring tensions: • Standardization vs. adaptation • S ingle disease management vs. chronic disease management uality improvement • Q (transformation) vs. quality reporting (compliance) • C ommitment to innovation vs. capacity for change • Leadership nimbleness vs. constancy of purpose This article describes these tensions, why they exist, and what steps clinics took to manage these tensions to make steady progress in improving care.

Standardization vs. adaptation The first tension is between the benefits of standardization through the use of evidence-based medicine and systems of care vs. the need to adapt care recommendations based on the needs and values of each individual patient. This creates a tension sometimes expressed as “cookbook medicine” on one side and physician “autonomy” on the other. Administration and staff with mandates to improve quality, or implement a specific care pathway, sometimes attempt to create standardized processes without involving physicians, resulting in requirements that did not get the needed “buy-in,” which creates discord between the system and individual practice. How clinics addressed this: Modern guidelines include specific steps in care processes where customization of care should occur, such as through the use of shared decision-making

and other patient engagement strategies. Standardization can be used to assure that these discussions reliably and effectively occur and that the decisions made are accurately and reliably implemented. For example, this entails systematically assuring

Chronic disease management is a continually expanding component of medical care. that patients have the information they need about statins, having a discussion to understand the risks and benefits they might see from starting the medication, and ensuring that the decision is systematically implemented, including routine follow-up. To make progress toward this end, clinics created a forum to engage physicians in collaborative conversations about evidence-based recommendations and models of care. This forum included processes to be systematized and a structure for physician consensus for approving and implementing practice changes. All staff engaged in discussions on implementing evidence-based care to assure that roles and responsibilities were understood and all team members were able to participate at the top of their license. Single disease management vs. chronic disease management Chronic disease management is a continually expanding component of medical care, with an ever-increasing number of care improvement programs, guidelines, and accountability measures being presented to clinics, primarily focused on single disease states. Clinics are constantly expected to implement specific disease programs that have been proven effective in other settings. Clinics may be able to say, “Here’s what we do for a hypertension patient,” and “Here’s what we do for a patient with depression,” and show

MINNESOTA PHYSICIAN DECEMBER 2016

separate registries used for each condition. However, they have not taken advantage of or even understood their ability to build care pathways that can be used for multiple conditions. A single pathway for all chronic conditions is seen as too complex to

design and too complicated to implement. How clinics addressed this: Clinics used process mapping to understand the care processes they had in place for chronic conditions, identifying similarities and commonalities. This helped them see that a “system” for chronic condition management includes the common steps of pre-visit planning, rooming protocols, office visit activities, between visit care, registry work, and patient self-management plans. Using and reusing well-established disease-specific processes (e.g., what works well with diabetes or asthma) and adding new chronic condition care processes (e.g., for hypertension) sped up implementation. A single registry for all conditions eases work and better supports the care of patients with multiple chronic conditions. Quality improvement (transformation) vs. quality reporting (compliance) Another identified tension is between the data and reports required by various organizations for accountability and payment vs. the data and reports needed to support care improvement activities. Producing reports to comply with myriad external obligations has taken up a major portion of “quality department” work. This move toward compliance reporting leaves less capacity for collecting and analyzing data needed to evaluate improvement activities and change efforts. In many

smaller clinics, the quality department is a single person or small team held accountable for accomplishing all improvement work in addition to compliance reporting. How clinics addressed this: Wit h the help of practice facilitators, clinics undertook “refresher” courses in improvement science, to understand how to build local improvement teams, design and conduct small tests of change, and collect and analyze the realtime data needed to understand if the tested change resulted in an improvement. Clinics reviewed the data that was available from various sources and determined what was and wasn’t valuable for understanding these tests of change. Clinics developed simple, but useful data collection tools and used run charts and other foundational analytics to show improvement and share success with other improvement teams. Commitment to innovation vs. capacity for change This tension causes strain, especially for leadership, as they strive to balance resources needed for innovation, including positioning themselves for new payment models and mandated quality improvement vs. the resources needed to care for patients and conduct business as usual. Our participating clinics are all doing more with less. People are stretched, and dealing with various types of transitions along with changing and competing priorities. Burnout and resource availability have a significant impact. Physicians and other staff may understand and support the need to make change, but feel that they do not have any additional capacity to support the efforts. How clinics addressed this: Leaders began by developing a clear understanding of their priorities and, with operational staff, a clear understanding of current capacity to undertake change. This included the workforce’s base understanding of the knowledge, skills, and tools needed to undertake a change effort. Clinics took the time to

lay the needed foundation, with training on improvement science and structures to agree on models of care, as well as other identified needs. Once improvement projects were begun, reasonable goals were set and the teams held accountable for

they could begin. Answers to these questions were also used when communicating to staff to ensure their understanding of how the change would support organizational goals, and the realization that the change wasn’t a standalone “flavor of

[Leaders] … need to be both nimble and constant.

steady progress. The pace was adjusted in real time, based on anticipated and unanticipated changes that had an effect on the teams (staff turnover, new regulations, holidays, etc.), but continual movement toward goals was expected. Leadership nimbleness vs. constancy of purpose In this time of uncertainty for all of health care, clinic leadership has a responsibility to be prepared for multiple eventualities, and quickly make changes in response to environmental pressures. At the same time, leadership must, to quote W. Edwards Deming, “Create constancy of purpose toward improvement of product and service, with the aim to become competitive and to stay in business, and to provide jobs.” This constancy is particularly important to staff as they experience the discomfort caused by the unsettled environment. The need to be both nimble and constant, creates communication challenges for leaders at all levels.

the month” initiative. Continual leadership support reinforced the importance and connectedness of the work to the organization’s success. Conclusion ICSI continues to actively work with clinics across the state and finds these five tensions to be present across varied clinical settings. We found that it is beneficial for clinics to identify these and other tensions affecting

their systems and understand the burden they place on staff and how they can limit system improvement. The strategies described here were helpful for multiple clinics as they pursued improvements in care, and have broad application. When clinics are able to work creatively with tensions rather than see them as barriers, it results in changes that are supportive of physicians and staff while improving care for patients with chronic diseases.

Audrey Hansen, BSN, MA , PMP,

is project manager/health care consultant at the Institute for Clinical Systems Improvement. Sarah Horst Evans, MA, is project manager/health care consultant at the Institute for Clinical Systems Improvement. Claire Neely, MD, is chief medical offi-

cer at the Institute for Clinical Systems Improvement.

How clinics addressed this: Leaders engaged in thoughtful conversation about the improvement support that ICSI offered. Two key questions were discussed: First, was the offered opportunity in alignment with and clearly supportive of current priorities? Second, did leadership have the capacity to engage in and support the work? The answers to these questions determined whether the clinics chose to engage in the work at all, and if they chose to participate, when DECEMBER 2016 MINNESOTA PHYSICIAN

The SMART program from cover

Stress and burnout The World Health Organization (WHO) has called stress “the health epidemic of the 21st century.” Currently, 83 percent of Americans find their workplace stressful. The top four stressors are money, work (occupation), family responsibilities, and health concerns. Stress is costly for the individual as well as for society. American industries lose an estimated $300 billion annually due to stress-related absenteeism, decreased productivity, employee turnover, excess health care costs, illness, poor morale, and reduced efficiency and performance. A high level of stress is associated with an unhealthy lifestyle, increased disease risk, accelerated disease progression, more frequent symptom reporting, greater health care utilization, and higher mortality.

Health care workers are at a particularly high risk of experiencing occupational stress and burnout due to high expectations, time constraints, long work hours, shift work, tight timelines, heavy caseloads, sleep deprivation, difficult/challenging patients, professional

and a sense of low personal accomplishment. The manifestations of emotional exhaustion may include loss of enthusiasm for work, and a feeling of being helpless and defeated. Depersonalization occurs when health care providers objectify patients, and treat them indifferently.

More than 50 percent of physicians experience burnout.

self-doubt, exposure to suffering and death, and difficult family interactions. Burnout is a state of vital exhaustion related to long-standing organizational stress that results in emotional exhaustion, depersonalization,

With depersonalization, providers may view patients cynically and somehow deserving of their troubles. With low personal accomplishment, there is the tendency to evaluate oneself negatively, feel unhappy about oneself, withdraw from responsibilities, and experience a sense of detachment from work. More than 50 percent of physicians experience burnout. In addition, 82 percent of medical students experience at least one form of distress, and 49 percent of residents start their training already experiencing burnout. The consequences of medical professionals’ anxiety and burnout are very expensive to the system, and lead to absenteeism, job switching, early retirement, increased rate of medical errors, and a decrease in patient satisfaction rates. This is particularly important given physicians’ propensity to underreport mental health issues and delay in seeking help. Managing stress This article outlines two broad strategies to help manage stress and decrease risk of burnout, with a particular focus on a novel approach to stress management that we developed and tested in multiple prospective studies. If we think of stress as a load we have to lift, stress and burnout can be reduced by using

MINNESOTA PHYSICIAN DECEMBER 2016

two approaches: 1) decreasing the load and /or 2) building resilience to enable you to lift the load. Prospective studies of interventions using both these approaches, alone or in combination, as currently offered, show modest efficacy. Decreasing the load Several organizational level interventions have been tested to decrease stress and burnout, including decreasing work hours, optimizing patient load, reducing administrative work, improving relationships, and managing other responsibilities better. These are difficult fixes, though where appropriate and feasible, they need to be applied. However, societal ability to decrease the load, in health care and other professions, quickly reaches ceiling effect because of the business focus on austerity and a “more with less” attitude. Building resilience Resilience is the core strength we use to lift the load of life. Resilience has three aspects: 1) w i t h s t a n d i n g a d v e r s i t y, 2) bouncing back from adversity, and 3) growing despite life’s downturns. Resilience overlaps with hardiness, reflecting toughness, and the ability to recover. Resilience can be seen as an underlying trait, a process, and an outcome. Although resilience can be an innate personality trait, it can also be cultivated. Resilience building is important as it correlates with positive physical health, mental well-being, better relationships, and work performance in both observational studies and controlled clinical trials. Resiliency training programs Several recent meta-analyses have reported on the efficacy of resiliency training for four groups of outcomes: 1) emotional h e a lt h , 2) p hy s i c a l h e a lt h , 3) social well-being, and 4) work performance. Overall, the programs show moderate efficacy for improving emotional health with weak effects on physical health, social well-being, and work performance. Several of the programs have long training times and offer suboptimal

long-term engagement and efficacy. Novel programs that are more scalable, pragmatic, and have large effect size are needed to move the field forward. The SMART approach SM A RT is an innovative approach toward resilience enhancement developed by Sood et al. and tested in several clinical trials. SMART is adapted from Attention and Interpretation Therapy (AIT) and combines neuroscience, evolutionary biology, psychology, and philosophy. SMART has three core components: 1) awareness, 2) attention, and 3) attitude (mindset). Awareness (insight) SMART helps participants understand the neural mechanisms that generate stress, particularly from an evolutionary perspective. It emphasizes educating participants about the brain given our brain’s intimate relationship with generating

stress and hosting resilience. Core awareness involves three neura l v ulnerabilities that deplete resilience: 1) focus, 2) fatigue, and 3) fear. Focus: SMA RT shares a modified network model of the brain pertaining to its higher order functions (attention,

when a person is doing or experiencing what he or she enjoys— generally when the experience is interesting, entertaining, and meaningful. Default mode is that of mind wandering and distracted focus, such as reading a half page in a book without registering any of it. The human

Resilience is the core strength we use to lift the load of life.

thinking, and emotions). The human brain is a complex information processor made of 86 billion neurons. SMART postulates that the brain networks are organized into two modes in which the brain seesaws all day long—focused and default mode. Focused mode is engaged

mind wanders, and can be in default mode for more than half of the day. We experience greater mind wandering on days we feel stressed and aren’t experiencing novelty. This is important because “a wandering mind is an unhappy mind.” Modern day distractions are compounded

by the complexity of our life— an average person these days at any time has 150 uncompleted tasks. Emerging research suggests that this excessive default activity may predispose us to attention deficit, post-traumatic stress disorder, depression, and even cognitive decline. SMART strives to help people spend more time in the focused mode. Fatigue: Research shows that the human brain gets tired after 90 minutes of sustained cognitive effort, particularly when doing something it doesn’t enjoy. Cognitive fatigue is very common given that we do not organize our work day around resting our brain every two hours and a significant proportion of work isn’t engaging or enjoyable. Fatigue initially manifests in subtle ways, such as with a reduction in focus,

The SMART program to page 14

DECEMBER 2016 MINNESOTA PHYSICIAN

The SMART program from page 13

irritability, desire for stimulants such as coffee, and decline in performance and engagement. If fatigue is unmitigated it can lead to severe exhaustion, even predisposition to stroke and

and motivation, multiple times during the day. Fear: Just a few hundred years ago the most common cause of mortality was external injuries. Our ancestors who paid selective attention to threats, either to external physical threats or to words and emotions that sig-

An average person these days at any time has 150 uncompleted tasks.

death. SMART strives to help people develop a discipline so their brain gets short periods of rest before it accumulates extraordinary fatigue. This entails taking a break from planning and problem solving and intentionally relaxing, experiencing uplifting emotions,

naled impending threats, had a greater chance of survival. As a result, we experience an ingrained negativity bias, where we selectively attend, remember, and act on thoughts, words, and actions that threaten our survival, both physically and emotionally.

This default state of the brain with its propensity to wandering attention, fatigue, and negativity bias, while it may not initiate the stress response, perpetuates and multiplies it. For example, at the end of a busy and stressful day, instead of spending rewarding and relaxing time with the family, physicians often spend considerable time passively thinking about their work. Such thoughts are often negative and unproductive. SMART helps decrease these unhelpful ruminations and instead replaces them with more productive and positive thoughts and more intentional presence in the world, through training attention and interpretation. Attention (focus) Each experience in your life has two aspects—attention and interpretation (see Figure 1). Attention brings information through the senses to our brain. The information then is interpreted based on one’s beliefs, preferences, and biases. Instinctive attention spends considerable time in the wandering mode, is superficial, and often not in one’s control. SMART helps participants develop a deeper, sustained, and intentional form of attention. Recognizing that most people struggle

Attention

Interpretation

Figure 1. Each experience in your life has two components: attention and interpretation. We receive information using our attention; this information is then interpreted using our pre-stored constructs. Early in life we have deeper attention (A), but as we become familiar, our attention often becomes quicker and superficial (B).

MINNESOTA PHYSICIAN DECEMBER 2016

with practicing longer forms of meditation, SMART offers only brief spurts of deeper attention, one to three minutes long. These short meditations contain an element of positive emotions that increase their value and effect. Here are a few examples: • Morning gratitude: Before you leave your bed in the morning, think about and send silent gratitude to five people in your life who you know care about you, or who you care about. • Two-minute rule: Give at least two minutes of undivided attention to one person in your life who deserves such an attention but isn’t currently getting it. • Curious moments: Notice one new thing every day in the world around you. • Kind attention: Send silent good wishes to people you meet or see during the day. The total time invested in daily “formal practice” to work on your focus is only about five to 10 minutes, ensuring easy integration into your day. In addition, most of the practices in SMART are relationship centric offering the additional benefit of improving relationships and helping alleviate perceived loneliness. For participants interested in the more conventional meditations, SMART offers several paced breathing meditations designed so participants can practice slow deep breathing at about five breaths per minute. After a few weeks of meditating to achieve deeper attention, participants can begin to work toward improving their quality of thinking (i.e., their mindset). Attitude (mindset) Human thinking and attitude are often judgmental and prioritize greater attention to threats and imperfections. SMA RT guides participants to use five core principles: 1) gratitude, 2) compassion, 3) acceptance, 4) meaning, and 5) forgiveness,

to optimize their thinking and attitude. Each of these principles is summarized here: Gratitude is the acknowledgment and appreciation of life’s blessings. Gratitude isn’t just appreciating the good things that happen in one’s life, but

internally accepts the human limitations in influencing an outcome. The practice of acceptance enhances our objectivity and flexibility, hence our willingness to see things as they are. Acceptance applies to people as well as life situations. Sev-

Table 1. Daily themes to adjust the mindset in the SMART program.

Day

Principle

Monday

Gratitude

Tuesday

Compassion

Wednesday

Acceptance

Thursday

Meaning

Friday

Forgiveness

Saturday

Celebration

Sunday

Reflection/Prayer

also habitually focusing on and seeking out the positive aspects of life. Gratitude is associated with better physical and emotional health in observational studies. Prospective studies show that intentionally practicing gratitude has a significant and meaningful effect on several well-being measures, particularly positive affect. Compassion is feeling another person’s suffering, which often translates into action to relieve that suffering. Compassion enables kind and prosocial actions; however, seeing suffering, particularly suffering that one cannot relieve, can lead to compassion fatigue. The practice of compassion also includes self-compassion, which is associated with greater well-being. Several prospective studies show that learning and practicing compassion can improve life satisfaction. Acceptance is working creatively with what is and expending the energy to fight the problem instead of fighting the self. Acceptance recognizes and

professional help and the help of trusted loved ones and friends might be essential. In the early part of training, each principle is assigned a particular day in the sequence shown in Table 1. As the training continues, each of these principles are accessible every day to help people reframe their lives. Evidence that SMART works SMART has been tested and found efficacious for improving resilience, stress, anxiety, quality of life, and mindfulness in several published studies, including five masters and PhD theses. Several studies show a large effect size (more than one standard deviation improvement) with the intervention for emotional health measures. Additionally, in several completed but unpublished studies, SMART has shown efficacy for improving happiness, health behaviors, and burnout in health care employees. Current

studies are evaluating the efficacy of SMART on the organization of brain networks, gut microbiome, and inflammatory markers. The program is widely offered to health care, support staff, and students at Mayo Clinic. Mayo Clinic is currently developing SMART into a resilience program (Mayo Clinic Resilience) offered from Mayo’s platform. The authors hope and strive to disseminate the science and skills of the SMART program more broadly to help larger segments of the population within health care and other fields.

R i c h a S o o d , M D, is a s s is ta n t professor of medicine at Mayo Clinic in Rochester.  Amit Sood, MD, is professor of medicine at Mayo Clinic in Rochester and the owner of Global Center for Resiliency and Wellbeing.

eral studies have validated the positive physical and emotional health effects of practicing acceptance. Meaning in life and finding a higher meaning helps to connect your daily actions with a larger purpose. With a secure and worthy meaning, you become better equipped to do difficult and repetitive tasks that might otherwise be boring. Pursuing a higher altruistic meaning has many advantages, including improved health and better psychosocial adjustment to adversity. Forgiveness is not justifying, condoning, excusing, or denying a wrong; it is acknowledging that the misconduct happened and choosing to let go of the hurt, for your own benefit. Forgiveness is actually more for the benefit of the forgiver than the forgiven. Voluntarily giving up bitterness has been shown to improve blood pressure, sleep, and immunity and lower heart rate and overall stress. Forgiveness is often not easy and for the most egregious hurts, getting

DECEMBER 2016 MINNESOTA PHYSICIAN

RESEARCH

Addressing health disparities The role of demographic research By Dylan Galos, MS, and Dimpho Orionzi

y a ny measu re, the demographics of Minnesota are changing. The immigrant population of Minnesota is growing, and age distributions and the working population are changing. New residents come to Minnesota from other parts of the United States along with immigrants and refugees from other countries. According to 2016 projections from Minnesota Compass (a social indicators project), the racial and ethnic composition of Minnesota is changing, and the proportion of people of color in the Minnesota population is steadily increasing. Likewise, the age distribution is changing

as well, with the number of adults over 65 expected to almost double by 2030, with other older adults making up 20 percent of our future population (Minnesota Compass, 2016). This increased diversity means that a health care delivery system focused on the values and health behaviors of white, middle-class populations will function best by being inclusive of other groups. With a changing population comes creativity, energy, new ideas, and the opportunity for growth as a society, as well as the potential to make changes in health equity. This requires changing how primary care is delivered to serve a more diverse patient population.

MINNESOTA PHYSICIAN DECEMBER 2016

Understanding health equity In 2011, researchers in the Division of Applied Research at Allina Health examined rates of adherence to the Optimal Diabetes Control (ODC) measure for differences across and between demographic characteristics. The results were stark. Rates of ODC were 51 percent among White patients, Black patients were at 37 percent, and American Indian patients were at 37 percent. These findings served as a catalyst for staff from Allina Health to participate in the Disparities Leadership Program at Massachusetts General Hospital to learn about creating and implementing a health equity framework in a health care system. This ultimately led to the creation of the Allina Health Equity Program in 2011. The purpose of the program is to 1) identify and understand health care disparities through multidisciplinary and community-engaged research, and 2) inform targeted culturally responsive, evidence-based solutions to eliminate disparities. In a 2015 interview with Minnesota Public Radio News, Dr. Penny Wheeler, president and CEO of Allina Health, discussed the importance of understanding how equal care may not lead to equal outcomes for all patients. She stressed how important it is to understand the unique needs of each patient. Prior studies have indicated that there are a range of positions and orientations with respect to providing health equity in health care settings. One such orientation uses a population health perspective when viewing patient data. This refers to the health outcomes of a group of individuals or in this

case a patient panel as well as the distribution of such outcomes within the group. Another orientation points out the difference between equity and equality. Rather than giving all patients the same treatment, equity is about providing each patient with the individual resources needed to achieve good health outcomes. This article describes how a collaborative partnership between primary care providers, operational leaders, and research staff at Allina Health, and faculty from the University of Minnesota designed an intervention to understand what types of information and resources would help support providers in providing equitable care. Why is health equity important? To understand the importance of demographic changes and health equity, itâ&#x20AC;&#x2122;s best to review the current state of affairs. Minnesota is a national leader in many areas: preparing students for careers in engineering and science, having a well-educated workforce, maintaining an extensive park system, building miles and miles of bike lanes and trails, and providing exemplary health care. A glaring issue not often discussed are the racial disparities found in Minnesota (Peterson-Hickey & Ayers, 2014). Across systems that serve the public (e.g., child protection, education, and health care), there are persistent gaps between Minnesotans of color and white Minnesotans with reports suggesting consistently poorer educational outcomes, poorer health, and more contact with child protection for Minnesotans of color (Abanu

et al., 2016; Peterson-Hickey & Ayers, 2014; Brubaker, 2015). Recent studies have pointed out that income and poverty alone cannot explain racial gaps, though they play a part (Kawachi, 2005). In addition, leaders in health care have argued that an important component to achieving health equity is addressing social determinants

if a physician understands the composition of their patient panel, this could help them communicate care requirements, understand if patients need help boosting their health care literacy, and know where best to refer patients with cultural or language barriers. For example, if a physician discovered that 30 percent of their patients listed

Improving equity is important for everyone.

of health (Heiman & Artiga, 2015). Social determinants of health may be beyond the scope of primary care physicians, but understanding a patient’s social context can allow physicians to deliver better care. Understanding demographic composition To better understand the role that a patient’s life experiences and environment play, providers need to start by understanding the demographic composition of their patient panel (who they serve). Health behaviors and needs, while always specific to individuals, often are specific to culture, race, and ethnicity. For example, the leading causes of death differ between racial and ethnic groups, age groups, and gender (Burwell, Frieden, & Rothwell, 2016). How patients navigate the health care system and the role that family plays in their care may vary by culture, race, and ethnic group. Thus, in order to deliver the most effective care, it may be necessary for providers to understand the unique needs, assets, and barriers to care for their patients. This can help physicians be more effective when communicating so that patient, family, and physician are all on the same page. This approach asks more of physicians who are often already busy and have little time between patients. But,

Lithuanian as their primary la ng uage, th is in for mation could lead to finding language appropriate services. Knowing and using this type of information can lead to better and more appropriate care delivery and better outcomes for patients. The intervention With this in mind, the Health Equity Program at Allina Health was interested in understanding if providing physicians with information about the demographic composition of their patient panels would be useful. Given that physicians see thousands of patients per year, getting this kind of information is not a simple matter. Thus, a partnership was built between the University of Minnesota and Allina Health to apply for a Serendipity Grant from the University of Minnesota Office of the Vice President of Research to design a study called, Introducing an Epidemiologic Lens to Primary Care Providers— Examining the Effects of Exposing Frontline Providers to Demographic Data on Their Patient Panels. The study premise is to understand what types (data, education such as articles, or the opportunity to have a discussion) and levels (physician, clinic, or community) of information are useful to physicians when providing care to a continually changing population.

Specifically, the goals are: • To understand what types of information and resources would be helpful at the provider, clinic, and system level. • To determine what level of information is needed to increase awareness of panel demographics among providers. • To identify how knowledge of patient panel demographics may best contribute to the tailoring of resources in support of providers and clinics. Currently, data that exists in the electronic health record is not easily retrievable and digestible for physicians. Allina Health uses electronic dashboards, a data visualization tool that displays the current status of metrics and key performance indicators, to collect and dispense data for use. Internal dashboards are available to all Allina Health employees, but need to be configured to display meaningful information

and are not readily accessible to physicians providing clinical care. To overcome this barrier, the decision was made to provide each study participant with a customized data packet. Each packet contained race, ethnicity, language, and gender data at the physician, clinic, and community level. The second component of the intervention used articles to introduce concepts to physicians: the population health perspective; health outcomes of a group of individuals, including the distribution of such outcomes within the group (Kindig & Stoddart, 2003); and equity vs. equality, where equity requires providing different types of supports and resources to meet the specific needs of individuals and populations, and equality, which requires treating everyone the same. The final component was the opportunity to

Addressing health disparities to page 38

DECEMBER 2016 MINNESOTA PHYSICIAN

PROFESSIONAL UPDATE: NEUROLOGY

Cervical total disc replacement Better outcomes and cost savings By Charles R. Watts, MD, PhD

“I

am enthusiastic over humanity’s extraordinary and sometimes very timely ingenuity. If you are in a shipwreck and all the boats are gone, a piano top buoyant enough to keep you afloat that comes along makes a fortuitous life preserver. But this is not to say that the best way to design a life preserver is in the form of a piano top. I think that we are clinging to a great many piano tops in accepting yesterday’s fortuitous contrivings as constituting the only means for solving a given problem.” —R. Buckminster Fuller (1895–1983, American architect, systems theorist, author, designer, and inventor)

Neck pain and cer v ica l dysfunction are a common diagnosis in the U.S. patient population. Approximately 80 percent of all adults will have at least one episode of neck pain during their lifetime and persistent neck pain will affect 10 to 34 percent of the adult population. Although the causes of neck pain are multifactorial, a significant portion of these will be due to osteoarthritic degeneration of the cervical spine. By the time women are 65 years of age and males 55 years of age, 95 percent will have radiographic evidence of cervical arthritis. For most patients, management is conservative: non-steroidal

MINNESOTA PHYSICIAN DECEMBER 2016

anti-inflammatory drugs, ice, heat, physical therapy, traction, and, in selected patients, injection. For those patients with evidence of intractable pain that is radicular or myelopathic in nature, surgical decompression and stabilization has been the treatment of choice. The advent of cervical total disc replacement presents a paradigm shift for the treatment of these patients with advantages for the patient and the health system. Anatomy The functional cervical spine consists of seven cervical vertebrae, six intervertebral discs (including cervical7-thoracic1), the cervical spinal cord, eight cervical spinal nerve roots, and the ascending nerve roots of cranial nerve XI. The junctions between the occiput, the first cervical vertebral body and the first and second vertebral bodies represent unique anatomy with unique biomechanics and associated pathologic states and will therefore not be discussed further. Anterior, the vertebral body-to-disc-to-adjacent vertebral body junction is an amphiarthrodial joint that is unique to the spine. Posterior, the junction that occurs between the facets of two adjacent vertebral bodies is a diarthrodial joint having synovial membranes between the two articulating surfaces similar to many other joints in the body. The disc can be divided into two distinct anatomic components: the central nucleus pulposus, a soft spongy material formed from glycosaminoglycan; and the external annulus, which is composed of tough multiple layers of collagen fibers oriented obliquely to each other. In the cervical spine, the annulus tends to be more crescent shaped, thinner, and shorter dorsally and taller and thicker

ventrally, resulting in a gentle backwards curve to the cervical spine known as lordosis. Pathology Two types of degenerative disease may occur. With age, the nucleus pulposa of the discs progressively lose hydration and elasticity, resulting in progressive collapse. The loss of normal disc height and alignment tends to cause biomechanical instability resulting in small tears that occur at the attachment of the annulus to the vertebral body end plate. The body compensates with subperiosteal bone spurring and ligamentous hypertrophy causing central canal and neuroforaminal stenosis. Alternatively, tears form within the fibers of the annulus that may result in either bulging of the disc or herniation of the nucleus pulposus, which may cause spinal cord or nerve root impingement. These degenerative processes may result in axial neck pain, cervical nerve root impingement (radiculopathy), or cervical spinal cord irritation (myelopathy). For patients failing conservative management (epidural steroid injections, physical therapy, and/or traction) or patients with significant neurologic deficits or myelopathy, surgery is the treatment of choice. Success for cervical surgical procedures, as judged by patient satisfaction and/or the ability to achieve a bony fusion, is high (80 percent to 90 percent). Small subsets of patients are candidates for less invasive, motion-preserving procedures such as the posterior microforaminotomy or microdiscectomy. Most patients require the more extensive, anterior cervical discectomy and fusion (ACDF) which has been the gold standard for operative treatment.

Figure 2. Flexion/extension X-rays of the cervical spine demonstrating appropriate implantation of the cervical total disc replacement and preservation of motion at the cervical5cervical6 level. Source: Mayo Clinic Health Systems-La Crosse and Mayo Foundation.

The ACDF does, however, cause a loss of cervical mobility (5º to 10º loss of flexion/extension, axial rotation, and lateral bending per fused level), increased mobility at levels adjacent to the fused level with an increase in biomechanical stresses in the associated discs and facet joints, and a statistically significant increased risk of adjacent segment degenerative disc and

What are difficult to account for though are surgeon preferences.

facet disease requiring surgical intervention (2 to 3 percent per year, 25 percent predicted at 10 years). Anterior cervical fusions may also take a long period of time to obtain a solid bony fusion with the risk of developing a painful pseudarthrosis requiring revision surgery in

outcomes for both treatment arms could be regarded as excellent, those patients receiving CTDR demonstrated a statistically significant greater improvement in the median Neck Disability Index (NDI), SF-36, and median return-to-work rate than those patients undergoing ACDF. The reader however should take into consideration that all three investigations were conducted as non-inferiority studies and insufficiently powered to demonstrate superiority of CTDR versus ACDF. While prior CTDR trials have focused on treatment of isolated single level disease, in 2013, a non-inferiority IDE was completed for Mobi-C compared to two-level ACDF. A total of 330 patients were enrolled and treated, 225 with Mobi-C and 105 with a two-level ACDF. Consistent with prior single level disease trials, at 24 months, patients receiving CTDR had a statistically significant improvement in NDI, SF-36, and pain scores, preservation of normal

segmental neck range of motion, lower re-operative and perioperative complication rates, and returned to work sooner. Similar two-level results were recently released by Medtronic for the Prestige-LP with seven years of follow-up data and subsequent FDA approval. Based on the prior clinical trial inclusion criteria, candidates for CTDR should generally meet the following: • History, neurological examination, and imaging studies (CT, CT myelography, and/or MRI) documenting single (or two) level degenerative disc disease and an accompanying correlating radiculopathy and/or myelopathy with near preserved disc height and without significant facet arthritis or previous surgery at the involved level(s). • Flexion/extension films of the cervical spine

Cervical total disc replacement to page 36

some subsets of patients, particularly those with a history of nicotine abuse or surreptitious intake of NSAIDS during the post-operative period. Cervical total disc replacement The known biomechanical drawbacks of an ACDF have led investigators and medical device companies to have a high level of interest in developing a cervical total disc replacement (CTDR) (see Figure 1). With completion of the investigational device exemption (IDE) studies in 2007, the Medtronic, Prestige and BRYAN, and DePuy Synthes, ProDisc-C became available to patients in the U.S. market. In the three multicenter trials, a combined total of 865 patients were enrolled and treated (541 for the Prestige, 209 for ProDisc-C, and 115 for BRYAN). Of the treated patients, 435 received a cervical disc replacement device (276 Prestige, 103 ProDisc-C, and 56 BRYAN), while 430 were treated with ACDF. Though the DECEMBER 2016 MINNESOTA PHYSICIAN

SPECIAL FOCUS: SENIOR AND LONG-TERM CARE

Montessori Inspired Lifestyle A new paradigm for dementia care By Cameron J. Camp, PhD

here are two primary models of dementia care in this country. The first is that of a hospital, where people with dementia are viewed as patients. The term “nursing home” reflects this model, and those with dementia are viewed as having a chronic, debilitating illness that can only be treated symptomatically. Keeping residents “clean, dry, and odor-free” while ensuring that medications and meals are dispensed efficiently represents successful job performance. Activities are seen as diversions, (in some places, such as Australia, these staff are referred to as “diversional therapists”), which are

dispensed sporadically by staff who are viewed as having the least amount of status and influence in the care system. The second model is that of the hotel, where people with dementia are permanent guests. It is the job of staff to do as much for residents as possible to ensure they have an enjoyable stay. Décor and environments are resort-like, and activities staff are viewed as directors of entertainment, similar to a cruise ship. This model predominates in assisted living settings, and is less prevalent when Medicaid is a primary means of support for residents with dementia, as is the case in many skilled nursing residences.

A new standard of care The Centers for Medicare & Medicaid Services, the Veterans Health Administration, and others are calling for “personcentered care” to become the standard of care for dementia. This approach emphasizes a focus on the person who has dementia, with the idea that it is critical to understand the individual, including his or her interests, aspirations, and needs. It represents a rebellion against the objectification of human beings and reducing them to their conditions (e.g., “the broken hip in room 212” or “the screamer in room 113”). The challenge for dementia care is and will be how to implement and sustain a person-centered care approach. A successful model for achieving these goals is the Montessori Inspired Lifestyle. In the U.S., the first senior living and health care management company to adopt the Montessori Inspired Lifestyle

communities located in St. Anthony. The approach is also found at Terracina Grand and Villa at Terracina Grand in Naples, Florida and at The Inn on Westport in Sioux Falls, South Dakota. Gaining control over your life The Montessori Inspired Lifestyle is an approach to dementia care based on the Montessori method, which was developed by the first female physician in Italy, Maria Montessori. It has been implemented successfully on an international scale for more than 100 years as an educational system for children aged 18 months to 18 years. I have adapted this method as an approach to dementia care. The Montessori Inspired Lifestyle represents a set of values, a philosophy, and a practical means of enabling people to gain control over their own lives. The central values of the Montessori approach are respect, dignity, and equality.

“Everything you do for me you take away from me.” Dr. Maria Montessori

on a wide scale is The Goodman Group, based in Chaska, Minn. I am partnering with this group to integrate this resident-driven approach into their 19 memory care communities nationwide. So far in Minnesota, this approach has been rolled out at St. Anthony Health Center and Chandler Place Assisted Living, both memory care

MINNESOTA PHYSICIAN DECEMBER 2016

The philosophy involves providing a social and physical environment that supports independence, development of respectful relationships, and formation of a community connected to the larger world. For example, Dr. Montessori said, “Everything you do for me you take away from me.” For example, in a Montessori school children

are encouraged to water plants, prepare food, select appropriate activities they would like to engage in, etc., with procedures using the cognitive and physical capabilities available to people of this age. This statement, applied to dementia care, reflects a very different approach and a new paradigm. The job of all staff members becomes one of enabling people with dementia to circumvent deficits by using the abilities they still have and by providing effective environmental supports to achieve this goal. Rather than trying to do everything for residents, staff members are encouraged to enable residents to do as much for themselves and for each other as possible. Residents are given back control over their lives through choice and meaningful activities throughout the day, such as fulfilling social roles for the community. For example, residents can choose the clothes they want to wear each day, and the activities they prefer to have available. Residents form committees to determine the outings they prefer (e.g., restaurants, visits to their friends in the hospital, jewelry shows); entertainers or speakers to invite to their residence; how to greet new residents; how to memorialize residents who pass away; and more. Dr. Montessori specialized in pediatrics and rehabilitative medicine. She used rehabilitation techniques as an educational approach, and described a “prepared environment” that would be adapted to the cognitive and physical capabilities of the people being served. Her first school was named “The Children’s House.” Montessori used this approach to enable impoverished children in Rome to learn academic skills with great proficiency at an early age (adding three-digit numbers and reading by the age of four), but also how to dress themselves, prepare and serve snacks and meals, and independently take care of their environment and

each other. Another quote from Dr. Montessori further reinforces this method, “We do our work best when they do not know that we are present.” Practice is key A central feature of the Montessori Inspired Lifestyle is the utilization of learning systems that are available in early childhood and maintained in people with dementia. Dr. Montessori emphasized an approach to learning that involved active manipulation of materials and successful, guided practice. She said, “They will learn through their hands.” This was a foreshadowing of what is known as procedural or implicit learning

involves applying a set of key principles. Some of these principles are: 1) offer choices whenever possible, 2) always demonstrate what you want someone to do before asking the person to do it, 3) match your speed to their speed, and 4) break tasks down into steps. What does research show? Research has shown that when these values and principles are applied, and residents with dementia are provided meaningful, engaging activities and choices throughout the day, a cascade of positive effects results. These include significant and substantial decreases in use of psychotropic

Where it has been used before The Montessori Inspired Lifestyle approach is widely used in Europe (France, Switzerland, Slovenia, Belgium, Spain, the Netherlands, Ireland, Northern Ireland, and soon in Czechia, Norway, and Italy) as well as Singapore, Hong Kong, Taiwan, Australia, Canada, and soon in Latin America and South America. Our approach involves a train-the-trainer model, with staff members applying the Montessori Inspired Lifestyle with residents, and then training other staff members in this approach using materials for internal training developed by the company. Dedication to making it work Staff members now take the following pledge:

The central values of the Montessori approach are respect, dignity, and equality.

I will… • Remember that I am a guest in the home of my residents. • Treat everyone I meet with respect, dignity, and equality.

in neuroscience today. For example, she used the term “muscle memory” to describe how motoric patterns are learned through practice (interestingly, dancers still use this term to describe how dance routines are learned). In neuroscience, the analogous term is “motor learning.” Thus, the same procedures can be used to teach individuals with dementia how to use chopsticks at a Chinese restaurant or how to cook and serve a celebratory meal for family members. For those with dementia, the effects of practice accumulate and are maintained, even if they cannot recall having practiced a procedure. However, through classical conditioning, they can learn to feel confident in themselves (and also feel resentful toward staff members who do not treat them with respect or provide choice). The use of the Montessori method for people with dementia

medications, anti-depressants, and hypnotics. For example, when residents are awake and engaged during the day, they sleep at night. It is that simple. Use of pain medications are significantly reduced as a result of active engagement and movement during the day, compared to sedentary behavior produced in other settings. There are significant reductions in agitation and other responsive/challenging behaviors. We’ve found that staff turnover decreases as the residents’ capacity for taking part in the activities of daily living increases. Weight generally stabilizes or increases. For example, in a managed senior living community in Sioux Falls, simply putting up a sign saying “Help Yourself” by a water station resulted in memory care residents periodically getting water for themselves and others throughout the day. UTIs decreased significantly too.

• Remember that I must earn the trust of my residents and that they must learn to trust me. • Apply the Montessori principles in everything that I do. • Treat everyone I meet the way I wish to be treated. • Work to create a place where I would want to live. Truly, this represents a new paradigm for dementia care. It also represents a better way to live for all people. Cameron J. Camp, PhD, is a psychol-

ogist specializing in applied research in gerontology. He currently serves as director of research and development for the Center for Applied Research in Dementia. He gives workshops on designing cognitive and behavioral interventions for dementia internationally. These interventions are designed to reduce challenging behaviors and increase the level of functioning for people with dementia.

DECEMBER 2016 MINNESOTA PHYSICIAN

SPECIAL FOCUS: SENIOR AND LONG-TERM CARE

Early detection of Alzheimer’s Having a diagnosis matters By Michael H. Rosenbloom, MD; Deb McKinley, MPH; and Michelle Barclay, MA

lzheimer’s disease is a common, progressive neurodegenerative condition affecting memory and cognition, ultimately leading to impairments in social and occupational function. The condition presents a significant epidemiological challenge to the health care system, affecting 5.4 million individuals and expected to triple by 2050. Like so many other chronic diseases, Alzheimer’s is a major challenge within value-based care delivery. The toll on people with the disease and their caregivers is immeasurable with an extraordinary cost burden: average per person Medicare costs for those with

Alzheimer’s and other dementias are three times higher than for those without these conditions, and Medicaid spending is 19 times higher. Similar to other brain-based conditions, Alzheimer’s dramatically complicates people’s ability to manage their overall health. The situation is compounded by the fact that most people with Alzheimer’s have one or more other serious medical conditions. Patients with memory disorders are more likely to experience a lapse in medication compliance, leading to greater morbidity and more costly health care outcomes. The Alzheimer’s Association estimates that the

presence of dementia in people with diabetes increases their Medicare costs by 81 percent and for people with cancer by 53 percent. In September, more than 135 health care leaders from across Minnesota came together at the ACT on Alzheimer’s Health Care Leadership Summit to explore creative solutions for how to advance care and support for people with dementia and their caregivers. The summit’s call to action was clear: We need early detection and a team approach using care coordination to avoid more preventable crises and improve quality of life and care for people living with dementia. Early detection and diagnosis are key Less than half of the estimated 90,000 people in Minnesota that have Alzheimer’s disease ever receive a diagnosis. Currently on average, those who are diagnosed find out years after onset of symptoms, when they have advanced to the moderate or severe stages.

have a fundamental right to know about a life-changing brain disease.” He recommended a shift beyond a paternalistic “Don’t ask, don’t tell” approach to person-centered care, where efforts are focused on the early diagnosis of Alzheimer’s followed by supportive care coordination to manage this chronic disease. Preliminary research suggests that early detection may be a mechanism for reducing health care expenditures. A HealthPartners study showed that in the 18 months leading up to a detection visit, unrecognized cognitive impairment was associated with more ambulatory visits, ER visits, hospitalizations, phone encounters, and canceled appointments. Other research shows that nearly half of people with cognitive impairment visit the ER every year and 26 percent are hospitalized each year with an average length of stay of 5.9 to 9.2 days. Early identification may be one way to prevent unnecessary ER visits or hospitalizations.

Less than half of the estimated 90,000 people in Minnesota that have Alzheimer’s disease ever receive a diagnosis.

Some physicians debate the value of an Alzheimer’s diagnosis since the only trajectory of this progressive neurodegenerative condition is a decline in the patient’s health and well-being. “Time to end the debate—having a diagnosis matters,” said Dr. Terry Barclay from the HealthPartners Center for Memory and Aging at the summit. “Patients

MINNESOTA PHYSICIAN DECEMBER 2016

Recent studies have demonstrated that patient and family knowledge of a dementia diagnosis alone may improve patient outcomes. You only have to talk to people with early Alzheimer’s or their caregivers to know that, though getting the diagnosis is life altering, early identification places patients at the helm of their care and allows them

to navigate how to live most effectively with this debilitating disease. Marv Lofquist, PhD, a person living with dementia for over four years, emphasized the importance of early detection and diagnosis, when he spoke at the ACT Summit. “Recognizing

Research-based practice protocols One of the major messages from the ACT on Alzheimer’s Health Care Leadership Summit was that health care organizations need to adopt standardized protocols for identification, diag-

includes delayed recall of three words and drawing a clock. In its pilot, Essentia Health incorporated the Mini-Cog into Medicare annual wellness visits and found that 24 percent of patients failed the test, a similar failure rate as other studies, indicating

CMS Codes for Beneficiary Management Procedure

CMS Code

Annual wellness visit, first visit

HCPCS G0438 and G0439

Annual wellness visit, subsequent visit a Welcome to Medicare exam a

HCPCS G042

Chronic care management a

CPT Code 99490 — cannot be billed during same month as: Transitional Care Management — CPT 99495 and 99496 Home Healthcare Supervision — HCPCS G0181 Hospice Care Supervision — HCPCS G9182 Certain ESRD services — CPT 90951-90970

Care transitions b

CPT Code 99495 — communication with the patient or caregiver ithin two business days of discharge. This can be done by phone, w e-mail, or in person. It involves medical decision making of at least moderate complexity and a face-to-face visit within 14 days of discharge. CPT Code 99496 — communication with the patient or caregiver within two business days of discharge. This can be done by phone, e-mail, or in person. It involves medical decision making of high complexity and a face-to-face visit within 7 days of discharge.

Advanced care planning c

CPT Code 99497 to be billed for the first 30 minutes, and 99498 for each additional 30 minutes.

a. AAP website; b. HHS-CMS website; c. HHS-CMS website.

Table 1. CMS codes applicable to Alzheimer’s detection, diagnosis, and post-diagnostic care. Source: From a presentation at ACT on Alzheimer’s Health Care Leadership Summit: A National Perspective on Healthcare Quality, Shari Ling, MD, Sep. 29, 2016.

the process of Alzheimer’s allows the person to more smoothly adapt to new realities, find new ways to function, and integrate the necessary life style changes,” he said. “Ignoring changing abilities slows the adaptation process that can help with future function. Early in the disease a person will be more adaptive than they will be later. Early in the disease is the time to find new strategies and new support tools.” Dr. Lofquist’s perspective is further supported by studies showing that 80 to 90 percent of U.S. adults would want to know if they had Alzheimer’s.

nosis, and care coordination. Standardized detection tools improve recognition of cognitive impairment over a physician’s personal assessment, particularly in milder stages and in older adults subject to disparities in health care quality due to sociodemographic factors— such as low education, low literacy, and non-English speaking. Severa l orga n izations, including HealthPartners and Essentia Health, have piloted cognitive screening in the asymptomatic elderly population using the Mini-Cog. This a three-minute cognitive assessment that

the presence of cognitive impairment. Also consistent with other research, both organizations found that the Mini-Cog could be administered by non-physicians and did not significantly disrupt clinic workflow. Following an abnormal score on a cognitive assessment instrument, many health care providers struggle with the diagnostic process and medical decision-making associated with dementia management. ACT on Alzheimer’s has developed and tested a suite of provider best practice tools and resources for use in work with patients and

clients who have memory concerns and to support their care partners (see the sidebar on provider practice tools). Both Essentia and HealthPartners have integrated ACT’s electronic medical record (EMR) decision support tools into their EMRs to assist their health care providers in dementia detection, diagnosis, and management. Post-diagnostic care Alzheimer’s disease is a challenging diagnosis that requires a multidisciplinary approach extending beyond the physician’s office, involving the surrounding community and making use of its supportive resources. Much like patients with complex medical conditions such as congestive heart failure or diabetes who are at increased risk for hospitalization, individuals with Alzheimer’s benefit from care coordination. Multiple studies have demonstrated improvements in care quality and reductions in cost through the implementation of a multidisciplinary team approach to care. For instance, the Collaborative Aging Brain Care Model uses a team comprised of the primary care physician, memory care provider, care coordinator, and community-based service organization staff to provide interventions for home environment modification, self-management, medical management, and caregiver support. A cost analysis of this model suggested annual net cost savings per patient of $2,885 to $4,227. The patients spent fewer days in the hospital, were less likely to die after a hospitalization, were less likely to drive, and were more likely to have assistance to appropriately manage with medications and finances. Reimbursement mechanisms The Centers for Medicare & Medicaid Services (CMS) has reimbursement options in place for dementia, including the Medicare Annual Wellness

Early detection of Alzheimer’s to page 32

DECEMBER 2016 MINNESOTA PHYSICIAN

MEDICAL FACILITY DESIGN

Lean process analysis in clinic design Efficiency equals profitability By Daniel J. Abeln, MArch, MBA, and Chad Frost, BSME, BSEM

linical design is ever evolving, with influences such as insurance reimbursement, patient expectations, administrative migration, and regulatory guidelines. These influences increase the complexity of the overall care system, and historically have created waste and interruptions of flow within the core processes of a clinic. When designing a clinic it is important to provide a safe, private, comfortable environment to all patients, while maintaining maximum efficiency in clinical operations. Efficiency equals profitability and that efficiency must be analyzed with an intense focus on reducing waste

and improving flow. Consumables, travel distances, throughput times, or perhaps most notably, talent, should all be taken into consideration, yet these are often ignored when it comes to clinic design. That’s where lean is very useful. The lean process According to the Lean Enterprise Institute, lean is most simply defined as “creating more value for customers with fewer resources.” Originally developed by the Toyota Motor Company, lean was transferred from manufacturing to the service industry, which changed management’s focus

to “optimizing the flow of products and services through entire value streams that flow horizontally across technologies, assets, and departments to customers.” Once designers start to observe the flow, they immediately see interruptions in the flow caused by waste. The concept of “waste” in lean is defined by the opposite of what customers value. For instance, how many customers consider it a value to wait longer than 30 minutes in a waiting room or walk more than 100 feet to interact with a care provider? If a customer is not willing to pay for something because it is not of value to them, then the supplier must rationalize it as a form of waste and determine how to minimize or remove it from their process. It is in this

through reduced wait and travel times, and maximize throughput by leveraging adjacencies and technology. In addition, several recent industry surveys have indicated that the biggest challenge facing health care administrators is shifting their concern from “behind-the-scenes” financial issues to meeting the needs of skilled front-line staff and licensed and registered nurses. It’s important to consider how to attract, compensate, and retain top talent. With expenses always a concern and heavily scrutinized, paying staff at a higher rate is not always possible. Effective clinic design creates a more desirable working environment, but taking increased patient throughput

Lean is most simply defined as “creating more value for customers with fewer resources.” Lean Enterprise Institute

regard that the value of using the lean process in health care design and delivery becomes immediately evident. Clinic design and valuebased reimbursement Two hot-button issues to surface over the past couple of years are tied to legislative changes in reimbursement and health care staffing. Legislation mandated that reimbursements be based on patient satisfaction and effectiveness of treatment. Reductions in reimbursement levels have strengthened the incentive to maximize staff efficiency and patient throughput. Effective clinic design can both increase patient satisfaction

MINNESOTA PHYSICIAN DECEMBER 2016

and satisfaction in mind may ultimately lead to higher revenue, lower staffing requirements, and greater compensation possibilities. All of this points to the cohesive goal of designing and constructing patient care facilities that alter how we look at traditional practice methods and emphasize a new approach. This is how architects and health care providers can collaborate to make things better. Patient-centered care models The medical home model of patient care, where patients and staff enter exam rooms through separate doors on opposite sides of the room, is an emerging

trend in outpatient clinic design. In this model, there is a natural separation of “on-stage” and “off-stage” areas, so patients no longer travel past nursing stations and sensitive information on their way to the exam room. Taking this medical home model a step further, Altru Health System recently opened an orthopedic clinic at the Profession-

occupied. This eliminates the need for a nurse to escort patients to exam rooms, freeing up their time for more skilled tasks. It also eliminates the oversized waiting room and pre-appointment waiting—both points of patient dissatisfaction. Reducing waiting room size, replacing private physician offices with modular workstations and shared staff

Analyzing the design post-occupancy We were given the unique opportunity as the designer of Altru’s orthopedic clinic to perform a post-occupancy validation from a lean waste and flow perspective. Leveraging our expertise in lean manufacturing, we spent time reviewing the layout for potential opportunities

Table 1. Design impact on patient travel distances.

Layout Design

“New Patient” Cycle— Walking Distance (ft.)

Number of Patient Stops (e.g., Waiting)

Old

466

New

420

Difference

(46)

(1)

Source: Abeln and Frost

al Center in Grand Forks that incorporates wearable technology in the clinic. This technology allows patients to find their way to the exam room on their own, and alerts staff when a room is

bullpens frees up extra clinic space. This enables the clinic to add more revenue-generating space and further enhance efficiency in throughput and reducing waiting.

to reduce waste and increase flow. We followed that up with a Gemba walk, which was a series of informational tours and interviews with key participants about the operational space of

the final facility to collect data regarding the design’s impact on key efficiency indicators. To ach ieve th is cr itica l measurement, a specific value stream process, identified as “New Patient,” was defined using the current state of the process (e.g., old layout) and the future state of the process (e.g., the new medical home model). A lean tool for visual creation of actual flow, called spaghetti diagramming, was utilized to map the steps and stops of patients as they proceeded through the current and future states of the specific New Patient value stream process (see Table 1). In comparison to the previous operation, patients in a typical New-Patient Process saw an 11 percent reduction in travel, which may not seem significant until you look at it from the perspective of a 100 New Patient cycles per day, where that reduction equals

Lean process analysis to page 29

DECEMBER 2016 MINNESOTA PHYSICIAN

ORGANIZED MEDICINE

Joining a professional organization What are the benefits? By Nick Hernandez, MBA, FACHE

etting involved in a professional organization can benefit you in many ways. Yet, membership in professional organizations is generally down as budgets are squeezed and time is increasingly limited. In addition, with a busy career and social life, you canâ&#x20AC;&#x2122;t possibly get involved with all the organizations in which you might be interested or with those who want you as a volunteer. There are organizations at the national, state, and county levels; some are aimed at physicians, some at managers, and some are specialty-specific with some medical specialties having several organizations targeting the same membership

demographic. How do you decide which organizations are right for you? There is often a duplication in services provided by some of these organizations, so the choice is not easy. Deciding which organization or organizations to join takes some diligence on your part and the decision is a matter of your professional objectives. This article will help to guide you through some of the decision-making process. Regardless of your objective though, becoming involved in any organization is about developing meaningful relationships from which you will learn and hopefully grow your practice. This means a commitment of personal time

MINNESOTA PHYSICIAN DECEMBER 2016

and resources in terms of membership fees or fundraising. The bottom line is that consistent and active involvement is the key to successfully developing relationships and business opportunities. The benefits There are plenty of health care professional organizations, but are the yearly dues worth it to join? As budgets get squeezed, many physicians and practice managers have been cutting back on the number of professional associations they belong to. Although there is often a lack of perceived benefit, membership in professional associations yields a number of

benefits. Taking an active role in professional associations can benefit physicians through networking opportunities, policy alerts, continuing education, and more. Many association members who lead busy professional lives depend on their association to brief them on important industry trends, new legislative rulings, and advances in technology. Education Perhaps the most important benefit is education. The field of medicine is always in a state of change and health care professionals can keep up with the newest developments and

scientific breakthroughs through their association. (A plea here to physicians is to remember this applies to your practice managers. If you want a successful practice, run by a talented practice manager, you must be willing to support his or her professional continuing education.) Most associations provide an enormous amount of access to

Networking Another important benefit is networking. For most people, creating professional relationships is important, and joining a group allows you to have a sense of security and trust. From this, you are able to support and help one another in reaching your professional goals. There is no better way to connect with

Members who get the most out of an association are the ones who get involved. resource information such as: case studies, articles, and white papers and books written by experts in your field or area of interest. Providers and managers can keep up with the newest developments (clinical and operational) through their association membership benefits, including conferences. Take advantage of all the information your associations provide and remember that most of it is online and free.

peers and industry experts than through professional association membership. There is often a variety of possible venues to network at (e.g., listservs, membership connections and groups, national conferences, regional seminars, etc.), providing you are willing to become engaged with other members. Networking with professionals outside your place of employment can give you a broader perspective

on the market and health care in general. Attending local and national meetings and conferences reveals your commitment to excellence in your profession and introduces you to the other players. These events also help you keep current on trends, developments, new products, vendors, and potential opportunities to enhance your career and mentor others. Industry standards Professional organizations sometimes offer courses, seminars, and/or lectures to keep themselves and their members up to date on the latest industry innovations, research, and trends. Staying informed on your industryâ&#x20AC;&#x2122;s trends will help you in the long run and put you one step ahead of the competition. Webinars are frequent these days as a means to deliver information on hot topics such as best practices, new statistics, etc. No matter what your specialty is, staying on top of all of these issues is important.

Policy updates All of us in health care know how much one piece of legislation can impact our profession. Professional associations not only update members about these types of changes but also often play an advocacy role on behalf of the membership. I have been involved in advocacy with professional associations and it can often be a tiring effort to work with legislators at the state and national level. However, associations involved in this are able to inform members how to prepare for any upcoming change. Professional organizations provide valuable, expert input to public debate about policies that affect members of that profession, whether proposed by a government entity or an industry-guiding body. Group benefits Often, members have the ability to save money with group benefits. These could involve Joining a professional organization to page 28

DECEMBER 2016 MINNESOTA PHYSICIAN

Joining a professional organization from page 27

discounts with insurance such as medical malpractice liability or a host of other vendorrelated industry discounts. Some organizations offer access to capital for members looking to grow their practices. By taking advantage of these membership benefits, not only does the physician practice win, but the association benefits as well in that the vendors gain a true understanding of the value of their support to the health care professional organization. Membership in many groups includes a free subscription to the organization’s magazine. Some associations also offer their members free publications and discounts on CDs, journals, videos/DVDs, and other materials. Members are often given priority registration for their organization’s convention and may receive discounts on conference fees or special rates on related expenses, such as hotel reservations.

Jobs Take advantage of career resources. Associations often post job listings online or in print available only to their members. This is a great way to find targeted job postings for your area of interest. Most people already know that they can search for jobs on association job boards as members.

annual meetings, workshops, CME courses, and legislative committees. Taking an active role in leadership positions or committees not only helps the association, but also helps you personally (from leadership development to networking, to potential job searches). Professional associations give you an

Staying informed on your industry’s trends … will put you one step ahead of the competition. Keep in mind that your practice may want to utilize these job boards to post positions for your practice. Recruiters will often post on job boards as well, so if you are working with a recruiter, be sure to let them know about your preferred associations. Intrinsic value In addition to money, associations need support to survive. Associations are always in need of new blood to help organize

MINNESOTA PHYSICIAN DECEMBER 2016

opportunity to develop your skills as a leader, and this is important not only for personal growth, but possibly also for your growth in the organization. As the saying goes, “You get out of it what you put into it.” Undoubtedly the members who get the most out of an association are the ones who get involved and are more interactive. Giving back can be the greatest reward and benefit. Participating in forums, chat groups, or discussion boards sponsored by an association is also

a great way to grow your network. This allows you to use your peers as sounding boards and often make some great friends with the same interests as you. Conclusion He a lt h c a r e a s s o c i at ion s r epr e s ent a c ol le c t ion of professionals working toward the common goal of promoting and improving the medical profession they are associated with. These health care organizations champion their members by providing resources, information, and opportunities they might not have had otherwise. Members are bonded together as they advocate for their peers and share their challenges and triumphs among one another. Joining an association provides members with a competitive advantage because they become active, informed members within their industry. Nick Hernandez, MBA, FACHE, is CEO and founder of ABISA, an independent consultancy specializing in solo and small group practice management.

Lean process analysis from page 25

upwards of 26 miles of reduced travel distance in just one month. When this same comparison is done from a staff nursing perspective, the results address the hot button issues identified by administrators as a top priority regarding staff fatigue and retention (see Table 2). In comparison to the previous operation, nursing staff in a typical New-Patient Process saw an 81 percent reduction in travel distance and the elimination of at least two trips (e.g., transport waste). Looking at over 100 New Patient cycles per day, the reduction equals upwards of 53 less miles traveled per month and almost 500 hours of eliminated transport time for the nursing staff with a 50 percent reduction in trips required for a month’s worth of New Patient cycles. Results and next steps The results in terms of patient and staff satisfaction are not scientific at this time, but those who voluntarily answered our queries, were overwhelmingly positive about the new clinic layout. Providing a space where staff feel they can be effective and thrive is a low-cost way to attract and motivate talent. As the familiarity with the space grows, and the immense data we are collecting is analyzed, these efficiencies could likely contribute to increased revenue, staffing reductions, or both.

Table 2. Design impact on nurse travel distances.

Layout Design

“New Patient” Cycle— Walking Distance (ft.)

Number of Nurse Trips (e.g., Transport)

Old

116

New

Difference

(94)

(2)

Source: Abeln and Frost

and analytics through the patient tracking software all provide further opportunities and insight when designing clinics in the future.

director of Business Excellence at EAPC Architects Engineers. Chad is a certified Six Sigma Black Belt and lean practitioner, an ASQ certified

LEAD Auditor for ISO 9001 Quality Management Systems, and a senior member in good standing with ASME and ASQ.

Conclusion Going forward, it is important to view the architecture and design factors that go into truly efficient and effective clinical operation through a lean lens. Lean-based design can allow for a reduction in footprint (or more revenue-generating space within a pre-determined footprint), reduced throughput times (meaning more patient cycles per day), increased patient and staff satisfaction, and increased profits. Well directed capital investments can also be offset by reduced st a f f i ng r e qu i r ement s or increased revenue generation from the more efficient use of resources. Obviously, there is much to be gained from applying lean principles to the design and operation of health care spaces where our clients provide important, and often critical, services to patients in our communities.

Architects and health care providers can collaborate to make things better.

Additional lean assessments and tools could further refine the clinical process, and are being integrated more and more each day. Inventory tracking systems, specialty casework that can be accessed from both on-stage during consultation and off-stage by non-providers, and long-term data collection

Daniel J. Abeln, MArch, MBA, is an architect and senior project manager at EAPC Architects Engineers with a focus in health care design. Daniel is a LEED Accredited Professional, an NCARB Certificate Holder, and a member of the American Institute of Architects. Chad Frost, BSME, BSEM, is a mechanical engineer and the

DECEMBER 2016 MINNESOTA PHYSICIAN

MEDICAL EDUCATION

The changing state of health care Training future leaders By Susan E. McClernon, PhD, FACHE

hen it comes to the future of health care, one thing is certain: The industry is growing and will continue to grow. According to the Bureau of Labor Statistics (BLS), 13 percent of all U.S. jobs are currently in health care, and it is estimated that the U.S. will add 5.6 million health care jobs between 2010 and 2020—the largest projected increase for any industry. There is enormous demand as BLS has projected a 23 percent growth in the need for qualified health care management professionals, both locally and nationally. Given the changing state of the health care industry, it is paramount

that physicians, dentists, nurses, pharmacists, and clinicians possess strong leadership and business skills that will effectively shape the future direction of health care. To meet the market’s need for qualified health services management professionals, the University of Minnesota has developed a new Bachelor of Applied Science (BASc) in Health Services Management (HSM). The vision of the HSM program is to advance the health and well-being of people, organizations, and communities by producing graduates who are leaders primed to transform health services through applied innovation and

collaboration. The curriculum is designed to assist clinicians who are already leaders or who want to become administrative leaders through our online and evening in-classroom options. To meet and anticipate the changing needs of the health care market, the HSM program has identified the 21st-century skills and competencies necessary to succeed in an increasingly complex digital and changing health care system. We believe the competencies of leadership, management, collaboration and communication, strategic and business planning, innovation, and ethics and social responsibility are designed to prepare the next wave of health services professionals to address tomorrow’s challenges. Leadership In medicine, clinical protocols based on evidence from published literature and studies have determined better ways to provide safe, quality care. This evidence-based research is also useful in determining how leadership and management can enhance the quality and productivity of teams and ultimately an organization. As clinicians and management work together closely to serve patients and their loved ones, it is important to realize that all members of a health care team bring value and skills to the table. With so many changes and frustrating situations in our health systems today, it is critical that we understand the impact of positive and proven leadership skills and management strategies that drive results, improve outcomes, and manage risks. For example, as the focus on building effective Accountable Care Organizations (ACOs) continues, the size, diversity, complexity, and virtual nature of corporate teams

MINNESOTA PHYSICIAN DECEMBER 2016

is increasing. Research using teams to solve hard problems proves that 60 percent of the success of a team’s performance depends on the foundation built by the leader before the team even meets, 30 percent is attributable to how the team is launched, and 10 percent is determined by how the leader handles the team once the team is working (HBR, 2011). Additional studies of successful teams show a positive correlation with executive support, the strength of the team leader, the structure of the team, human resources practices, and collaboration (HBR, 2007). Using evidence-based leadership to create a positive organizational culture that embraces change and inspires teamwork, professionalism, productivity, and innovation is extremely important. Management It is important to leverage sound current business principles and technology to guide operational, clinical, strategic, and day-to-day decisions that ensure delivery of value-based health services. For example, health services management leaders must be able to understand health care accounting and finance principles and regulatory changes in order to communicate with and assist clinicians with flexible operating and capital budgeting, cost management, and changing reimbursement methodologies. Furthermore, the ability to read financial statements, including the balance sheet, cash flow, profit and loss statements, and key financial ratios at both a departmental and organizational level may make the difference between being able to staff your programs, create a proposal for innovative care, and/or purchase capital equipment or new medical technology. In order to continue their mission and achieve

their goals of serving patients, financial pressures are a constant reality within health systems, large or small. There are management tools available to help solve problems more effectively. Assessing and implementing information systems and new medical technology, data mining and analytics, managing project implementation, supply chain contracting, negotiations, and pe0ople strategies are all important management skills needed in today’s health services management environment. Collaboration and communication One of the key 21st century skills necessary to transform patient care and improve value is collaboration. This is evident within health services as the need to communicate and collaborate within and between disciplines and within a community is crucial to achieving peoplecentered care. Developing and lever aging collaborative relationships

is critical to changing organizational culture from a provider focus to a patient and family focus. Ensuring smooth transitions of care is now a top priority when hospital Medicare reimbursement is directly related

communication among patients from different cultures and inter-organizational collaboration will support the improvement of health literacy. The identification and formation of strategic collabora-

Thirteen percent of all U.S. jobs are currently in health care. to readmissions and patient experience survey results. Excellent communication skills include proficiency in writing, speaking, and listening and are essential in providing quality health services. Research notes that 90 million U.S. adults lack the health literacy skills needed to understand and act on health information. Poor health literacy is “a stronger predictor of a person’s health than age, income, employment status, education level, and race” (IOM, 2004). Improving cross-cultural

tions for medical innovation and value-based partnerships are necessary to achieve population health. For example, success has been reported when an administrator and emergency room medical director reach out to local dentists and mental health leaders in the community to design new call networks and urgent care solutions to prevent unnecessary and repeat visits for patients with mental health issues. Long-term care organizations are working with health systems in improving

rehabilitation care for patients with total knee and hip replacements. The ability to develop and leverage relationships among and between health services disciplines and organizations are now needed to transform care and improve value. Strategic and business planning Each clinician and health care leader needs to understand their organization or department’s strategic plan and how the organizational structure influences operations, both clinically and financially. Setting an effective strategy is no longer the sole role of senior managers, planning departments, consultants, or boards of trustees. Sound market and financial analysis, as well as clear vision, goals, values, and strategies are required. The formulation of strategic plans and an understanding of

The changing state of health care to page 34

DECEMBER 2016 MINNESOTA PHYSICIAN

Early detection of Alzheimer’s from page 23

Visit, d iag nostic work-up, chronic care management, which includes Alzheimer’s as a qualifying chronic condition, and advance directives (see Table 1). CMS recognizes that dementia increases the complexity of care and is evaluating additional reimbursement pathways for dementia patients through proposed changes to the 2017 Medicare Physician Fee Schedule. The movement toward value-driven and accountable care offers additional incentives for timely detection and disease management, such as avoiding unnecessary hospitalization, reducing 30-day readmissions, and focusing on health and care quality. It’s time to ACT on Alzheimer’s If you see older patients, dementia undoubtedly impacts your

practice. One in nine people age 65 years and older has Alzheimer’s, increasing to one in three by age 85. If you see older African Americans, Latinos, and women, your rates may be even higher due to a greater prevalence in these populations. The disease could affect

as other chronic diseases and conditions, such as heart disease and cancer. It’s time for physicians to embrace a new level of care standards for Alzheimer’s diagnosis and management. As Dr. Penny Wheeler, CEO of Allina Health, said at the summit: “We know how to

“Patients have a fundamental right to know about a life-changing brain disease.” Dr. Terry Barclay

the health of your patients who are caregivers of people with the disease as well. People with dementia and their caregivers at the Health Care Leadership Summit requested that the health care system be held to the same standards for early detection, diagnosis, and management

do this, and we have the tools. We just need to ACT.” Join us in acting on Alzheimer’s. ACT on Alzheimer’s is an award-winning, statewide, multidimensional collaboration seeking large-scale social change and building community capacity to transform Minnesota’s response to Alzheimer’s disease. A signature goal is to help health care providers and systems become dementia capable. Michael H. Rosenbloom, MD, is a

board-certified neurologist, director of the HealthPartners Center for Memory and Aging, and chairman of the HealthPartners Neurology Department. He participates in patient management as well as ongoing clinical research at the Center for Memory and Aging. Deb McKinley, MPH, is communica-

tions director at Stratis Health. She led development of the ACT on Alzheimer’s Dementia-Friendly Communities Toolkit with a broad-based community group—adopted nationally by Dementia Friendly America. Michelle Barclay, MA, is executive

co-lead of ACT on Alzheimer’s and the recipient of a 2016 Practice Change Leader in Aging and Health Award from the Atlantic Philanthropies and the Hartford Foundation for ACT on Alzheimer’s health care practice change work.

MINNESOTA PHYSICIAN DECEMBER 2016

Alzheimer’s Provider Alzheimer’s Provider Practice Tools Practice Tools ACT on Alzheimer’s has a suite of provider best practice tools and resources for use in your work with patients and clients who have memory concerns and to support their care partners. http://www.actonalz.org/ provider-practice-tools Clinical provider practice tool: Provides physicians with a streamlined protocol for managing cognitive impairment and guiding decisions for cognitive screening, diagnosis and disease management. • Videos and webinars on administering and scoring Mini-Cog, SLUMS, MoCA • Tips for screening and diagnosing in diverse populations Delivering the Diagnosis [video]: Portrays an actual physicianto-patient interaction for delivering an Alzheimer’s diagnosis during a medical visit. https://www.youtube.com/ watch?v=vy2ZC5ZSZL8&feature=youtu.be Managing dementia across the continuum: Provides physicians with a streamlined protocol for treating, managing, and supporting people with mid- to late-stage dementia, including information on non-pharmacological approaches to managing behavioral symptoms. Care coordination practice tool: A practice tool to support the coordination of care of patients with dementia and their care partners or caregivers, including a Dementia Care Plan Checklist. Electronic medical record (EMR) decision support tool: Provides a template to assist clinicians in implementing a standardized approach to all aspects of dementia care within the health record.

DECEMBER 2016 MINNESOTA PHYSICIAN

The changing state of health care from page 31

strategic thinking are key attributes and skills of successful managers and leaders at all levels in todayâ&#x20AC;&#x2122;s health care organizations. Effective strategic plan implementation is preferred to having a strategic plan that sits on a shelf collecting dust. An organizationâ&#x20AC;&#x2122;s strategy needs to be flexible and current as the health care environment changes rapidly. Organizations are faced with learning how to strategically transition to value-based reimbursement now being proposed by federal regulatory agencies. Strategic plans must be realigned to redesign the health care organizationâ&#x20AC;&#x2122;s role in population health. Strong data analytics and scenario-based planning are needed to improve health, while reducing costs and accomplishing a solid business strategic plan that has a focused vision and is flexible.

Innovation With rapidly changing insurance, clinical practices, information systems and medical technology, it is important to understand, i ncor p or ate, a nd encou r age innovation. Innovation allows an organization to find ways to differentiate its services and products, for example by developing new collaborative relationships and/ or new systems of care. Leaders in health services management must understand how and when to make changes in continuum of care and in their organization. Applying innovative strategies that combine design thinking with conceptual and analytical skills are required as we continue to find ways to transform our health care system. Simply changing a process can improve things, but to leap forward with a truly innovative idea requires out-of-the-box thinking. For example, securing a foundation grant to study how the Fitbit can help type 2 diabetics self-manage an exercise regimen shows innovative thinking.

MINNESOTA PHYSICIAN DECEMBER 2016

Using patient and family advisory boards to redesign health services or medical facilities is a new way of approaching an issue. Ethics and social responsibility Health services managers need a strong ethic and sense of social responsibility within their organization. Ethical behavior, social justice, and equitable care are important in medicine and health services management. For example, health care leaders may be forced to determine whether awarding bonuses to managers is ethical if it results in personnel layoffs to ensure a better bottom line at the end of a fiscal year. The use of frameworks such as Just Culture and the Culture RoadMap developed by the Minnesota Alliance for Patient Safety have shown effectiveness and efficiency for handling patient safety and quality incidents in a moral and ethical manner. Health literacy correlates with social justice and cross-cultural

work. Finding ways to support sustainability in utility use and facility design transfers well to our industry. Understanding ethical and social responsibility as a leader in health services management is important to our future. Conclusion As we enter the 21st century, it is so important for future health care leaders to focus on the competencies of health services management so they can meet the increasingly complex challenges they will face. With the continued growth of the health care industry and the need for qualified management professionals, it is vital to have leaders able to be innovative and to transform the industry. To ensure successful leadership requires a higher level of specialized training and applied expertise. Susan E. McClernon, PhD, FACHE,

is faculty director for the Health Services Management and Applied Business programs at the University of Minnesota.

DECEMBER 2016 MINNESOTA PHYSICIAN

Cervical total disc replacement from page 19

demonstrating ≤ 3.5 mm of sagittal plane translation and ≤ 20° of sagittal plane angulation at the involved level(s). • Neck Disability Index score ≥ 30. • For all females ≥ 65 years or postmenopausal females with medical causes for possible bone loss and males ≥ 70 years, a DEXA bone-density scan demonstrating a T score ≤ -2.5. Implantation of an artificial cervical disc device is generally contraindicated in the following settings: • Infection • Acute or subacute trauma with suspected or documented vertebral instability • Significant vertebral instability not related to trauma • Tumor • Significant cervical kyphosis • Severe osteoporosis

• Spondylolisthesis • Severe segmental ankyloses • Multi-level disease (more than two levels) • Significant facet disease • Combined significant anterior-posterior disease • Allergy to implant materials The expert use of these guidelines for patient selection insures optimal patient outcomes and decreases perioperative complication rates and the potential need for subsequent revision surgery. Cost analysis The two main utilization challenges of CTDR have come from the insurance carriers and health systems. The first challenge arose shortly after completion of the IDEs; many insurance carriers claimed that the available devices were experimental and not approved by the FDA. This statement is false and based on widespread ignorance of how device approval is conducted. An IDE allows the investigational device to be used in a

MINNESOTA PHYSICIAN DECEMBER 2016

clinical study in order to collect safety and effectiveness data. Clinical studies are most often conducted to support a premarket approval (PMA). All four available devices had successfully completed PMA prior to marketing to patients and providers in the United States. The second challenge has been based on the cost of the CTDR implant compared to that of an ACDF. This cost comparison however is very complex and does not hold true in all cases. The estimated cost differential of a CTDR implant versus ACDF construct is approximately $1,500 to $2,000 per treated level.

work. The authors calculated a five-year QALY for the health system as well as an incremental cost-effectiveness ratio (ICER) to determine societal cost. The results demonstrated an ICER of $8,500 per QALY for the health system and an ICER of $165,000 per QALY for society. The societal costs where heavily influenced by the significant differences in return to work rates (80 percent compared to 65 percent) resulting in substantially less productivity loss and the greater length of time that patients undergoing CTDR spent in a state of mild disabil-

The two main utilization challenges of CTDR have come from the insurance carriers and health systems.

What are difficult to account for though are surgeon preferences for ACDF grafting material (autograft, allograft, PEEK, or titanium) and the manufacturer and type of plating system used. All of these can vary significantly making a “standard” ACDF significantly more or less expensive and depend to a large extent on hospital system contracts with vendors. The other cost factors that this type of comparison does not take into account are: rates of adverse events and revision surgery, postoperative medications, office visits, and pre-/postoperative disability. There have been several recent meta-analyses on single level CTDR using longterm follow-up data from the IDE trials. The five and seven year data from these trials generally tends to favor CTDR over ACDF by approximately $10,000 to $20,000 per quality-adjusted life years (QALY). The most comprehensive analysis to date was recently published by Ament and co-authors in Neurosurgery (2016) using the five year data from the two-level Mobi-C IDE. This study used a Markov chain model with multiple simulations to account for pre- and postoperative disability and return to

ity compared to prolonged mild and greater disability in the ACDF cohort. Conclusion Cervical total disc replacement presents a clinically efficacious and cost-effective alternative to ACDF in a select group of patients for single and two-level degenerative disc disease with resulting radiculopathy and/or myelopathy. Although the initial cost of the devices are in general higher than an ACDF, the deceased cost of postoperative medications, decreased rate of perioperative adverse events and subsequent revision surgery as well as the rapid return to work and lower disability rates strongly favor use of CTDR from a social and health system perspective. Charles R. Watts, MD, PhD, is an

assistant professor of neurosurgery at Mayo Clinic College of Medicine in Rochester. He practices emergent hospital based neurosurgery at St. Mary’s Hospital and is a member of the Department of Neurosurgery at Mayo Clinic Health System in La Crosse, WI where he treats emergent and elective patients. He is boardcertified in neurosurgery, surgery critical care, and neurocritical care.

DECEMBER 2016 MINNESOTA PHYSICIAN

Addressing health disparities from page 17

discuss reactions to the information (data and articles) to understand if the opportunity to ask questions and have discussions makes the information more useful.

patient and organizational needs with equity in mind. Second, improving equity is important for everyone, but most important we want to conduct our research in a way that acknowledges providers’ hard work while emphasizing that being more inclusive is something everyone needs to do. Improving provider knowledge about disparities and how

The racial and ethnic composition of Minnesota is changing.

What can be gained from this work? While in the early stages of our research, our team kept the bigger picture in mind of how this work is relevant and important to Allina Health and to the community at large. First, this work has the potential to increase awareness of how to approach

they affect patient care has the potential to improve communication between providers, staff, and patients. Last, this work has the potential to better serve the public—as Allina Health gets to know these demographics better and identifies growing demographic groups, it can continue to improve services.

MINNESOTA PHYSICIAN DECEMBER 2016

Conclusion As of October 2016, our prepilot research began with one clinic in order to test the feasibility and logistics of conducting the study in a clinical setting. Although hospitals and clinics are required to collect some demographic data, conveying its relevance and using it in patient care is not a simple task. This is where research can play an important role. Physicians’ work is important and difficult so it is equally important to design processes that are not burdensome. Conducting a study to understand the feasibility and logistics of a process is important not only for the research process, but for making the findings more meaningful. An applied and inclusive research approach can improve how information is shared and make it more accessible and user-friendly. Because this study was a pre-pilot, future studies will examine the types and levels of information that are most effective for scaling

up this work and inform us how best to provide resources and supports for delivering care to changing populations.

Dylan Galos, MS, is a doctoral candi-

date in epidemiology at the University of Minnesota. Dylan has worked in many research settings and areas: health care, burnout, HIV prevention, and most recently family science and child welfare. Dylan’s research interests involve quantitative methods, social epidemiology, and the impact of trauma on health. Dimpho Orionzi is a research asso-

ciate in the Division of Applied Research at Allina Health working on health equity and population health research. Her primary role is managing the development of the health equity agenda and research activities for the Backyard Initiative, a large community health improvement project in South Minneapolis.

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