Minnesota Health care News February 2011

Your Guide to Consumer Information

FREE

February 2011 • Volume 9 Number 2

Bones Patrick Yoon, MD

Uterine fibroids Jon Nielsen, MD

Rheumatology Paul Waytz, MD

One Heart, One Mind, One Universe May 8, 2011 at Mariucci Arena, University of Minnesota Medicine Buddha Empowerment: A Tibetan Cultural and Spiritual Ceremony Promoting Personal and Societal Healing featuring His Holiness the 14th Dalai Lama 9:30 - 11:30 a.m.

Peace Through Inner Peace: A Public Address featuring His Holiness the 14th Dalai Lama 2:00 - 3:30 p.m.

May 9, 2011 at University Radisson Hotel Second International Tibetan Medicine Conference: Healing Mind & Body 9:00 a.m. - 7:30 p.m. (* His Holiness is not expected to be in attendance.)

2 Days Only, 3 Events

The Minnesota Visit 2011 His Holiness the 14th Dalai Lama

A special invitation to health professionals: The Second International Tibetan Medicine Conference May 9, 2011 This event will bring to the Twin Cities the foremost practitioners of Tibetan medicine from the Men-Tsee-Khang, the Tibetan Medical Institute of His Holiness the Dalai Lama, in Dharamsala, India. By the end of the conference, participants will be able to meet the following objectives involving Tibetan Medicine: Examine the relationship between ethics, spirituality, and healing.

Investigate participants' own unique constitution.

Determine what lifestyle choices to make, based on participants' own constitution.

Explain how to heal from the source and develop health through balance.

Describe research about Tibetan medicine, as well as propose additional research needed.

Apply teachings of Tibetan medicine personally and professionally.

etan Ame Tib r

Minnesota of

For tickets and more information, visit www.dalailama.umn.edu or call 612-624-2345

un n Fo dation ica

CONTENTS

4 7 8

FEBRUARY 2011 • Volume 9 Number 2

NEWS

16

CALENDAR National Donor Day

18

HEALTH CARE ROUNDTABLE Comparative effectiveness

26

SPECIAL FOCUS: WOMEN’S HEALTH COPD

PEOPLE

PERSPECTIVE Dirk Miller, PhD, LP, MPH The Emily Program

10

MINNESOTA HEALTH CARE ROUNDTABLE

10 QUESTIONS Paul Waytz, MD Arthritis & Rheumatology Consultants, PA

12

TAKE CARE Lactose intolerance

14

ORTHOPEDICS Close to the bone

By Carolyn Suerth Hudson, RD, LD

By Jill Heins Nesvold, MS, Charlene McEvoy, MD, MPH, and Chris Wendt, MD

28 32

Uterine fibroids

By Jon S. Nielsen, MD

CARDIOLOGY From “no options” to new options

By Timothy D. Henry, MD, Mohammad Sarraf, MD, and Rachel E. Olson, RN

By Patrick Yoon, MD Your Guide to Consumer Information

FREE

February 2011 • Volume 9 Number 2

Bones Patrick Yoon, MD

Uterine fibroids Jon Nielsen, MD

T H I R T Y- F I F T H

SESSION

Background and focus: Until recently, when the word wellness came up in organized medicine it was regularly dismissed as pseudo-science. Our health care delivery system, or as many call it “sick care delivery system,” evolved in a way that doctors were not paid to keep patients well and thus wellness strangely fell outside the purview of medicine.

Obviously it is better to stay healthy than try to fix complex and someA changing focus in health care times avoidable medical conditions. Selling servApril 28, 2011 ices supporting this 1:00 – 4:00 PM • Duluth Room approach was often Downtown Mpls. Hilton and Towers criticized for lack of randomized clinical trial research; inadequate licensing, credentialing, and oversight for practitioners; and many other concerns. Wellness as an industry, with its wide diversity of methods and approaches, was kept at arm’s length by the medical establishment. Economics have forced this to change and now everyone is engaged with using an old tool in new and more collaborative ways for the betterment of all.

The Wellness Revolution

Rheumatology Paul Waytz, MD

www.mppub.com

Objectives: We will explore the definition of wellness, why today there is a wellness revolution, and why doctors now embrace the concept. Examining multiple collection methodologies and sets of data, we will discuss how and why employers are driving this new approach to health care. We will consider privacy issues and many other challenges to an already overburdened administrative process posed by collecting and storing individual health care data in places such as work sites and health clubs. We will discuss the breadth of wellness initiatives, their pros and cons, and how they can lower the cost of health care while improving individual health status.

PUBLISHER Mike Starnes mstarnes@mppub.com EDITOR Donna Ahrens dahrens@mppub.com ASSOCIATE EDITOR Martha Malan mmalan@mppub.com ASSISTANT EDITOR Scott Wooldridge swooldridge@mppub.com ART DIRECTOR Elaine Sarkela esarkela@mppub.com

Please send me tickets at $95.00 per ticket. Mail orders to Minnesota Physician Publishing, 2812 East 26th Street, Minneapolis, MN 55406.

Tickets may also be ordered by phone (612) 728-8600 or fax (612) 728-8601.

Name

OFFICE ADMINISTRATOR Juline Birgersson jbirgersson@mppub.com

Company

ACCOUNT EXECUTIVE John Berg jberg@mppub.com

Address City, State, Zip

Advisory Board: Minnesota Medical Association (MMA), Minnesota Hospital Association (MHA), Minnesota Medical Group Management Association (MMGMA), Buyers Health Care Action Group (BHCAG), Minnesota Business Partnership (MBP), Minnesota Healthcare Network (MHN), Advocates for Marketplace Options for Mainstreet (AMOM), Minnesota HomeCare Association (MHCA), Minnesota Physician-Patient Alliance (MPPA), Physicians Service Network (PSN), Minnesota Center for Rural Health, and Minnesota Council of Health Plans.

Minnesota Health Care News 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; e-mail 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 this publication may be reprinted or reproduced without written permission of the publisher. Annual subscriptions (12 copies) are $36.00. Individual copies are $4.00.

Telephone/FAX Card #

Exp. Date

J Check enclosed J Bill me J Credit card (Visa,Mastercard, American Express, or Discover)

Signature Email

Please mail, call in or fax your registration by 4/21/2011

FEBRUARY 2011 MINNESOTA HEALTH CARE NEWS

3

NEWS

Dayton Listens to Opponents, Signs Medicaid Measure In an unusual signing ceremony, Gov. Mark Dayton signed an executive order expanding Medicaid coverage for poor Minnesotans and also let protesters take the podium to express their opposition to the measure.

Signing on to the Affordable Care Act’s measures for a Medicaid opt-in program was a campaign promise of Dayton’s, after more than a year of political fighting over the General Assistance Medical Care program.

At the Jan. 5 signing ceremony, Dayton calmed a large crowd and told them that opponents as well as supporters of the measure would be allowed to speak.

Dayton said the Medicaid optin measure would provide coverage to 95,000 Minnesotans and create up to 20,000 jobs at no net cost to the state. “This money goes to benefit the low-income recipients, but really the dollars

4

themselves go to Minnesota hospitals and doctors, nurses, and others who provide essential health care to all these citizens and to all of us,” Dayton said.

Opponents of the measure questioned whether the state could afford the long-term costs of covering poor Minnesotans and said such programs were better provided by religious charities.

Feinwachs Out as MHA Counsel After Criticizing PMAP David Feinwachs, general counsel of the Minnesota Hospital Association (MHA) for almost 30 years, was fired from the organization recently, not long after making a controversial video questioning the administration of state health plans by private insurance companies.

Neither Feinwachs nor MHA is willing to discuss the reason for the dismissal, but Feinwachs concedes his work in questioning the lack of transparency around pay-

MINNESOTA HEALTH CARE NEWS FEBRUARY 2011

ments for the state’s Prepaid Medical Assistance Program (PMAP) was “controversial.”

Feinwachs made two videos for the PMAP Reform Advocacy Group in spring and fall of 2010; the second was posted online in September. In the video, Feinwachs describes the PMAP system as a “black box” with no realistic accounting oversight for the billions of tax dollars that fund state health plans.

Under the current system, PMAP is administered by private health plans and funded by state and federal Medicaid dollars.

Feinwachs says that, according to a report by the General Accounting Office (GAO), the standards for oversight of funding for programs such as PMAP are nonexistent.

Janice Hennings, MHA spokeswoman, declined to provide details on Feinwachs’ dismissal, saying that MHA could not comment on personnel matters. She says the hospital group is committed to transparency on issues like PMAP.

Feinwachs says he was proud of his tenure at MHA. “I considered it an honor and a privilege to serve Minnesota hospitals for almost 30 years,” he says. “I’m extremely proud of the things we accomplished during that 30-year period. Things like negotiating with the attorney general’s office to put an end to egregious collection practices and to provide some level of discounted care to people with no insurance, things like standardization of billing processes and administrative simplification, things like the adverse event reporting law in Minnesota. I was delighted to play at least a small part in such important efforts.”

Insurance Premiums Rose by 41 Percent in Six Years, Study Finds Health insurance premiums have risen sharply in the past six years, according to a new report from the Commonwealth Fund. The report, which looks at national

trends and state-by-state numbers, finds that, nationally, premiums for employer-sponsored family health insurance increased more than three times faster than median incomes in the United States.

Across all states, insurance premiums increased an average 41 percent from 2003 to 2009, the report finds. While rates are rising, insurance companies are providing less coverage, the report adds, with deductibles rising 77 percent per person during that time period.

In Minnesota, premium rates have risen less sharply, but still have increased 25 percent for individual policies and 31 percent for family plans, the data shows.

The report examines how the Affordable Care Act (ACA) will affect the trend of rising premiums. It finds that the provisions of the act have the potential to reverse the trend toward higher premiums and out-of-pocket costs.

“Whether you live in Montana, Texas, or New York, private insurance costs have been increasing faster than workingfamily incomes,” says Commonwealth Fund Senior Vice President Cathy Schoen, lead author of the study. “For more than a decade, families with job-based insurance have been sacrificing wages to hold on to health insurance. The good news is that the Affordable Care Act reforms provide a foundation to improve coverage and slow health care cost growth in the future.”

The report says the ACA may change the rising trend in premium costs with provisions that require health plans to put more dollars into medical care rather than administrative costs, giving states more authority to review and question premium increases, establishing health insurance exchanges that have consumer protections, and providing federal subsidies for individuals and businesses to purchase health insurance.

Hospital’s Pilot Program Reduces Patient Returns A pilot program at Fairview Southdale Hospital has reduced readmissions of Medicare Advantage patients by as much as 44 percent, officials announced last week. The project, which began last February and is ongoing, is a joint effort of Fairview Physician Associates, UCare, and Fairview Southdale Hospital to improve patient care and experience, and reduce costs. The program covered all admitted UCare for Seniors patients but targeted those with diabetes, chronic obstructive pulmonary disease, and heart disease.

Officials say preventing avoidable readmissions keeps patients healthy and holds costs down.

Each prevented readmission could save $10,000 in avoidable cost, according to William Nersesian, MD, MHA, chief medical officer of Fairview Physician Associates.

Officials with the groups say they hope to extend the program to other Fairview hospitals, which could eventually save several million dollars.

Blue Cross Expands Online Care Service Blue Cross and Blue Shield of Minnesota has expanded its online health service to all Minnesotans.

The Online Care Anywhere service was first introduced one year ago as a pilot program serving Blue Cross employees. It has since been expanded to employer groups and is now available to all Minnesotans at www.onlinecare anywheremn.com.

Online care services are becoming more common, with HealthPartners and UnitedHealth Group both introducing online care options in the past few months. Blue Cross officials say their experience gives them an advantage.

“We were really an innovator in launching this type of service in the Twin Cities,” says Sig Muller,

Cataract Specialists

From left (top): Sherman W. Reeves, MD, MPH; David R. Hardten, MD, FACS; Richard L. Lindstrom, MD; Thomas W. Samuelson, MD; Patrick J. Riedel, MD. From left (bottom): Elizabeth A. Davis, MD, FACS; William J. Lipham, MD, FACS.

Surgery Locations: Arlington Blaine Bloomington Maplewood

Minneapolis Mora New Prague Sandstone

Cataracts A cataract is a clouding of the eye’s natural lens that inhibits or diminishes the passage of light to the retina. Cataracts progress at different rates and can affect one or both eyes at the same time.

When a cataract develops, a patient may wish to have it surgically removed. The surgery is performed as an outpatient procedure under local anesthesia and takes approximately 10-20 minutes. Once the cataract has been removed, a new clear lens, called an intraocular lens implant (IOL) is put in place of the natural lens. Most patients return to their normal work or lifestyle in a day or two.

Cataract surgery is one of the most common and successful surgical procedures performed today.

Many patients report vision that is even better than before they developed cataracts, especially with the optional newer implant that often eliminates the need for close vision glasses after surgery.

New alternatives for treatment In choosing an intraocular lens for cataract surgery, you have several options. Speak with your family eye doctor and your surgeon to determine which is best for your eye and your lifestyle.

Meet us online at mneye.com or call us at 1-800-Eye-To-Eye

News to page 6 FEBRUARY 2011 MINNESOTA HEALTH CARE NEWS

5

News from page 5 vice president of business development at Blue Cross. “We’ve been in the market for more than a year now and it’s really important to us as part of our mission to provide broader access to health care and help drive down costs.”

The Blue Cross service is modeled after a traditional doctor’s office visit and is staffed by providers from Fairview Health Services, including physicians and nurse practitioners. Users can connect face to face with providers via webcam, or can access the service by phone. Blue Cross officials stress the convenience that such a service offers and say consumers have reported saving an hour per visit with physicians online as opposed to traveling to a clinic in person.

“The reality of life is that sometimes you don’t have time to schedule an appointment,” says Pamela Sedmak, chief strategy and innovation officer for Blue Cross. “Online Care Anywhere lets

you step to the front of the line and literally be seen moments after you first think about seeing a doctor. You can discuss your symptoms, get a quick diagnosis and prescription for common illnesses, such as bronchitis or a sinus infection.”

Muller says the average online visit lasts 13 minutes and costs $45. Blue Cross insurance is accepted or consumers can pay via a credit card. Although Muller notes that other health plans won’t cover the visits at this time, the visits can be submitted for coverage under some medical spending accounts such as health savings accounts.

CIPRAP Study Looks At Lessons from H1N1 With so many victims of the 2009 H1N1 pandemic being young adults, colleges and universities played a large role in the nation’s response, according to a new study.

The report, “H1N1 and Higher Ed: Lessons Learned” was

released recently by the University of Minnesota Center for Infectious Disease Research and Policy (CIDRAP). The publication examines the impact of H1N1 on the Big 10+2 universities and reports on successful strategies and best practices that were developed.

The CIDRAP report finds that, with college-age populations at such high risk from the disease, the effect on higher education operations was widespread.

According to Jill DeBoer, MPH, director of the Academic Health Center’s Office of Emergency Response at the U of M, universities could not take a business-asusual approach.

“H1N1 response required an unprecedented level of community organizing over an extended period of time,” DeBoer says. “We are not just schools; we are not just workplaces: We act like cities.

On a daily basis, that is how we operate. We are really responding at a community level in the face of a pandemic or other public health emergency.”

Unlike typical seasonal flu patterns, the H1N1 virus was widespread and active during the summer months in the United States. There was little immunity built up in most populations, and vaccines were not available when the disease was most active in the U.S. Also, most of the deaths caused by H1N1 occurred among younger people, including those who were otherwise healthy.

The report outlined some of the successful strategies that universities and colleges employed, including using phone and Web technologies in new ways to register people quickly for vaccination clinics; coordinating key messages within the university and with state public health departments; harnessing the power of student volunteers to ease the burden on the health care workforce and effectively reach other students; determining how to manage attendance policies at odds with health recommendations; and identifying how to reduce the spread of influenza in residence halls.

Specializing in Eating Disorder Treatment Anorexia • Bulimia • Binge Eating Personalized care in a comfortable home-like environment Intensive Outpatient (multi-day) Treatment with a holistic approach • Adult group therapy programs Binge eating programs • Individual therapy Bariatric pre-surgery assessment and therapy Family therapy • Dietitian consultations Body-Image groups • Chaplain • Yoga

Immediate openings Easy access from anywhere in the Twin Cities area

www.watersedgechc.com

6

MINNESOTA HEALTH CARE NEWS FEBRUARY 2011

952-898-5020

PEOPLE The Minnesota Association of Community Mental

NOW hear this!

Health Programs, Inc., presented awards to two mental health professionals at the association’s annual community mental health conference in Duluth. Anne Gearity, PhD, LICSW, received the 2010 Clinical Service Excellence award. Gearity is a therapist, educator, and trainer in the fields of social work, child development, and children's Anne Gearity, PhD, LICSW

mental health treatment. The award cited

Gearity’s consistent, effective, high-quality direct care services for clients’ needs and goals for more than 30 years of clinical work. The association also honored Eugene R. Bonynge, PhD, posthumously with its Distinguished Career Award, in recognition of his long-lasting contributions to the field. Bonynge was CEO of nonprofit mental health center Woodland Centers, in Willmar, from 1995 to January 2010, when he unexpectedly died of cardiac arrest. Prior to his tenure as Woodland Center's CEO, he was clinical director for three years.

He was a psychologist at the Willmar Regional Treatment Center for more than 20 years. Bonynge served as president of the Minnesota Association of Community Mental Health Programs in 1999 and 2007 and participated in numerous community mental health organizations and initiatives.

The Minnesota Optometric Association has hired Elizabeth

D

o you know of family members, friends or neighbors who have difficulty using their telephone? Do they have trouble hearing, speaking or have a physical disability that prevents them from using a standard telephone?

The Minnesota Telephone Equipment Distribution Program can provide special telephone equipment at NO CHARGE to Minnesota residents of all ages!!

The equipment includes amplified (corded and cordless) phones, speakerphones, captioned telephones, telephone ring signalers, deafblind equipment and other special equipment.

To learn more about this program visit our Web site at: www.tedprogram.org or contact us at (800) 657-3663, (888) 206-6555 TTY. Eligibility requirements do apply.

Coleman as its new executive director. Coleman took over leadership of the statewide professional organization in November 2010. Her professional background includes 13 years in the New York Legislature staff and 12 years in Chamber of Commerce management. Most

The Telephone Equipment Distribution Program is administered by the Department of Commerce Telecommunication Access Minnesota (TAM) and funded by a telephone surcharge.

recently, Coleman served as executive director of the Parks & Trails Council of Minnesota. Previously, she was president and CEO of the Clearwater Chamber of Commerce, Clearwater, Fla. The North Central Chapter of the Arthritis Foundation has named Karen Larson, MBA, chief executive officer of the foundation’s Upper Midwest Region, the organization resulting from the recent merger of the

Independent Practitioners ... freer to give you: More Attention More Choices And be your best Advocate

North Central and Wisconsin chapters. Larson will also serve as a member of the national Arthritis Foundation’s CEO Cabinet. Previously, Larson has served as past board chair of the National Multiple Sclerosis Society of Minnesota.

The Human Development Center (HDC),

Karen Larson, MBA

Duluth, has hired therapists Nicole Clover, MSW, and Linda Tougas, MSW, at its Lake County office. In Clover’s six years at HDC, she has done extensive work with children and youths in a community setting.

She provides services to children and adults in HDC’s Two Harbors and Silver Bay offices, and provides on-site services at Minnehaha Elementary School and William Kelley School in Silver Bay. Tougas’s professional experience includes work in chemical dependency, children’s mental health, and children’s protective services. She serves children and adults in her practice at HDC. Erik Mikkelsen, MD, has joined Children’s Hospital staff and Children’s Respiratory and Critical Care Specialists, PA as a pediatric intensivist. Mikkelsen finished a pediatric critical care fellowship at Cincinnati Children’s Hospital in 2010 while simultaneously obtaining a master of education in curriculum and instruction at the University

Thank you for choosing independent medical care.

of Cincinnati. He attended the Medical College of Wisconsin– Milwaukee and completed his pediatric residency at Children’s Mercy

www.midwestipa.org • 952-883-3133

Hospital in Kansas City, Mo. FEBRUARY 2011 MINNESOTA HEALTH CARE NEWS

7

PERSPECTIVE

Eating disorders: serious, complex, common With professional help, recovery is possible

T

here are many misconceptions about eating disorders. For example: They affect only young women. They’re all about not eating in order to look good. If the person would just eat, everything would be fine.

None of those statements is true.

Eating disorders are more serious, complex, and common than many people realize.

Dirk Miller, PhD, LP, MPH The Emily Prrogram

Dirk Miller is founder and executive director of The Emily Program, which takes a holistic and humanistic approach to treating clients with eating disorders.

A licensed psychologist, Miller earned his MPH and PhD in counseling psychology from the University of Minnesota. In 1985, he began Indiana’s first comprehensive, hospital-based eating disorders treatment program.

In 1993, he opened The Emily Program as a comprehensive outpatient eating disorders treatment program. It now serves nearly 3,000 clients at seven sites in St. Paul, St. Louis Park, Burnsville, Stillwater, and Duluth.

For example, more than 202,000 Minnesotans have eating disorders. Conservative estimates suggest that about 6 percent of women and 3 percent of men struggle with an eating disorder. In Minnesota, that’s 99,000 women and 46,000 men. Among adolescents, the rates are higher: nearly 18 percent for girls and 6.5 percent for boys. That’s more than 57,000 Minnesota adolescents.

Awareness is growing. A recent National Eating Disorders Association survey finds 82 percent of Americans believe eating disorders are a physical or mental illness and should be treated as such, and more than half say they know someone with an eating disorder.

Because eating disorders are so complex, no one treatment modality can successfully address every client’s needs. Effective treatment has to be personFortunately, recovery is possible; there is hope and alized; respond to the whole person; and draw on help. With a clear sense of the problem, and new elements of individual, group, and family therapy, nutrition education, psychiatry, skills to cope, individuals can medicine, and complementary overcome the shame and secretherapies.

Eating disorders cy of eating disorders.

Eating disorder basics Here are some essential facts about eating disorders:

This complexity means that recovery requires time, patience, and support—especially support from key people in an individual’s life. Because eating disorders affect families so profoundly, families have a profound role in helping someone with eating disorders to recover.

are as prevalent as breast cancer in the United States.

Anorexia nervosa and bulimia are not the only eating disorders. In fact, eating disorders not otherwise specified (ED-NOS) and binge eating disorders are more common than anorexia (severely restricting the amount of food one eats) or bulimia (bingeing on food and then purging what one has eaten).

Eating disorders do not discriminate. Eating disorders affect females and males of any background, from preteen to senior. They disrupt the health and well-being of individuals, their families, and their communities.

The prevalence far exceeds treatment resources.

Even though eating disorders are as prevalent as breast cancer in the United States, Minnesota has only 55 residential and inpatient beds—all of them in the Twin Cities—for the most seriously ill eating disorder patients. Large areas of Greater Minnesota have no access to any eating disorder specialists.

Identifying a problem If you suspect a problem, act quickly.Talk to a physician, therapist, dietitian, or an eating disorders professional.

Ask these six questions about yourself or your loved one: • Do you feel like you sometimes lose or have lost control over how you eat?

• Do you ever make yourself sick because you feel uncomfortably full?

• Do you believe yourself to be fat, even when others say you are too thin?

• Do food or thoughts about food dominate your life?

And this inadequate access to care is better than nearly any other state’s. As a result, nine out of 10 people with an eating disorder never even seek treatment.

• Do thoughts about changing your body and/or your weight dominate your life?

Other illnesses often accompany eating disorders, including chemical dependency, post-traumatic stress disorder, depression, anxiety disorder, morbid obesity, and other problems.

Two or more “yes” answers strongly indicate the presence of disordered eating.

Eating disorders have no single origin. Eating disorders are affected by, and affect in turn, biological, psychological, emotional, familial, cultural, spiritual, sexual, gender, and social factors.

Eating disorders are difficult to overcome without professional help. However, through treatment that may include individual, group, and family counseling; nutrition education; medications; complementary therapies; and, in some cases, hospitalization, you or your loved one can find hope and healing.

They are deadly serious. Anorexia nervosa has the

8

highest mortality rate of any mental illness. Binge eating disorder and compulsive overeating can lead to morbid obesity, type 2 diabetes, heart disease, high blood pressure, and other illnesses.

Anorexia and bulimia can result in heart failure, suicide, early-onset osteoporosis, kidney failure, pancreatitis, and other serious problems.

MINNESOTA HEALTH CARE NEWS FEBRUARY 2011

• Have others become worried about your weight and/or eating?

Recovery is possible

All we wanted was help in dealing with Parkinson’s.

At Bethesda Hospital, we found a team of specialists with a comprehensive approach.

Hy Carpenter’s granddaughter first noticed a tremor in his hand as they read together.

When the tremor was diagnosed as a symptom of Parkinson’s Disease, the Carpenters turned to the Capistrant Center for Parkinson’s Disease and Movement Disorders, where a comprehensive team including doctors, PTs, STs, OTs, psychologists, social workers and support groups surrounded them with care. Over the years, they’ve learned that the diagnosis wasn’t the end of their story, but rather, a new beginning.

For more information about Bethesda Hospital, located in St. Paul, Minn., please visit bethesdahospital.org or call 651-925-2839.

10 QUESTIONS

& Paul Waytz, MD Dr. Waytz is a rheumatologist at Arthritis & Rheumatology Consultants, PA in Edina.

What is rheumatology? Rheumatology is the medical specialty that deals with disorders primarily affecting joints, muscles, soft tissues, and bones. There are more than 100 rheumatic diseases, a number of which have little or nothing to do with the musculoskeletal system. Some conditions affect the skin as well as internal organs, although arthritis—referring to something abnormal with a joint—is a usual hallmark. The “itis” portion of the word suggests that some form of inflammation is involved. “Rheumatism” is an outmoded term referring to aches and pain and is not a true disease.

What are the common causes of rheumatoid diseases? We do not know what causes most rheumatic diseases. Many of the more common conditions are coined “autoimmune,” implying a malfunction of our immunity. The immune system is complicated and necessary in our defense against infections, tumors, foreign antigens, and other insults.

With rheumatic illnesses there seems to be a breakdown in regulating the immune system.

Indeed, the situation may not be so much a deficiency as an overactivity. It is unlikely that there is one specific cause, with genetics, hormones, and environmental issues also playing a potential role.

What is the difference between rheumatoid arthritis and osteoarthritis?

Osteoarthritis is traditionally considered a disease of aging. Worldwide, it is the most common type of arthritis. Simplistically, it can be thought of as a wearing away of cartilage with secondary effects on bone and surrounding structures. Obesity and injury are common causes. Rheumatoid arthritis is the prototypical inflammatory or autoimmune disease. It affects between 1 percent and 2 percent of the population, usually starting between the ages 20 to 40, and has the potential to be severely deforming and destructive. Treatment is directed against the complex mechanisms that provoke an inflammatory response and can erode cartilage, bone, and soft tissue. Five percent of patients with rheumatoid arthritis are diagnosed under the age of 16. Unfortunately, differentiating osteoarthritis and rheumatoid arthritis may not be cut and dried, and having one condition does not preclude getting the other.

What is the process for a patient to get an appointment with a rheumatologist? Primary physicians refer most people. Patients can directly call a rheumatologist’s office as well, but insurers may overrule this self-referral process; it’s best to double check on coverage.

Photo credit: Bruce Silcox

10

What is lupus and how is it treated? Lupus is another autoimmune condition that commonly affects the skin and joints, but also can cause fever, hair loss, and pleurisy. Lupus has the potential to cause very serious problems when the inflammation attacks the kidneys, central nervous system, or other vital structures. A limited form of lupus affects only the skin. Treatment needs to be tailor-made to fit the situation. Prednisone, a form of cortisone, is often utilized, but the dosage (and subsequent potential for side effects) can be quite variable. A simple medication commonly used is Plaquenil, a drug originally used to treat malaria. In serious cases of lupus, potent drugs that affect the immune system are necessary and essential. One difficulty in managing lupus is that it occurs more frequently in women and is most often diagnosed during the childbearing years, which requires consideration of effects on the reproductive system and/or developing fetus.

MINNESOTA HEALTH CARE NEWS FEBRUARY 2011

“

”

We can do our best when a diagnosis and referral are made early enough—before there is damage.

How do bursitis and arthritis differ? Arthritis implies a process affecting just the joint itself. A bursa is a soft-tissue structure lying just outside the joint at the area where a tendon attaches to bone. Bursitis is an inflammation of this “pocket” and occurs with tendonitis. The most common cause is overuse or repetitive use.

Please explain gout and pseudogout. Gout and pseudogout are types of crystalline arthritis, an inflammatory arthritis that can cause abrupt and severe pain in one or several joints. Gout is caused by a buildup of uric acid crystals in the joint, pseudogout by specific calcium crystals. These crystals incite an inflammation quite different from rheumatoid inflammation.

What is the relationship between what a rheumatologist does and the work of orthopedic surgeons?

Rheumatologists do not perform any operative procedures. Rheumatologists medically manage patients to prevent joint damage that might require something surgical. We are doing a better job of this with newer medications. However, when cartilage is completely gone from a joint and there is significant pain or deformity from bone rubbing on bone, we refer to orthopedists for surgeries such as joint replacement. We also refer for procedures such as carpal tunnel release if this does not respond to medicine or injections.

How is integrative medicine used in the treatment of rheumatic disease? We recognize that there are complicated

processes causing rheumatic diseases, many of which are still unknown. There is a long history of sideshow remedies, “alternative” medicines, and other treatments that may be either worthless or dangerous. Yet we now understand that medicine such as glucosamine helps some people with osteoarthritis, some fish oils have antiinflammatory properties, and vitamin D has possible regulatory effects on certain cell functions. We need to be open in considering integrative therapies, but still vigilant in watching for toxicities.

Importantly, however, I do not want someone to give up or forestall traditional and scientifically based approaches and recommendations.

What’s on the horizon for state-of-the-art treatment of rheumatic disease? Referring to inflammatory arthritis, such as rheumatoid arthritis, we still have no true cures available and rely on current medicines, often in combination, that do a tremendous job in limiting and, in some cases, actually preventing joint damage. Unfortunately, not everything works for everyone and sometimes, for no obvious reason, medication that has been effective for a particular person stops working. I think we will see a new medicine every year or so for a while. These will function to limit specific immune activities that promote inflammation. Amazingly, we can now pinpoint many of these reactions and come up with an almost “designer” type of medicine to retard or negate the process. In reality, the best horizon is one where a diagnosis and referral are made early enough— before there is damage. That is when we can do our best.

A spine center approach to back & neck pain.

R

esea c has esearch as sshown ow tthat at tthee optimal opt a ccare a e for o ccomplex omplex problems problems is is provided provide d d through through Centers Centers of of Excellence.

Excellenc nce. At At Summit Summit Orthopedics Orthopedics we’re we’re trying tr ying to to improve improve how how we we care care ffor or spine spine care care iinn 22010 010 through through a spine Spinecare spine ccenter enter approach. approach. SSummit ummit Sp inecare ccombines ombines the the expertise exxpertise of of three three nnon-surgical on-surgical spine spine specialists, specialists, three three ffellowship-trained ellowship-traained spine sppine surgeons, surgeons, two two spinespinespecialized specialized ttherapists, heraapists, X-ray, X-raay, MRI MRI and and iinjection njection suite suite — all all under under one one roof. roof. We’ve We’ve invested invested in in patient patient

eeducation ducat o wwith t aan on-line o e sspine p e encyclopedia e cyc oped a at at www. w w w.

SSummitSpinecare.com.

Su mmitSp S inecare.com. AAlso, lso, as as a ffree ree community community sservice, er vice, wwee provide provide a 36-page 36-page Home Home Remedy Remedy Book Book that wwith ith exercises exercises th at relieve relieve neck neck and and back back pain. pain. Call Calll us us aand nd we’ll we’ll ssend end you you 20 20 copies cop o ies for for you you to to provide provide as as a rresource esource to to your your patients. patients.

By By having having itit all all in in oone ne place, place, the the back back or or neck neck ppain ain sufferer sufferer no no longer longer has has to to ddrive rive around around town town aanymore. nymore. Now Now isn’t isn’t tthat hat a welcome welcome relief? relief?

NON-SURGICAL NON-SURGIC AL SPINE CCARE ARE

SPINE SURGEONS RGEONS

M.D..

TTom om CCesarz, esarz, M.D BBoard-Certified oard-Certified Physical Physical Medicine FFellowship-Trained ellowship-Trained in spine

PPaul aul D. D. Har tleben, M.D. M.D. Hartleben, BBoard-Certified oard-Certified Orthopedic Orthopedic Surgeon Surgeon FFellowship-Trained ellowship-Trained Spine Spine Surgeon Surgeon

John A. DDowdle, owdle, M.D M.D..

BBoard-Certified oard-Certified Orthopedic Orthopedic Surgeon Surgeon

BBryan ryan J.J. Lynn, Lynn, nn, M.D. M.D. BBoard-Certified oard-Certified Orthopedic Orthopedic Surgeon Surgeon FFellowship-Trained ellowship-Trained Spine Spine Surgeon Surgeon

Kristen M.D..

Krist en M. Zeller, Zellerr, M.D BBoard-Certified oardd Certified fi d Pain Pain Management Management FFellowship-Trained ellowship-Trained PPain ain Managemen Managementt

NNicholas h l JJ.. Wills, Wills lls, M.D. M.D. FFellowship ellowship Trained Trained Spine Spine Surgeon Surgeon

The sspine The pine sspecialty pecialt y ccenter e nt e r o off S Summit um mi t O Orthopedics r t h o p e di c s 2 09 0 W o o d w in d s D rive, W oodbur y, M N5 5125 2090 Woodwinds Drive, Woodbury, MN 55125 A p p o int m e nt s & R eferrals: Appointments Referrals:

651.738.BACK 6 51.738.BAC K

www.SummitSpinecare.com w ww.SummitSpinecare.com FEBRUARY 2011 MINNESOTA HEALTH CARE NEWS

11

TA K E C A R E

T

he good news that people with lactose intolerance don’t need to exclude dairy foods from their diet has been reaffirmed after an expert look at scientific evidence. A year ago, the National Institutes of Health (NIH) convened a panel of independent experts to develop a consensus statement on lactose intolerance and health. The NIH panel reviewed the latest research on lactose intolerance, strategies to manage the condition, and health outcomes of diets that exclude dairy foods. After a thorough review of the scientific evidence, the panel created a statement, which is available at http://consensus.nih.gov/2010/lactosestatement.htm.

The statement addresses some common misperceptions. If you have been diagnosed with lactose intolerance, you can use the expert panel’s findings to help better meet your nutrient needs.

What is lactose, and why can’t some people tolerate it?

Lactose is a carbohydrate in milk and milk products. During digestion, an intestinal enzyme called lactase breaks down lactose into smaller, more easily digested sugars (glucose and galactose).

Lactose maldigestion occurs when an individual produces too little lactase to fully digest the amount of lactose consumed. However, not everyone with a shortage of lactase is lac-

Eliminating dairy unnecessary for most While lactose intolerance may seem like a minor annoyance that can easily be solved by dairy avoidance, this approach may not only deprive you of a food group you would like to consume, but may also lead to nutrient shortfalls and contribute to bigger health problems in the long run. According to the NIH panel’s statement, “Many individuals with real or perceived lactose intolerance avoid dairy and ingest inadeBy Carolyn Suerth Hudson, RD, LD quate amounts of calcium and vitamin D, which may predispose them to decreased bone accrual, osteoporosis, and other adverse health outcomes.” In addition, the panel concluded that most people with lactose intolerance do not need to eliminate all dairy foods. They can effectively manage their intolerance by consuming small amounts of milk, yogurt, natural cheeses, and lactosereduced foods, the panel said.

Lactose intolerance A closer look

Cancer Summit 2011 Looking Forward During Changing Times

Keynote Speaker: Dr. Lawrence Wallack Dean, College of Urban & Public Affairs, Portland State University March 24, 2011 8am-4:30pm Minneapolis Airport Marriott, 2020 American Boulevard East Bloomington, MN 55425 For more information www.mncanceralliance.org (763)712-7636 or (800)782-1878 Ext.167

12

tose intolerant. Some people with lower levels of lactase may not experience digestive discomfort at all when they consume milk or milk products. So the term “lactose maldigestion” refers simply to the incomplete digestion of lactose.

Lactose intolerance, on the other hand, refers to the gastrointestinal (GI) disturbances that may occur following the consumption of more lactose than the body is able to digest. Left undigested, lactose is fermented by “healthy” bacteria in the intestinal tract. This fermentation produces uncomfortable symptoms such as gas, abdominal pain, or bloating.

It’s important to note that there are varying degrees of sensitivity to lactose. Some people may experience GI disturbances every time they eat foods with lactose, while others may experience this disturbance only if they consume a large amount of lactose on an empty stomach.

MINNESOTA HEALTH CARE NEWS FEBRUARY 2011

Why dairy matters The U.S. Department of Health and Human Services and U.S. Department of Agriculture, in their “Dietary Guidelines for Americans,” recommend that adults and children ages 9 and older consume 3 cups of low-fat or fat-free milk or equivalent milk products every day. Milk and milk products are such an accessible source of important nutrients that it’s difficult for most people to meet recommendations for key nutrients—calcium, potassium, magnesium, and more—without consuming at least three servings daily.

Researchers have found that higher dairy intake as part of a healthy diet leads to higher nutrient intake and better diet quality and bone health; may help people maintain a healthy weight; and has been associated with reduced risk of osteoporosis, hypertension, metabolic syndrome, and type 2 diabetes. Studies also have found that higher dairy intake as part of a healthy diet led to reduced risk of colon cancer.

Lactose intolerance or milk allergy?

Being lactose intolerant is not the same as having a cow’s milk allergy.

Here are some key differences, as outlined by the National Digestive Disease Information Clearinghouse and the Allergy and Asthma Foundation of America (also see Table 1):

Table 1. Lactose intolerance vs. milk allergy • Lactose intolerance is sensitivity to the carbohydrate (sugar)—called lactose—found naturally in milk and milk products, while a milk allergy is an allergic reaction to the protein found in milk and milk products.

• Lactose intolerance is related to the incomplete digestion of lactose in the GI system, while a milk allergy, like all allergies, is triggered by the immune system.

• Milk allergies most commonly occur in young children, whereas lactose intolerance is rare in young children and, if it were to emerge, would most likely happen in late adolescence or adulthood, as lactase efficiency decreases.

• While people with milk allergies need to avoid milk and milk products, most people with lactose intolerance can—and should—continue to enjoy dairy foods such as milk, natural cheeses, and yogurt.

What you can do The following strategies are based on findings from the NIH Consensus Development Conference Statement on Lactose Intolerance and Health: • Get a formal diagnosis. To help prevent nutrient shortfalls that can result from avoiding dairy foods, make sure you receive a formal diagnosis and personalized nutritional counseling.

• Tell your doctor about your GI disturbances or other discomforts after eating.

For more information on lactose intolerance, including free educational materials, visit www.midwestdairy.com.

• If you do experience GI disturbances, ask your doctor to administer a lactose tolerance test, a hydrogen breath test, a stool acidity test, or one of the emerging methods of testing— all of which are reliable ways to measure the lactose absorption in the digestive system.

• Talk to your doctor or request personalized nutritional counseling on strategies for including dairy foods in your diet and/or finding other dietary sources for the many nutrients found in dairy foods.

• Recognize that there are individual variations in the amount of lactose that can be comfortably consumed. Research shows that people with lactose malabsorption can generally consume at least 12 grams of lactose (equivalent to the lactose found in 1 cup of milk) in one serving with little or no discomfort. People can generally tolerate larger amounts of lactose if it is consumed with meals throughout the day.

Lactose Intolerance

Milk Allergy

A sensitivity

An allergy

Occurs in GI system

Triggered by the immune system

A sensitivity to milk carbohydrate (lactose)

A reaction to milk protein

Rare in young children

Generally affects young children; may be outgrown

Can enjoy milk and milk products with simple management strategies

Should avoid milk and milk products unless allergy is outgrown

nutrients as regular dairy foods.

• Sip it. Start with a small amount of milk daily and increase slowly over several days or weeks to tolerance.

• Stir it. Mix milk with other foods, such as smoothies, soups or sauces—or pair it with meals. This helps give your body more time to digest it.

• Slice it. Top sandwiches or crackers with natural cheeses such as Cheddar, Colby, Monterey Jack, mozzarella and Swiss. These cheeses are low in lactose.

• Shred it. Shred your favorite natural cheese onto soups, pastas, and salads. It’s an easy way to incorporate dairy foods that are low in lactose.

• Spoon it. Enjoy easy-to-digest yogurt. The live and active cultures in yogurt help to digest lactose.

Carolyn Suerth Hudson, RD, LD, is nutrition affairs manager for the Midwest Dairy Council, based in St. Paul.

Leg Pain Study Do your legs hurt when you walk?

Does it go away when you rest?

Or, have you been diagnosed with PAD? You may have claudication, caused by lack of blood supply to the leg muscles The University of Minnesota is seeking volunteers to take part in an exercise-training program, funded by the National Institutes of Health

To see if you qualify, contact the EXERT Research Team at

612-624-7614 or email EXERT@umn.edu or visit EXERTstudy.org

Managing lactose intolerance If you are lactose intolerant, you should know that there are practical solutions that may help you enjoy the recommended three servings of low-fat and fat-free dairy foods every day—without experiencing discomfort. Here are several: • Try it. Opt for lactose-free milk and milk products. They are real milk products, just without the lactose, and provide the same great

EXERTstudy.org FEBRUARY 2011 MINNESOTA HEALTH CARE NEWS

13

ORTHOPEDICS

F

Close to the bone Orthopedic experience piques children’s interest

By Patrick Yoon, MD

Urgent U rge rg gent C ge Care. arre.

24 h hours ours a da day, ayy,, 77days daays a week. weekk.

14655 Galaxie Avenue, Apple Valley, MN 55124 952-432-6161 www.applevalleymedicalcenter.com

14

MINNESOTA HEALTH CARE NEWS FEBRUARY 2011

or many young scholars, fascination with science begins to fade not long after they’ve enjoyed the baking soda volcano experience in third or fourth grade.

So how do children develop an interest in becoming doctors or scientists?

It’s not like they can walk into an operating room or research lab and “try it out.” Or can they?

There is a unique program in the Twin Cities that exposes youth to the many careers available in orthopedic surgery, including patient care and research. Excelen Center for Bone & Joint Research and Education teams up with orthopedic surgeons from Hennepin County Medical Center (HCMC) to give students as young as fifth grade hands-on experience in a number of areas of orthopedics.

“We are committed to training the next generation of physicians and scientists, and we welcome the opportunity to get children excited about careers in medicine and science,” says Tim Mowbray, Excelen CEO and president. “We are a community resource, available to all, and this program gives us an opportunity to give back.”

Excelen is a nonprofit research and education organization—a consolidated resource for orthopedic scientists, engineers, physicians, and students. In addition to a 30-year history of research-driven medical breakthroughs that have led to improved patient outcomes and quality of life, Excelen offers educational programs that have helped hundreds of researchers, both scientists and physicians, to develop their skills.

In a state-of-the-art bioskills laboratory, physicians, medical students, and medical device professionals are trained on the latest medical procedures and equipment. Eight stations, set up like operating suites, provide a realistic medical setting in which to learn.

Students from junior high and high schools, youth programs, and science camps also come to Excelen to learn that orthopedics can be interesting, fun, and an attainable career choice.

Hands-on orthopedics education The youth program starts with a presentation given by an orthopedic surgeon who explains what orthopedic surgery is and what orthopedic surgeons do—surgery involving bones and joints. In addition, students learn about all the people involved in the orthopedic team, from anesthetists to nurses to x-ray technicians to medical students to the orthopedic surgeon. They learn how researchers study new treatments and products designed to enhance people’s quality of life. They see that there are many orthopedic career options, from surgery to research to medical device design. The surgeon always explains that the first step is to do well in school.

Many times, he will also offer children an opportunity to come back and shadow him for a day, spending time in the operating room, watching surgery, and seeing firsthand what it is like to work in a hospital.

After the surgeon’s presentation, the students move to the bioskills lab where they find the workstations with operating room lighting. Working on synthetic bones, they’re trained to use plates, screws, and drill to fix two different types of fractures—a femur (thigh bone) and a tibia plateau (right below the knee) fracture.

(Although orthopedics involves many types of surgery, a lot of it

To talk with Excelen about participating in its Mentor Connection Program, call Joan Hursh at (612) 454-4250.

involves fixing broken bones.) Working in pairs, the young students learn how to fix a femur fracture by first aligning the broken pieces, and then stabilizing them using a titanium nail and screws. Working on the fractured tibia, they again align the broken bones correctly and then stabilize the pieces, this time with a metal plate and screws. Throughout both processes, the students learn to work together towards a common goal and to use various types of operating-room equipment such as power drills, mallets, and screwdrivers.

It takes a team to put on these courses. Orthopedic surgeons and residents from HCMC and skills laboratory staff from Excelen donate their time to work with the children. Medical device companies such as Smith & Nephew and Stryker donate the plates, screws, and rods, and their representatives help the students with the instruments used in their “surgeries.”

might be just the spark they need to consider a career in orthopedics. It reminds us to stop and think about all the people who helped us get to where we are and that we need to give back and do that for others. If we make time, we can make a difference.

Patrick Yoon, MD, is an orthopedic surgeon at Hennepin County Medical Center, where he is director of foot and ankle trauma in the Department of Orthopedic Surgery. He is also an assistant professor of orthopedic surgery at the University of Minnesota.

When you’re e told

your daughter’s daughter ghter’s esophagus us isn’t connected, you think it’s the hardest news you’ll ever have to swallow.

Rewarding for all The students love it. Their backgrounds are diverse, from an Urban 4H group to children attending BioMed Camp at the Science Museum of Minnesota.

The Urban 4H group was in HCMC’s backyard, meeting at the Elliott Park Youth Center. Called Believe and Achieve, the program focuses on looking at college and preparing youth for careers.

Eleven young men who grew up at the rec center across the street from HCMC learned about orthopedic medicine and also that the hospital sees them as part of its community.

“This was a very impactful experience for our students and they loved having hands-on learning in what was clearly a state-of-theart place where doctors come to train,” said Kathryn Sharpe, the coordinator of the program. “It was phenomenal and the young men were honored to be taken seriously by people at the hospital.”

The Science Museum’s BioMed Camp was teaching children how biomedical technology changes our world. They got the inside scoop on how the body works and learned how scientists search for cures for disease and develop instruments from pacemakers to bone splints. As part of the camp, Excelen hosted 45 10- to 13-year-old children who were interested in science careers.

“The children loved visiting the lab,” said Julia, the person who coordinated the visit for the Science Museum. “They talked about it for days and kept asking if they could go back.”

The orthopedic education program for youth is rewarding for everyone involved. Surgeons can get into this grind where we just put our heads down and do our work. We forget about the outside world. These children come in, with no background in orthopedics, and then they go into the lab and get the hang of fixing a bone. It

Then, following sur surgery, gery, you’re you’re told infection n is thr threatening eatening her life. fe. F Fortunately, ortunatelyy, w wee can tell yyou ou to takee her home;; where w tak wee ccan contin continue ue infusion therapy therapy, pyy, and nd beat the infection. W Wee pro provide v the comprehensi vide comprehensive ve pediatricc homecare ser services vices Ireland needs — at home; where she thri thrives. rives.

Meet the miracle at ir irelandthrives.com eland ndthrives.com

visit www www.pediatrichomeservice.com w.pediatrichomeservice ice.com click

FEBRUARY 2011 MINNESOTA HEALTH CARE NEWS

15

February Calendar Transplant Support and Education Joining a support group after receiving an organ transplant can be of great benefit to you, your family, and your friends. Sharing your concerns and triumphs can be comforting.

Education can provide encouragement and confidence.

1 & 15

Blood and Marrow Transplant (BMT): Graft versus Host Disease BMT physicians and other health care professionals regularly speak at the group.

Meetings are held the first Tuesday of the month from 9:30 to 11 a.m., and the third Tuesday of the month from 5:30 to 7 p.m.

Call 612-273-2800 to register.

Tuesdays, see above for meeting times, Hope Lodge, 2500 University Ave. S.E., Minneapolis

7

Lung Transplant For information, call Marget Schmidke at 612-273-5796. Meetings are held the first Monday of the month: 7–8:30 p.m.

All other Mondays: 11 a.m.–noon.

Mondays, see above for meeting times, Lillehei Heart Institute, Nils Hasselmo Hall, 312 Church St. S.E., Education Rm., Minneapolis

10

Heart Transplant This group meets on Thursdays.

Call Lilli Bauman at 612-273-5670 for more information.

Thursdays, Feb. 10, noon–1 p.m., U. of Minn. Medical Ctr., Fairview, 500 Harvard St., 8th Fl., Bridges Conference Rm., Minneapolis

10

Liver Transplant Come and meet with pre-/post-transplant patients and their families. The group meets every Thursday. For more information, call Susanne Hollister at 612273-3165.

Thursdays, Feb. 10, noon–1:30 p.m., U. of Minn. Medical Ctr., Fairview, 500 Harvard St., Main Hospital, 7th Fl., Rm. 120, Minneapolis

Plan for a 30–40 minute appointment.

Preparation is required. Call 1-866-9049962 to register. Fee: $30 per person.

Saturday, Feb. 12, 7–11 a.m., Mercy Hospital, Heart & Vascular Ctr., 4050 Coon Rapids Blvd., Lower Level Conference Rm., Coon Rapids

National Donor Day Feb. 14, 2011 According to the U.S. Department of Health and Human Services, about 77 people each day receive organ transplants.

However, 19 people die each day waiting for transplants that can’t take place because of the shortage of donated organs.

Minorities overall have a particularly high need for organ transplants because of diseases and certain blood types that are found more frequently in the racial and ethnic minority population.

Each organ and tissue donor saves or improves the lives of as many as 50 people. Many donor families say that knowing other lives have been saved helps them cope with their loss. The heart, kidneys, pancreas, lungs, liver, intestines, cornea, skin, heart valves, bone, blood vessels, connective tissue, bone marrow/ stem cells, umbilical cord blood, and peripheral blood stem cells (PBSC) can be donated.

17

Ringing in Your Ears: Managing Tinnitus According to the American Tinnitus Association, more than 50 million Americans are affected by ringing in their ears. Come and find out what tinnitus is, what causes it, and how you can manage it. Free, but advance registration is required. Call 651-430-4697.

Thursday, Feb. 17, 6:30–7:30 p.m., Lakeview Hospital, 927 Churchill St. W., Stillwater

24

Art Therapy for Cancer Patients Art therapy isn’t about creating masterpieces. You will be guided in the creative process using a wide assortment of art supplies. No art experience necessary.

Free. For more information, call Katie at 320-251-2700, ext. 79943.

Thursday, Feb. 24, 10:30–11:30 a.m., Coborn Cancer Ctr., 1900 CentraCare Circle, Carlson Classroom, St. Cloud

28

Nicotine Anonymous Support Group This support group welcomes all those seeking freedom from nicotine addiction, including those using cessation programs and nicotine withdrawal aids. The group meets every Monday. Call 651-3262273 for more information.

Monday, Feb. 28, 7–8 p.m., Maplewood Professional Building, 1655 Beam Ave., Ste. 202, Watson Education Ctr., Maplewood

Take these steps to be a donor: 1. Register with your state donor registry.

Visit http://organdonor.gov/ 2. Carry a donor card with you.

3. Designate your decision on your driver’s license.

4. Help your family understand your wish to be an organ and tissue donor before a crisis occurs. They can then serve as your advocate for donation.

Send us your news:

12

Women’s Heart Health Screening and Education Women of all ages (10 and older) with cardiac risk factors or family history of heart or vascular disease are encouraged to attend. The painless tests can help to detect heart disease in its early stages.

We welcome your input. If you have an event you would like to submit for our calendar, please send your submission to MPP/Calendar, 2812 E. 26th St., Minneapolis, MN 55406. Fax submissions to 612-728-8601 or e-mail them to jbirgersson@ mppub.com. Please note: We cannot guarantee that all submissions will be used. CME, CE, and symposium listings will not be published.

America's leading source of health information online 16

MINNESOTA HEALTH CARE NEWS FEBRUARY 2011

Minnesota

Health Care Consumer Association

SM

Welcome to your opportunity to be heard in debates and discussions that shape the future of health care policy. There is no cost to join and all you need to become a member is access to the Internet.

Members receive a free monthly electronic newsletter and the opportunity to participate in consumer opinion surveys.

www.mnhcca.org

Join now.

January survey results...

50 40 30 20

15.4% 11.5%

35

19.2%

20 10 3.8%

1.9% 0

Strongly agree

Agree

No opinion

Disagree

Strongly disagree

Agree

No opinion

30.8% 30 20 13.5%

13.5%

10 0

Strongly disagree

Strongly agree

Agree

No opinion

Disagree

Strongly disagree

5. I would use online exams only if the providers were local.

40

32.7%

36.5%

35 26.9%

25

23.1%

20 15 10

Disagree

9.6%

7.7%

Percentage of total responses

25.0%

Percentage of total responses

Percentage of total responses

30

40.4%

40

1.9% Strongly agree

30 40

9.6%

7.7%

10

4. Data privacy issues would not affect my decision to use online exams.

50.0%

50

50

55.8% Percentage of total responses

Percentage of total responses

60

0

3. If my insurance did not cover online examinations, the convenience would make paying a minimal fee ($50 or less) worthwhile.

2. I feel online health care examinations should only be conducted by physicians.

1. I would use online examinations by health care professionals if they were available.

Each month members of the Minnesota Health Care Consumer Association are invited to participate in a survey that measures opinions around topics that affect our health care delivery system. There is no charge to join the association, and everyone is invited.

For more information please visit www.mnhcca.org. We are pleased to present the results of the January survey.

30 25

15

5

5 0

Agree

No opinion

Disagree

Strongly disagree

21.2%

13.5% 9.6%

10

0

Strongly agree

19.2%

20

Strongly agree

Agree

No opinion

Disagree

Strongly disagree

“A way for you to make a difference�

FEBRUARY 2011 MINNESOTA HEALTH CARE NEWS

17

M I N N E S O T A

H E A L T H

C A R E

R O U N D T A B L E

About the Roundtable MR. CHRISTENSON: How would you define comparative effectiveness research (CER)?

DR. BOTTLES: The U.S. Department of Health and Human Services (HHS) definition reads: “Comparative effectiveness is conducting and synthesizing of research comparing the benefits and harms of different interventions and strategies to prevent, diagnose, treat, and monitor health conditions in real-world settings.” Basically, we need to have research that tells us what works and what does not work in terms of treatments, surgeries, pills, and tests. What gets controversial about CER is how you use it: Do you use it to determine what Centers for Medicare & Medicaid Services (CMS) and, ultimately, other insurance companies will cover?

Minnesota Physician Publishing’s 34th Minnesota Health Care Roundtable examined comparative effectiveness research as set forth in the Affordable Care Act. Five panelists and our moderator met on Oct. 21 to discuss this topic. The next roundtable, on April 28, will examine the wellness revolution and its capacity to change the focus of health care.

role this is going to play in the health system and the choices of individual patients.

Comparative effectiveness

MR. CHRISTENSON: What are the worst things about comparative effectiveness research?

DR. HANSEN: To my mind, CER is being wielded as a means by which to make budgets work.

MR. CHRISTENSON: What are the best things CER offers us?

MR. GOODNO: Ideally, CER would offer us better results for patients. If you have the best treatments at the right time, you should lower the cost of the health care system in the long run. You should have more general satisfaction and better outcomes for the patient—not only the health outcome but also the lifestyle outcomes. That should be the focus of CER. DR. DANIELS: The opportunity to find out what works and what doesn’t, irrespective of the politics behind CER, could help us improve care.

DR. BOTTLES: I would link CER with the budget deficit even more strongly. Health care expenditures are making America uncompetitive in a global marketplace. If we don’t get the expenditures of health care under control, it means we don’t have money to spend on things like defense or energy policy or education. Linking CER to controlling the budget deficit is really, really important.

DR. DANIELS: I would add that spending 18 percent of the GDP for health care might not be bad if our outcomes were the best in the world. But they are not. They are barely better than some Third World countries.

MR. CHRISTENSON: Do you believe CER will improve outcomes?

DR. DANIELS: It is one tool in the toolbox. It alone will not accomplish what we need, and

18

Common sense or nonsense? the $1.1 billion that the stimulus bill designated to be spent for CER—although that sounds like an enormous amount of money—is not a lot of money to solve these kinds of problems.

MR. MONROE: None of us in the United States today should be proud of the outcomes we have versus the cost. The CER work is one step moving us forward. But we cannot pat ourselves on the back in this country and say that because we spend billions of dollars, we are automatically the best when our outcomes don’t stand up—our life expectancy doesn’t stand up. Survival rates at birth don’t meet other countries’. We have to figure out how to do it right.

DR. HANSEN: I disagree just a little. We have to look at how some of those metrics are designed. It’s also important to look at what we think comparative effectiveness research will or won’t do for us. One thing to keep in mind is that populations are not individual patients. How are we going to reconcile effectiveness research with treating individuals? The other truism is that not all outcomes are changeable, no matter what we do to intervene. We are going to have to decide what

MINNESOTA HEALTH CARE NEWS FEBRUARY 2011

MR. GOODNO: I differ a bit on the Third World comparison. Dealing with my daughter’s epilepsy and her seizure disorder, I want her to be here. When it comes to providing services and treatment for epilepsy, this is one of the best places to be in the world. We have to be careful about talking in generalities about health outcomes and the money spent. I agree that we are spending too much money on health care. We are spending money ineffectively. We could do a whole lot better job of how we spend it. Perhaps CER will help us do that. But it is a tool, and the effective use of tools will depend upon the people using them, if they know how to use those tools, and if they are using them in appropriate circumstances at the appropriate time. Put the tools in the wrong hands, and you are going to have terrible outcomes.

DR. HANSEN: From the provider’s perspective, I will go back to my first caveat: Some outcomes are not changeable no matter what you do. We cannot ignore the large body of research on the social and economic determinants of health. Medicine is quite a ways down the chain of things that affect population health. I wonder sometimes if we are not holding medicine to too stringent a standard on what the outcomes are for populations. The other issue here is metrics. What exactly are we measuring? Are we measuring length of life, are we measuring freedom from disease, are we measuring activities of daily living, or “health,” whatever that is defined to be? One of our biggest challenges is to decide exactly what we are trying to measure in individual patients as we move along in so-called effectiveness research.

DR. BOTTLES: The only negative thing I see about comparative effectiveness research is that it plays right into our partisanship and our polarization. We have to be able to understand what works and what doesn’t work.

We have to have a frank discussion among professionals, medical device companies, pharma, the general public—that the status quo is unsustainable. Health plans, doctors, patients, everybody has a piece of the guilt for why we have bad outcomes.

MR. GOODNO: The question is whether those negative outcomes are related to the health

care system or the environment or the consumerism that is going on out there and how people react and take care of themselves. We are looking at the outcomes and blaming it on one segment. We need to look at the whole picture and how that relates.

Comparative effectiveness research itself is a good thing. It is always good to have data on what works and what doesn’t. The biggest danger is that people will take that research and misapply it to individual situations. One thing that became clear when I was dealing with my daughter’s situation: There is the science of medicine, and there is the art of medicine. When you get into those areas, especially dealing with the brain, there is a whole lot of art that goes on in treating folks. We need to make sure we don’t use tools like CER to take the art out of it.

MR. CHRISTENSON: But do you believe that the best treatments are the most cost-effective treatments?

MR. GOODNO: Not necessarily. We have a disconnect between expectations in our society for how we take care of individuals at or near death or in life-threatening situations. And our expectations regarding people with disabilities don’t match up with the resources we are willing to spend. Those things have to come together, but we have to have an open discussion. Politicians are not going to tackle this issue unless the public is willing to talk about it.

MR. CHRISTENSON: Jim, do you have any concerns about the people who are writing these CER regulations and their experience?

MR. MONROE: We do. Physicians need to be more involved. My concern is that we have a lot of people with PhDs behind their names who have not practiced. We need the practitioners, we need the data, we need the population base. My biggest concern with CER is that we are operating as Luddites on data collection. We do not have the ability to pool the data; we look at small groups instead of large groups. Our group is a self-insured group of 124,000 lives. We need to look at groups like that. We need to take that data and look at what works, what does not work, not from a cost-effective basis, not from a cost-dollar expense basis, but what the outcomes are and what the true value of the delivery of services are. We aren’t doing that. We are only concerned with how quickly we can process claims

H E A L T H

C A R E

and how many procedures the docs are performing in order to get their billings in. We need to step back from that.

DR. DANIELS: I want to go back to the issue of cost effectiveness. My understanding is that the Affordable Care Act (ACA) does not even allow cost as a metric. Kevin’s point is a good one: We have to understand what cost effectiveness means. Are we talking about the cost of refilling a prescription, are we talking about the cost of keeping a child out of the ER, are we talking about the cost of having that child be able to live a normal life free from the side effects of the drugs that may be required to treat epilepsy?

Too often in health care we focus on the short-term goals and the easier ones to measure. One of the things that comparative effectiveness research will need to do is come up with the right outcomes. The most expensive knee replacement on the market might be worth it if it allows people to lead a more normal life.

DR. BOTTLES: I share the concerns about how ACA is going to be implemented. I came from a conference in West Virginia where they talked about the Patient-Centered Outcomes Research Institute, a publicprivate partnership that is going to run CER. Some at the conference were concerned that there was not enough of a patient voice on the board of governors.

MR. CHRISTENSON: Is using CER to develop physician compensation policies a good idea?

DR. HANSEN: I certainly am sympático with the thought of trying to have more providers’ input into the structure of public policy. I use my days off to show up at these so-called policy meetings at the Legislature to try to give my input. I find that when I show up to Minnesota Community Measurement or to whatever legislator’s office, they are maybe or maybe not interested in what I have to say about what it is like to take care of a patient. This committee in Washington is a perfect poster child for business as usual. Where the heck are the patients? Sometimes I think some of these things by design are meant to keep providers and patients from providing input because, quite frankly, it does not serve the agendas of the people with the purse strings.

MR. CHRISTENSON: Bobbi, how does the University of Minnesota Physicians group look at this?

R O U N D T A B L E A B O U T T H E PA N E L I S T S

Kent Bottles, MD, was president of the Institute for Clinical Systems Improvement (ICSI) from 2008 to 2010. Prior to that, he was chief medical officer of the Iowa Health System and held a number of leadership positions in academia, biotechnology, and community health systems. He currently serves on a National Quality Forum committee on quality and has been active in lecturing and writing about leadership topics. A board-certified pathologist, Bottles earned his medical degree from Case Western Reserve University in Ohio.

Bobbi S. Daniels, MD, is chief executive officer of University of Minnesota Physicians. Prior to her appointment as CEO in 2009, she was chief medical officer for the group. She has served on the UMPhysicians board of directors since 1996 and chairs the clinical practice committee. After earning her medical degree from the University of Washington School of Medicine in Seattle, Daniels came to the University of Minnesota in 1981. On completion of an internal medicine residency and a nephrology fellowship, she joined the medical school faculty, where she is currently professor of medicine.

Kevin Goodno, JD, LLM, is president of the board of directors of the Epilepsy Foundation of Minnesota and chair of the government relations practice at Fredrikson & Byron PA, in Minneapolis, where he focuses on health care and tax policy.

As commissioner of the Minnesota Department of Human Services (DHS) from 2003 to 2006, he served on the Governor’s Health Cabinet to develop ways to inform, partner, and create efficiency in the health care industry. Prior to joining DHS, he represented the Moorhead area in the Minnesota House of Representatives for 12 years.

Ronnell A. Hansen, MD, is immediate past president of the Twin Cities Medical Society (TCMS), licensed to practice medicine in 27 states, and president of Hansen Imaging Diagnostics. A University of Minnesota Medical School graduate, he completed residency in diagnostic radiology at the University of Michigan with fellowships in body imaging and information technology. Hansen served on the Minnesota Legislative Committee on Pooled Insurance in 2007–08, and is currently on the TCMS board of directors, co-chair of the TCMS public policy committee, on the executive committee of the Minnesota Radiological Society, and a member of the Minnesota Medical Association work group to advance health care reform.

Jim Monroe is executive director of the Minnesota Association of Professional Employees.

He holds a bachelor of arts degree from Ohio University. Prior to being appointed to his present position in 1999, he was chief operating officer of a life and health insurance company and, before that, executive director of independent publicsector labor unions in Washington, Maine, and Ohio. As a provider and consumer/employee representative for the past 37 years, Monroe has been actively involved in health-care provider, access, and quality issues at the state and national level.

Robert Christenson has been involved in health care policy since 1965 and has been a health care consultant since 1978. His specialties are governance training and integrative medicine.

DR. DANIELS: With 750 physicians FEBRUARY 2011 MINNESOTA HEALTH CARE NEWS

Bruce Silcox Photography

M I N N E S O T A

19

M I N N E S O T A and another 1,500 employees, there is a diversity of views. In terms of physician comp, right now the method by which physicians are compensated is irrational. Primary care physicians at the front line are making tough decisions, but not a lot of money compared to their counterparts. On the other end of the spectrum, you might have a physician who rarely sees a patient, is associated with very high-level technology, making three, four, or five times the level of compensation as a primary care physician. The whole physician comp issue needs to be considered completely separate from comparative effectiveness. Physicians should be incented to provide the right care to the right patient at the right time to accomplish the right outcome. The problem, a lot of the time, is that we do not know the data to allow us to determine when we have done that. To the extent that comparative effectiveness research allows us to do that, we can improve the delivery of health care and better align the incentives.

DR. BOTTLES: Here is a problem. In one of the few areas where we have comparative effectiveness research that has been published in a peer-reviewed journal and everybody accepts as good science, here is what happens: The COURAGE trial studied 200,287 patients for five years. The conclusion— that no one has challenged—is that patients with chronic chest pain usually receive no benefit from stents when used with a cocktail of generic drugs. We know that for this disease here is what we ought to do, and yet we continue to use stents in areas where they are not medically needed. We would save $5 billion a year in the United States if we just followed the scientific evidence of the COURAGE study. Yet we do not.

MR. CHRISTENSON: Does it have anything to do with the incentives that physicians have for treating their patients?

DR. BOTTLES: Well, cardiologists get $900 every time they do a stent procedure. What they are supposed to do is a cardiac stress test, which is not as expensive. I would have to conclude that, yes, reimbursement has something to do with it.

MR. MONROE: Having preferred networks for those who comply with comparative effectiveness research is the way to try to move. We are discussing it; we have not been able to negotiate it. It forces some discussion between the provider and the individual patient. If we are able to use documented

MINNESOTA

H E A L T H

C A R E

R O U N D T A B L E

results as a basis to compensate people for outcome-based decisions, as opposed to the number of procedures, you are going to open doors. Doors will open where there are true discussions held with the patient rather than saying, well, you have X, Y, or Z, and therefore we are going to do this.

DR. HANSEN: That is a key point. I agree with Kent that certainly Econ 101 does not go away when you are in the business of medicine. Even if we create a system of metrics, how do we avoid getting a bunch of providers treating to checklists?

MR. CHRISTENSON: When the regulation gets developed for comparative effectiveness research, how do you incorporate the role of the patient in assessing results?

DR. HANSEN: That, for many physicians, is the million-dollar question. We see how health care reform is evolving. To me the problem with a lot of it is that it does not seem to save a whole lot of money. The second thing: Where is the patient accountability in this? The social determinants of health have more impact on popula-

money and give patients what they want. The Cochrane Review, an evidence-based medicine review that is well respected, recently published a study about shared decisionmaking in cases of benign prostatic hypertrophy. There were videos to explain the tradeoffs and patients could talk to people who had chosen one treatment or the other.

The review found that if you do shared decision-making and sit down with patients and spend the time to talk to them, there is a 24 percent decline in demand for elective surgery or for tests. That 24 percent decline would be about $4 billion in savings for Medicare. The idea is you can give patients what they want and what they need—if they understand it. The other thing I would comment on: With the new bill everyone thinks we are going to have a transition from feefor-service, where we pay piecemeal, to some sort of global payment. When you pay people globally, you take out the incentive to do more. That transition is going to be huge, complicated, and difficult.

DR. DANIELS: Patient engagement flips accountability around and begins to put the patient in the driver’s seat. Kent has mentioned saving $5 billion with one simple

None of us in the United States today should be proud of the outcomes we have versus the cost.

Jim Monroe

tion health than anything I will ever do in medicine.

MR. GOODNO: Patients play a key role in the outcome of the disease or affliction they have. You can do all the research you want, but you can’t ignore the fact that you have to communicate with the patient. That communication aspect is key, yet it is quickly lost in this discussion. When you measure outcomes, you need to make sure you are measuring the right outcomes. It is not a checklist of inputs, it’s the actual outcomes and the benefits to the patients themselves.

DR. BOTTLES: If we sat down with patients and talked to them about the tradeoffs—and there are tradeoffs in everything, nothing is perfect in terms of treatment—there are studies that show that you can both save

H E A LT H

CARE

intervention and another $4 billion with an additional simple intervention. The amount of money proposed to be spent on CER is $1.1 billion. This is a relatively small amount of money to solve a huge number of issues.

When you think about what is out there to potentially be saved, the things we are doing that just do not make sense, we do not have to find many things before that $1.1 billion can be paid back. But, again, a lot of those are also political more than they are real.

MR. GOODNO: Isn’t it ironic that one of the key elements of the new ideas is that we’ll have better outcomes if we communicate with patients and engage them in their own decisions with regard to their health care?

Everything goes back to that basic.

ROUNDTABLE

sponsored by Minnesota Physician Publishing, Inc.

20

MINNESOTA HEALTH CARE NEWS FEBRUARY 2011

M I N N E S O T A MR. CHRISTENSON: Minnesota Physician Publishing recently conducted a physician opinion survey on the topic of CER. The leading response to every question, by an overwhelming margin, was “no opinion.” What might be inferred by these results?

DR. HANSEN: What it says is that physicians are physicians. They are not actuaries, bureaucrats, or statisticians. Many of the physicians in this particular market are employed.

They worry day to day about filling their patient lists. Many of them are employed because of the incredible bureaucratic hassles that went with private practice. In this particular subset of physicians, you have a bunch of folks that in some sense hope that it is just going to be taken care of. For those in private practice, many see this as a potential disaster in many ways.

MR. MONROE: If we could teleport ourselves back to 1965, the discussions and concerns on Medicare were the same. Medicare, in my way of thinking, came on faster than this transition. I think one of the reasons that “no opinions” were high is that we are talking about an act that’s got four more years for different pieces to come in. I do not think it is nonresponsiveness or people washing

Linking CER to controlling the budget deficit is really, really important.

H E A L T H

C A R E

R O U N D T A B L E

tive effectiveness research, you can take a deep breath and wait 17 years.

DR. BOTTLES: We have to have a frank discussion and say that the more expensive new thing is not always better. Direct-toconsumer advertising by pharmaceutical companies isn’t always better. We should have a frank conversation about what tradeoffs are involved in some of these things. An example: I am 58 years old, and I will never get a PSA test, the screening test that most people get for prostate cancer. Why? Because, for my values, I don’t want one. Because I understand that almost everybody who gets old and is male gets prostate cancer. I have done a lot of autopsies and it is always there. It turns out that I have a 97 percent chance in my life of dying of something other than prostate cancer. If you take a thousand men and screen them for 10 years, you will pick up one prostate cancer and maybe save a life.

You will also over-treat 50 men, and the treatment for prostate cancer includes things like incontinence and inability to have sex. I am not saying that everybody should do what I am doing.

But for me, as an informed individual

MR. CHRISTENSON: Explain the differences among utilization review, best practices, and now comparative effectiveness research.

DR. HANSEN: I feel that the evolving definition of utilization review is going to be: Who is using too much of X resource? I wish I could think of it in a benign sense. But once again, you get back to how are we going to balance the budget and pay for all this. I don’t know how we are going to do it, but I see upcoming utilization review as physicians using too much of X, Y, or Z— biologic drugs, imaging, etc.—for the care of their patients. To me, the very loaded concept of this is: Who, then, are physicians serving?

The health care system? The at-risk capitation model of the accountable care organization? Or are they serving their patient?

MR. CHRISTENSON: Jim, how do you, as an employer and representing employees, look at utilization review?

Kent Bottles, MD

their hands of it, it is just the magnitude of what we are dealing with. People put things off—until it happens.

MR. CHRISTENSON: What are the biggest challenges in conveying to physicians the potential of CER to help identify the most effective and appropriate treatments?

DR. DANIELS: Jim made a great point about how hard it is to get the information out. Go back to one of the first trials that showed the effectiveness of tight glycemic control for people with diabetes, or look at the things that have been demonstrated to be effective in treating heart failure. From when those studies were published to when the practices became commonly implemented—17 years.

For those who are worried about compara-

MINNESOTA

measurement folks: You have to be very, very careful about how you apply some of these things that may or may not be true. Kent has decided that it is not worth it for him to get this certain test. Bundled in that statement is the question of trying to figure out, if we decide as a system what we will pay for, what are we going to pay for in individual patients? Are we still allowing individuals to go outside the system and do whatever they deem is appropriate for themselves? We have to have a very frank discussion with the public, which I don’t believe political people are willing to have, on what we can and cannot afford to deliver to people.

with shared decision-making, I don’t want to have that test, because I don’t want to be one of the 50 people who are going to be overtreated. I may die of invasive terrible prostate cancer and then you can say, “He was stupid and made a bad mistake.” There is no gold standard for this stuff, no guarantee.

DR. HANSEN: Sometimes the truth is always moving. We think vitamin E is a great thing to add to cardiac patients—up until we figure out 30 years later that it kills people. We are very, very certain that very tight glycemic control is the best metric. So we impose that, and then people do worse. We are going to penalize docs if they don’t do best practice of vitamin E—and, oh yeah, the patients die.

Sorry, we’ve been doing that for 30 years. I always try to bring this up to the community

H E A LT H

CARE

MR. MONROE: I think the group as a whole tends to give us some good data. But many times utilization review tends to be used to justify holding care delivery down; it puts pressures on the providers that aren’t justified. Utilization review when I was running an insurance company was, “How do we cut the cost for the services being provided?”

DR. DANIELS: The insurance company retrospective utilization review as we currently know it is fraught with all of those difficulties. Take a step back, though, and think more broadly about how we use resources.

Look at the Dartmouth Atlas where Medicare data has been put together and analyzed on a geographical basis. Look at care in the last six months of someone’s life. The variability across the country is two- to three-fold and highly correlated with the number of specialists or the number of hospitals involved. Is that type of variability what we really want to

ROUNDTABLE

sponsored by Minnesota Physician Publishing, Inc.

FEBRUARY 2011 MINNESOTA HEALTH CARE NEWS

21

M I N N E S O T A use our health care dollars for? It is fine to think about a patient perhaps being harmed by utilization review, and sometimes that might indeed happen. But how about the other side of the coin, when the patient is struggling with being able to pay for food or rent—because they have to make a choice between those life essentials and their medications or their health care? That is a part of the patient cost we really haven’t taken into account. But that variability across the nation needs to be understood. Maybe it is justifiable. But I would submit that some of that variability is probably not appropriate.

MR. GOODNO: I take what Bobbi said and flip it a little bit. If you look at prescribing practices with regard to controlling seizures in this state, you will get a different prescribing practice from the specialist than you will from the general practitioner. I would argue that the prescribing practice of the specialist is probably more cost-effective, with better outcomes, because they know exactly what they are dealing with and how to use those tools they are given. We have to be careful when we are using statistics to automatically assume that the specialists are providing inappropriate care or excessive care. I think utilization review is a tool that can be used effectively, not necessarily in controlling costs but in training doctors and helping them address and follow through on best practices.

DR. BOTTLES: It is important to recognize the amount of variation. In 2005 the per-capita Medicare expenditures for CMS ranged from $5,281 in Rapid City, South Dakota, to $14,259 in Miami, Florida. Look at the last two years of life: If you live in Newark, New Jersey, you are going to spend 35 days in the hospital. If you live in Portland, Oregon, or Salt Lake City, Utah, 12 days in the hospital—35 versus 12 over two years. And the outcomes are the same. If we could get the people in Newark to treat people the way they do it in Portland and Salt Lake City, our problems of salvaging Medicare are gone— we have solved them. There is a 19 times difference in America on prostatectomy rates—19 times. This is a huge variation.

MR. MONROE: I did live in Portland. There is a different care delivery, a different environment, a different quality of life than there is in Newark. When we look solely at the dollar delivery without the other variables, we are starting to look at rationing care. That I will oppose from day one.

MINNESOTA

H E A L T H

C A R E

R O U N D T A B L E

DR. BOTTLES: We ration care right now—talk to any doctor.

MR. CHRISTENSON: Let’s address a criticism that comes up whenever health reform is attempted.

What is the best response to those who characterize comparative effectiveness research as too much government involvement in health care?

DR. BOTTLES: The best response is that government pays for more than half of health care, so they ought to have some say in it.

MR. GOODNO: Is it appropriate for government to help fund and help encourage CER—the actual research? Yes. Again, I would caution on how government or other payers will use those tools in trying to control the cost of health care.

MR. CHRISTENSON: Is it—to use another term—socialized medicine?

MR. MONROE: When you hear people talking about socialized medicine or death panels, it’s nothing but a political spin on what we are trying to do, based on who is trying to get in office. In 1990 the Republican Party nationally and locally was in favor of CER. In 1997 and 1998 they came out in opposition.

The average American is looking for higher quality of participation in care delivery and understanding of what the process is rather than being treated as a widget going down an assembly line. The reality is that CER, once we figure how to quantify the data, is going to provide a leap forward.

MR. GOODNO: You can have socialized medicine without CER, and you can have socialized medicine with it. In and of itself, it is not socialized medicine. It is a tool.

MR. CHRISTENSON: How can CER be designed to adjust to the significant variation among patients with similar conditions who require different treatments to achieve the best outcome?

DR. HANSEN: Eric Nussbaum, who is a neurologic surgeon at HealthEast in St. Paul, wrote an op-ed piece in 2009 regarding the art of medicine. He said, “Where science stops, the art of medicine begins.” He deals with very difficult cases—stroke, tumor, brain injury—that there aren’t any guidelines

H E A LT H

CARE

for. He and his team at HealthEast have extremely good results. Who knows why?

Sometimes long-term experience with patients and taking time with patients can reap benefits you can’t easily calculate or quantify.

DR. DANIELS: Shouldn’t we have a culture of inquiry to understand why they are better?

Then everyone else could learn from that kind of evidence. Maybe there’s something there—let’s find it out, instead of saying, “Everybody should be able to do whatever they want, because maybe they are right.”

Because maybe Eric is right, but the next Eric may be wrong. That is the challenge we have to confront in medicine.

MR. CHRISTENSON: Kent, is there a computer simulation program that would help with this?

DR. BOTTLES: There is a company called Archimedes in San Francisco that may represent the next generation of evidence-based medicine guidelines.

They are trying to take into account everything we know about a patient and translate that into very sophis-

We can’t intuit what we don’t understand.

Bobbi Daniels, MD

ticated mathematical equations, to come up with health status scores for individuals.

Guidelines by definition have a very sharp cutoff. If your blood pressure is over 140, you get treated; if it’s under 140, you don’t get treated. But some people who are under 140 probably should be treated because of other things—smoking history, exercise history, or others. Computer simulations are probably going to replace guidelines, and they can be personalized to each individual. That gets us to this personalized medicine that has been over-hyped and under-delivered.

MR. GOODNO: Medicine is a combination of art and science. You don’t want somebody to practice just the art of medicine without using the scientific background and studies that have been out there. If that computer model works, that’s great. More than likely, you will find it a guideline to set the base standard and beyond that you have to leave

ROUNDTABLE

sponsored by Minnesota Physician Publishing, Inc.

22

MINNESOTA HEALTH CARE NEWS FEBRUARY 2011

M I N N E S O T A it up to the flexibility of the physician. When the guidelines become the mandate, that becomes a problem.

DR. HANSEN: Unfortunately, patients are not Chevys. They do not all react in the same way to physical stresses or interventions. Reactions to medications can be idiosyncratic.

Each patient will tend to respond somewhat differently than the next patient. I can take five different antihistamines—one works for me. How much is that one and is it on formulary? I don’t care what’s on the formulary; I need the one that works so I can work.

Marrying the facts with the art or what the patient responds to appropriately is going to be a critical piece of this.

MR. CHRISTENSON: What can be done to keep CER from becoming another tool to justify large administrative fees, unfair provider reimbursement policies, and increased costs of care?

MR. MONROE: We are kidding ourselves if we assume that the Blue Crosses and HealthPartners of the world are somehow better because they are nonprofit than the

H E A L T H

C A R E

R O U N D T A B L E

MR. GOODNO: If your primary pressure is on the payment side and making sure you keep your rates down so your customers won’t yell at you or keeping your cost down so the legislatures that are managing it are approving your budget and are not yelling so much, your focus is more on the payment side and you use quality outcomes as an excuse to do that. If you are really looking at better outcomes for the patients, there’s less concern but you still have the pressure of cost.

DR. HANSEN: Or perhaps who you are. The question is not frequently about the money— it is all about the money. If we follow the dollars, we will find where the conflicts of interest are. I would like to believe that, at least in this country, the physicians are still the patients’ best advocate. Some of these socalled tools are going to be used to intervene between the physician/patient relationship and what is best for the patient. Rather than engaging the public in what we can and

Politicians are not going to tackle this issue unless the public is willing to talk about it.

Kevin Goodno, JD, LLM

for-profit Anthems of the world. They are not; they operate on the same business models. We are heading for some form of universal care. Even in a universal health care system, you still have a payer and if you have 100 payers or one payer, you still have the pressure on that payer or those payers to reduce the health care costs, and they will look for tools to try to reduce those costs.

That is the danger of allowing this tool to be used by the wrong people for the wrong reasons. If it is used as a tool by the health care professionals who are trained in using the tools and in diagnosing the patients and working with the patients, it is an appropriate use. But if it is used by payers, one or 100, I don’t think you can keep them from using it inappropriately to reduce cost.

MR. CHRISTENSON: In using CER, how much of it is directed by the money and how much is directed by quality outcomes?

MINNESOTA

cannot afford, this is being levered onto physicians to figure out how, in a sense, to ration resources. It’s an unfair move, but it is brilliant politically, because it does not throw me out of office when I have to tell people they can’t have everything they want. I am leaving that to the docs.

MR. CHRISTENSON: Bobbi, what role should employers play in this?

DR. DANIELS: For an employer, the cost of health care comes in a lot of different ways.

We just renewed our health insurance and made significant changes in the plan, because it was the way that we could afford to provide the best health care for our employees, but it certainly is a different plan than we have had in the past. If we are making those choices as a health care provider, I can only imagine what other employers are forced to do. The people who really come out on the short end are those employers who

H E A LT H

CARE

can no longer afford to buy health care.

About 20 percent of employers, even in this area, are not able to afford health care.

MR. MONROE: We have had five consecutive years as a self-insured group with no premium or out-of-pocket expense increases to the employees. The plan covers 124,000 lives. The doctors providing services under this plan are not making any less than they would if they were contracted with Blue Cross, because they are effectively contracted with Blue Cross, HealthPartners or PreferredOne—in reality, all three of them.

There is not a decrease in the services being provided. The reason is that we are selfinsured and we only contract out the administration, for a very limited amount of money.

DR. HANSEN: I was on the Legislature’s Pooled Insurance Committee, which looked at all forms of insurance to try to come up with a solution for small businesses in Minnesota. After nine months of grueling meetings, the only model that seemed to make sense was Jim’s state employee plan. There are a couple of big truisms about it: One was transparency on cost, the other was appropriate remuneration for people running the program and lack of incentive for those people to withhold profits. When all of the money is appropriately put into insurance programs for the people who are paying the premiums, such systems can work. As we think about reforms going forward, we have to ask: What was insurance intended to do, and what is insurance doing today? How much are people paid to run those corporations? Where do profits go? As Jim points out, when stuff is laid out very clearly and honestly, the books are transparent, you treat your enrollees correctly, and they participate in some measure of preventive programs in caring for their own health—these things work. I can’t necessarily give a billion dollars to shareholders on that, but I can provide health care.

MR. CHRISTENSON: If we use CER to determine what Medicare will cover, how do we avoid setting dangerous precedents that other insurers will use to take the patient out of the equation in making medical decisions?

MR. GOODNO: You can’t use CER to determine what is being paid for. If Medicare starts using it, then it is going to be used as a model by other payers and that is a danger.

You have to be very careful about misusing the tool at the very beginning. Because if it is

ROUNDTABLE

sponsored by Minnesota Physician Publishing, Inc.

FEBRUARY 2011 MINNESOTA HEALTH CARE NEWS

23

M I N N E S O T A

H E A L T H

C A R E

R O U N D T A B L E

being misused, especially by Medicare, it certainly sets the tone for everybody else.

MR. CHRISTENSON: What are the most important things for CER to compare?

DR. BOTTLES: It is important to recognize what’s actually in the law. The Affordable Care Act clearly says findings of CER may not be construed as mandates regarding payment or treatment or to deny or ration care.

That is written into the bill. Having said that, I will take the exact opposite position: It should be used. There is nothing wrong with using what works: Pay for what works, don’t pay for what doesn’t work.

MR. MONROE: What is the outcome of a procedure, what’s the overall cost, and how effective is it? That is what we have to look at.

DR. HANSEN: Works for what? We have to have the dialogue with folks to decide exactly what they want to get out of their health care. Do they want health? Ability to perform activities of daily living? I have to have some idea of what my patients want from their “outcomes.”

DR. BOTTLES: We can’t afford to have a carte blanche that everything will be covered by Medicare the way we do today. There ought to be some rationale for what we cover and what we don’t cover. Having scientific evidence of what works and what doesn’t makes sense to me.

MR. GOODNO: I agree with having a rational reason for what we cover and what we don’t cover.

What I am concerned about is using one tool to be the end-all that tells us exactly what we are going to do. Use it as a guideline. Don’t use it as “This is the only thing we are going to pay for, and if you happen to be an outlier, tough luck.”

MR. MONROE: Effective CER data—if it is made available so that people know the outcomes of decision A, B, or C—will lead to a high majority of people making the right choice on future care delivery. We underestimate the individual willingness to do what is right for themselves, and that ultimately helps hold the cost down.

DR. DANIELS: The problem I see with spending $1.1 billion on CER over the next few years is that it is not going to come anywhere close to providing the necessary breadth of knowledge. It would take a huge investment to get us to the point where, for the majority of the patients, we would know what was the most effective treatment.

MR. MONROE: But having that data available and people being aware that they have a right to ask questions of their physicians will start opening doors regardless of how far we get down the line. I am hoping my grandchildren have it available.

MINNESOTA

MR. CHRISTENSON: Is the source of data a major issue? Health plans consider so much of the data they hold to be intellectual property that they are not going to share. Where are we going to get good data to compare?

DR. BOTTLES: That is why there are billions of dollars now from the office of the national coordinator for health information technology to try to get every hospital and every doctor’s practice on a computerized system. You have to have data that is readily available.

You would no longer depend on health plan data. What matters is the outcome of the patient, not the surrogate endpoints of process measures. Even your hemoglobin A1c is not really what matters. What matters is whether you have complications from your diabetes.

measuring. I will go back to epilepsy. Say the outcome for a certain treatment is to stop the seizure. There are drugs out there right now that can stop any seizure, but you will probably stop most of the brain activity that is going on as well. The second issue is, OK, you can measure that outcome, stopping the seizure, but there are other issues that come along with that: lethargy, impact on development, weight gain—all those things are side effects. We are not even collecting that information right now. In our health care system right now, do we truly know what outcomes you are getting with your patients, where that is recorded, and how it is being shared?

Even if we make all the records interact with each other, how are we collecting that data?

Is it even out there? I would argue that, in most cases, it is not.

DR. HANSEN: Kevin brings up a great point here. The overhead for some of this stuff can be dramatic. Even for things like preauthorization, for example. Some private practices and probably some health systems had to hire new staff just to get

How are we going to reconcile effectiveness research with treating individuals?

Ronell Hansen, MD

MR. MONROE: The technology has evolved to gather the data, to aggregate it, to cleanse the database so I can’t tell who the patient is.

Once the data is gathered, our biggest problem is going to be how to make any sense out of it—because it is huge. The first step is getting all providers on an electronic system that can communicate. We are going to be gathering so much data, it’s going to be lightspeed intellectual growth on what we can do with that data. I’m not sure we have the technology once we get it aggregated.

MR. GOODNO: What we are talking about here feels like an exercise in futility. We’re saying, “Wouldn’t it be great if we had a perfect system? And if we had a perfect system, we would be able to do things like this and that is where CER comes in.” The key to all this comes down to what outcomes you are

H E A LT H

CARE

around these things. Some things that we believe are well intentioned in reality seem to be more along the lines of cost containment.

They don’t necessarily relate practically to a medical condition or logic in terms of treating the patient. Rather, they are a device to stem the hemorrhage of dollars. I don’t know how we get away from the duality of profit motive from some elements of the health care systems and the desire of physicians, who are service folks, trying to do the best for their patients. It seems like I am frequently at odds trying to deliver good care with somebody else trying to hold down my costs, largely because it affects the budget of the entity supporting the patient.

DR. DANIELS: Thinking about how we use the data, an important concept is that we can’t intuit what we don’t understand. That doc on

ROUNDTABLE

sponsored by Minnesota Physician Publishing, Inc.

24

MINNESOTA HEALTH CARE NEWS FEBRUARY 2011

M I N N E S O T A the front line can’t know what to do with any individual patient if she doesn’t have the knowledge that allows her to use her intuition to make the wise decision. At some point, we have to be formatting some body of knowledge that allows the physician, the nurse practitioner, the pharmacist, whoever, to be able to make those wise decisions. If we don’t have things like comparative effectiveness research, if we don’t have NIH trials, if we don’t have a great medical school and a great school of nursing, we are just not going to be able to do it. It isn’t that someone steps out of their residency and suddenly knows what the right answer is. One way to begin to make it easier for everyone to provide the care they need to provide, if they might not have the most outstanding intuition, is through some of the tools that we are talking about. If we don’t have the solid foundations to know what to understand, we are not going to intuit anything and provide that art of medicine. Because the art of medicine is intuition. It is not hocus-pocus that comes down from a bolt of lightning.

MR. CHRISTENSON: Let’s assume really good metrics come out of this. How can these important metrics for determining what treatment is most effective for a patient be communicated to individuals with limited ability to understand complex medical analysis?

DR. BOTTLES: We have a lot of tools that allow us to explain to people and yet we just haven’t had the ability to get that to the doctor/patient relationship at the point of service. There was a famous RAND study of people with insurance: Only 55 percent of Americans get platinum-level care for stuff we totally agree on. This drive to computerization can help us by embedded decision support. When I am seeing a patient, if I have a computer that can help me with drug interactions, that can help me improve on that 55 percent. Supposedly in my field there are 6,000 articles published every day that I should keep up with. No person can keep all of that in their mind. If we can get embedded clinical decision support at the point of service, it would help us.

DR. DANIELS: It gets worse, even if the doc remembers to do every possible thing. Let’s say the patient gets a prescription for a wonder drug to take care of some problem. They take the medication on average only 50 percent of the time. That is a problem. Dick Migliori, chief medical officer for OptumHealth, did an interesting study. He was looking at this incredibly expensive drug to treat chronic myelogenous leukemia. It cost something

MINNESOTA

H E A L T H

C A R E

R O U N D T A B L E

like $50,000 a month. He wanted to figure out how they could decrease the cost of using this expensive drug. The surprising thing they found is that when the patients took the really expensive drug their health care cost less than when they didn’t take the really expensive drug. Sometimes the way we think about cost is not right. We have to help docs do the right thing, we have to help patients do the right thing, but then we have to understand what is behind the right thing.

We don’t always know until we do something like comparative effectiveness research.

MR. CHRISTENSON: What must be done to create a standard in CER that everyone will accept?

DR. HANSEN: That is a tough question, because we can talk about it as a tool, but we have gone all around the circle of whose interest we are serving, whose dollars we are protecting, and what we are trying to get out of it. No matter which way we try to spin this, there is going to be some stakeholder that is going to spin it to their advantage.

That is not necessarily going to be in the best interest of patients or their providers. Who will get the upper hand? Is it going to be the government? Is it going to be the moneyed stakeholders that we have already mentioned—big pharma, large health care corporations, hospitals? Is it going to be physicians? I view myself, as a private physician, on the bottom of the influence pile.

MR. GOODNO: It will depend on how the results of the CER come out and how widely accepted that is. To have it accepted, you have to have people buying into the process, how it is being tested, and what outcomes are being measured. The best way to do that is to have more people involved from the front end and all the way through the process. In some cases, you may never be able to get all the right people at the table.

The challenge is to be as inclusive as possible. You need to do an analysis of what the upfront costs are, but you also need to pull the cost part out of the system to focus on the patient outcomes. Then you can make another analysis: This is a better outcome, but how much does it cost versus this, and what are the alternatives?

MR. CHRISTENSON: Let’s assume it is going to be pretty much impossible to create a standard everybody is going to accept. Given that, then what can be done to make CER work?

DR. BOTTLES: We are trying to take better care of patients; that would be the trumping thing. Then you have to have a fair process, and you have to be totally transparent. You

H E A LT H

CARE

have to be very candid about what your biases are and what they aren’t, and then we have to think about what is truly in the best interest of the patient. If we do all those things, then comparative effectiveness research may well be an important tool for us to give patients what they really want and help control health care costs.

MR. GOODNO: I don’t know if anybody would disagree with doing the research to see what is the most effective treatment and to get the right outcomes that we are expecting. I do think that once they determine that, there may be some people concerned about the pocketbook impact and whether we should have any limitations on what kind of treatments are out there. Getting the information is important. The challenge is how we use that tool and that information.

DR. DANIELS: In the absence of the information, the prospects are even more bleak.

MR. MONROE: We all are coming down on the same point: There is no viable alternative for care delivery in this country. We have to use CER. I urge everyone to look at the recent Kaiser Health Tracking Poll on the Web. At the top, it points out the strong number of people who are opposed to health care reform. But as you go down through the points, everybody is in favor of a majority of the points. We have to be accountable to the people who are being served. It doesn’t do anything to try to tie it up because of this or that or the other thing. As long as it stays patient-centered, we are going to get to the right end result.

MR. CHRISTENSON: One final question: Is there anything that can be done now to influence how CER regulations are going to be written to get the result that you are all talking about?

DR. BOTTLES: If you go to Washington as a representative of a group, you can get input.

It does not mean they always listen to you.

But physicians should take the time, through their professional societies, to make their voice heard. I would say the same thing for patients, health plans, government, and everyone else.

MR. GOODNO: The health care bill, although very lengthy, was silent in some areas. The silence was intentional, to get the bill passed.

It is very important for folks to be diligent about what is going on. You can’t have as much impact with the rule-making process as with the legislative process, but you still have to be engaged and be involved.

ROUNDTABLE

sponsored by Minnesota Physician Publishing, Inc.

FEBRUARY 2011 MINNESOTA HEALTH CARE NEWS

25

SPECIAL FOCUS: WOMEN’S HEALTH

C

hronic obstructive pulmonary disease (COPD) is no longer a disease of elderly men; increasingly, it is a disease of both middle-aged men and women. In the Minnesota Department of Health’s 2005 Behavioral Risk Factor Survey, the most recent data available, 7.4 percent of all Minnesotans age 65 and older reported having been told by their physician that they had COPD. In another survey, based on Medica Health Plans administrative data from 2004, 22 percent of the plan’s members with COPD were 60 or younger, making COPD a significant issue for working-age women as well as men.

The rate of COPD diagnosis in women has caught up with the rate for men for several reasons. One reason is that women’s lungs are more susceptible to developing COPD compared to men with the same exposure.

However, the main reason is an increase in tobacco use by women from the 1950s through the ’90s. Now, after almost a decade of concerted public health campaigns to discourage tobacco use, progress has stalled. In 2007, 18.3 percent of men smoked in Minnesota, compared to 14.7 percent of women. (This is lower than the national averages of 21.4 percent in men and 18.4 percent in women.) While the percentage of male smokers is still greater than the percentage of women who smoke, the gap has narrowed. Despite the anti-smoking campaigns, most new smokers today are teenagers, including 15 percent of female high school students.

Increased tobacco use is not the sole reason women are developing COPD. COPD can occur in individuals who have never smoked, and this is more commonly seen in women. This suggests that women may be more susceptible to other risk factors, such as pollution or biomass fuels used for cooking, as has been seen in many developing countries.

COPD Not an “old man’s disease”

By Jill Heins Nesvold, MS, Charlene McEvoy, MD, MPH, and Chris Wendt, MD

SPEND LESS T IME

26

R OAD

TO

RECOVERY.

Providing Family, Ob/Gyn, Optometry, Peds/Adult/Sports Medicine and specializing in you!

Gotcare?

Care?

Got 952-985-8200 952-428-0200 Burnsville - Lakeville - Savage Burnsville - Lakeville - Savage Edina - Chanhassen Edina - Eden Prairie

ON THE

www.QUELLO.com

MINNESOTA HEALTH CARE NEWS FEBRUARY 2011

New patients welcomed.

Most insurance accepted.

ease has lasting consequences on muscles and the cardiovascular system.

For your doctor Based on 1996–2006 Minnesota hospiSmoking cessation has been shown to improve quality of life and talization discharge data, the most survival in people with COPD. The American Academy of Chest common coexisting conditions for Physicians has made its Tobacco Cessation Tool Kit available to individuals with COPD are ischemic physicians, nurses, and cessation counselors. The kit, based on guidelines from the Agency for Healthcare Research and Quality heart disease, diabetes, gastrointestinal and the Office of the Surgeon General, assists in assessing an reflux disease (GERD), and kidney disindividual’s risks and level of smoking addiction and providing ease. Osteoporosis, a disease common motivational advice, drug therapy information, and follow-up and to many post-menopausal women, is relapse prevention techniques. Physicians can access the kit at highly prevalent in patients with http://tobaccodependence.chestnet.org/.

COPD, irrespective of gender.

COPD is also an independent Early diagnosis is key risk factor for lung cancer, irrespective of smoking. Lung cancer has now surpassed breast cancer as the No. 1 cancer killing women.

Once sick, women have a more aggresThe Centers for Disease Control and Prevention estimates that sive course of COPD compared to men. smoking reduces life expectancy by 13.2 years for men and 14.5 Unfortunately, COPD is often overlooked as a diagnosis in women, so they years for women. Given that current life expectancy in the U.S. is 77.8 years, this means that smoking can basically eliminate one’s may go longer without adequate treatretirement years. ment. Compared to men, women also report more severe shortness of breath (but similar degree of cough), decreased exercise capacity, increased anxiety and depression, and reduced quality of life.

It appears that women are more susceptible to the harmful effects of tobacco smoke, as the lungs of women with COPD often have more emphysema (lung destruction) and thickening of the airways. These pathological changes in the lung and the lack of early treatment may explain why COPD progresses more rapidly in women than in men.

Studies have shown that women This simple device, a with COPD are more likely to be hosspirometer, tests air pitalized and hospitalizations are a sigcapacity of the lungs nificant indicator of patients who will by measuring the volume continue to do poorly. Based on 2009 of air a patient breathes Minnesota hospital discharge data, 51 in and out. percent of COPD patients were female (at a rate of 9.9 per 1,000), despite smoking being more prevalent in men.

Given what we know about COPD in women, an accurate and early diagnosis of COPD can lead to initiating effective treatment and subsequently improving quality of life.

Outcomes and survival rates COPD is currently the third leading cause of death in the United States. In addition, the number of COPD cases, hospitalizations, and deaths in women has now surpassed those in men. In severe cases of COPD that require long-term oxygen treatment, women have higher relative mortality than men, both overall and for respiratory disease as well as for cardiovascular disease and cancer.

Individuals with COPD often have other related conditions. The reduced oxygen from COPD affects more than the lungs. The dis-

The conversation about smoking If you are a woman over 45 years of age with a history of smoking, ask yourself several questions developed by the Global Initiative for Chronic Obstructive Lung Disease (GOLD). These questions have been validated to identify people who are more likely to have COPD: COPD to page 31

Living with gout?

Keep enjoying life’s simple pleasures.

Gout is the most common form of inflammatory arthritis in men and affects millions of Americans. In people with gout, uric acid levels build up in the blood and can lead to an attack, which some have described as feeling like a severe burn. Once you have had one attack, you may be at risk for another.

Learn more about managing this chronic illness at www.goutliving.org

FEBRUARY 2011 MINNESOTA HEALTH CARE NEWS

27

SPECIAL FOCUS: WOMEN’S HEALTH

U

terine fibroids, also called myomas or—medically appropriately—leiomyomas, are the most common gynecologic tumor. They are made of normal uterine muscle cells that grow independently to form growths that are usually round and can grow as large as a cantaloupe. They rarely are malignant and are only important if they cause symptoms, which are usually abnormal uterine bleeding or discomfort, or cause infertility or pregnancy complications.

The purpose of this article is to increase understanding of this common condition and to outline treatment options when they become necessary.

Symptoms The size, location, and number of fibroids usually dictate the severity of symptoms and treatment options. As one would expect, the larger the fibroids, the more pressure they can put on surrounding organs and the more problems they can cause.

Typically, fibroids that get to the size of a lemon or larger can cause urinary or bowel difficulties by exerting local pressure.

Often they cause a sense of fullness and, when large enough, can be visually apparent by distending the lower abdomen.

The location within the uterus is also important, especially as it relates to bleeding. Fibroids that are deep in the uterine muscle or on the outside of the uterus usually do not cause bleeding abnormalities, no matter how large. Those that impinge on the inside uterine lining, however, may cause major bleeding abnormalities. This inside uterine lining, the endometrium, is the glandular portion of the uterus and is

Uterine fibroids Common, but rarely malignant, tumors

By Jon S. Nielsen, MD

Your quality of life deserves our quality of care.

Burnsville 952.435.8516

Edina 952.920.7200

Maple Grove 763.302.4114

Coon Rapids 763.427.8320

Golden Valley 763.588.0661

Outreach Clinics throughout MN & western WI

For directions or additional information about the Minneapolis Clinic of Neurology, visit us online at www.minneapolisclinic.com

28

MINNESOTA HEALTH CARE NEWS FEBRUARY 2011

the area that changes and bleeds with a menstrual period. Very heavy and/or irregular bleeding can occur, even with fibroids only an inch in diameter, when the fibroid interferes with the usual endometrial bleeding cycle by exerting pressure on the endometrium. The bleeding can be excessive, leading to fatigue resulting from blood loss anemia as well as the daily difficulties that accompany unpredictable bleeding.

Abnormal uterine bleeding is the most common indication for treatment of fibroids.

Fertility, pregnancy complications Fibroids also can cause infertility and pregnancy difficulties. If they are in the cavity of the uterus, fibroids can prevent the fertilized egg from implanting. Large fibroids can cause repetitive miscarriage, or premature labor. They can also obstruct labor by impeding uterine contractions, or blocking the birth canal. These reasons often mandate therapy for fibroids before pregnancy is attempted.

to shrink fibroids up to 50 percent of their mass, but unfortunately these effects are most often short-lived. Recent novel research in antiprogesterone therapy has been promising and may lead to effective long-term management.

A procedural, but not necessarily surgical, approach that has been effective for decreasing the size of fibroids and therefore decreasing their symptoms is a process called uterine artery embolization. It is based on the concept of decreasing blood supply to the fibroids to make cells die, therefore decreasing the size of the fibroids.

This procedure is done by interventional radiologists who, through an arterial access point in the groin, inject non-absorbable particles into arteries leading to the fibroids. This procedure often results in significant shrinkage of the fibroids and symptom relief. However, it is not recommended for women who wish to preserve their fertility and a significant number of patients still end up needing surgical therapy later.

Surgical therapy, usually by hysterectomy, has historically been the main therapeutic measure for symptomatic fibroids. New approaches have revolutionized the surgical treatment of fibroids.

Advances in surgical technique now allow fibroids located within the uterine cavity to be removed with an incision-less procedure called hysteroscopy. The approach is through the vagina, with access to the uterus through the cervix. The fibroids can then be removed in pieces through the cervix and the surgery is a minor outpatient procedure.

The largest breakthrough, however, has occurred in the arena of minimally invasive laparoscopic surgery. This surgery is done through abdominal incisions of one-fourth to one-half inch. Gynecologic surUterine fibroids to page 30

Fibroid causes unknown The natural history of fibroids is still poorly understood and the reasons for their development are unknown. They are much more common in certain ethnic groups, most notably blacks and Asians.

They require estrogen for maintenance and growth, thus leading to the concept of anti-estrogen therapy as a means of treatment. It is widely suggested that once menopause is reached the fibroids will “go away” and the problems will be over, presumably based on the postmenopausal lack of estrogen in the system. That is frequently not the case, however, especially in women who require estrogen therapy for the postmenopausal estrogen deficiency syndrome (a complex of symptoms including hot flashes, night sweats, and vaginal dryness, among others). Pregnancy, with its massive increases in estrogen, typically makes fibroids grow, sometimes very rapidly. The likelihood that they will get smaller and regress once they have become clinically significant is small. The fibroids usually continue to grow until and unless treated.

We’ve been “Expecting” You! Providing exceptional health care to the women of our community since 1954 • Evening Clinics • Conventional Obstetrics • High-risk obstetrics • Wellness Exams • Birth Control • Annual Exams

• Breast Screening • Infertility • Menopause Clinics • Urinary Leakage • Minimally Invasive Surgical and Office Procedures

• Osteoporosis • Certified Ultrasound Services • Lab Services

Treatment Treatment of fibroid tumors can be medical or surgical. Medical treatment revolves around efforts to decrease the fibroids’ access to estrogen. Estrogen is necessary to maintain fibroids, so anti-estrogen strategies should be helpful. Oral contraceptives have historically been thought to inhibit fibroid growth, but recent data suggest that effect is minimal. Anti-estrogen therapy in the form of injectable Depo-Lupron is much more effective and has been shown to be able

Maple Grove Hospital Campus 9825 Hospital Dr, Ste 205, Maple Grove • 763.587.7000 FEBRUARY 2011 MINNESOTA HEALTH CARE NEWS

29

Uterine fibroids from page 29

geons with advanced laparoscopic skills are able to do almost all hysterectomies with this technique. The laparoscopic hysterectomy can be done leaving the cervix in place, making it an easier procedure that does not affect pelvic floor support. Or the cervix can be removed in a total laparoscopic hysterectomy. It should be emphasized that these are usually outpatient procedures that last an hour or less and involve much less pain, a shorter recovery period (one to two weeks), and fewer complications than traditional open procedures. Instruments have been developed to morcellate, or cut into pieces, even a very large fibroid uterus through a ½-inch incision.

Despite technical and instrumental advances, the complex myomectomy (removal of fibroids without removing the uterus, thereby preserving fertility) done laparoscopically remains a challenge—so challenging that few gynecologic surgeons have been willing and/or able to move away from the traditional open approach for treating symptomatic fibroids.

The advent of the daVinci robotic laparoscopic assistance device, approved by the Food and Drug Administration in 2000, has made laparoscopic myomectomy more possible. This

Abnormal uterine bleeding is the most common indication for treatment of fibroids.

In the next issue..

• Pain medication • Smoking cessation • Anxiety disorders

tool allows the surgeon, sitting at a remote console with a three-dimensional laparoscopic view, to direct the robot’s laparoscopic tools, giving the surgeon added access and precision.

The robot is most helpful in procedures that require operating in very small areas and placing many sutures. Laparoscopic myomectomy is such a procedure, requiring fine tissue dissection, maximum blood loss control, and suturing of the uterine defects after the fibroids have been removed. In comparison with conventional laparoscopy, daVinci robotic myomectomy has been shown to decrease transfusion, blood loss, complications, and hospital length of stay. The disadvantage of the robot is that the surgery takes longer. However, as the surgeon masters the steep learning curve, operative times decrease.

Clearly the trend for surgical therapy for the fibroid uterus is to be “minimally invasive,” whether it is using uterine artery embolization, hysteroscopic resection of intrauterine fibroids, the laparoscopic hysterectomy, or the daVinci robotic myomectomy.

Jon S. Nielsen, MD, is an obstetrician/gynecologist at Oakdale Obstetrics & Gynecology PA in Minneapolis.

Stay in the Game.

Active Care for Active People

OSI

Physical Therapy

Forest Lake • Lake Elmo/Woodbury Lino Lakes • Maplewood • North St. Paul Shoreview • Stillwater • West St. Paul White Bear Lake• Somerset, WI

Call 651-275-4706

Most insurance plans accepted.

www.osipt.com

EXCLUSIVE PROVIDERS OF ATHLETIC TRAINING SERVICES FOR THE ST. PAUL SAINTS

30

MINNESOTA HEALTH CARE NEWS FEBRUARY 2011

COPD from page 27

• Do you cough several times most days?

• Do you bring up phlegm or mucus most days?

• Do you get out of breath more easily than others your age?

The number of COPD cases, hospitalizations, and deaths in women has now surpassed those in men.

If your answer is yes to one or more of the questions, ask your doctor for a spirometry test—a simple test to measure the air entering and leaving the lungs—to determine whether you have COPD.

Prevention and tobacco cessation aids The key to COPD is prevention. Because COPD is rare in people who have never smoked, the most important action to take to prevent it is to never smoke or to quit smoking. For those with symptoms, early diagnosis and treatment can make a difference.

With advances in drug therapy and pulmonary rehabilitation, effective treatment can reduce the number of flare-ups that individuals with COPD experience; ensure that patients with COPD maintain normal, active lives as long as possible; and help maintain their quality of life.

COPD education In 2005, the American Lung Association in Minnesota surveyed nearly 2,000 Minnesotans with COPD. Of those who completed the lung health questionnaire, one in three (32 percent) rated their doctor’s explanation of their breathing problems as “fair” or “poor.”

Asked which of the following topics they wanted or needed more education about, patients responded, in this order:

Discover

the benefits of yoga.

• • • • •

Exercise with COPD Disease progression Coping skills Pulmonary rehabilitation programs How to communicate better with their doctor Patients indicated that they preferred to get COPD educational materials as written information sent to their home (65 percent), information provided in physicians’ offices (45 percent), and in a video for home viewing (18 percent).

The American Lung Association in Minnesota has a number of resources available to patients who have or are at risk for COPD, including support groups, newsletters, and patient conferences. For more information, please contact ALAMN at 651-227-8014.

Jill Heins Nesvold, MS, is director of respiratory health for the American Lung Association in Minnesota, North Dakota, and South Dakota.

Charlene McEvoy, MD, MPH, is a pulmonary specialist and clinic lead physician at the HealthPartners Specialty Medical Center, Pulmonary and Critical Care Division, St. Paul, and an assistant professor of medicine at the University of Minnesota. Chris Wendt, MD, is section chief of pulmonary and critical care at the VA Medical Center, Minneapolis, and an associate professor of medicine at the University of Minnesota.

Eat fresh

discover healthful and delicious food, with menus changing daily

Right now, new students get a FREE WEEK of unlimited yoga.

www.seward.coop Open everyday 8 a.m. – 10 p.m.

See you soon at any one of our 8 Minnesota locations Eden Prairie • Edina • Minneapolis • Minnetonka St. Louis Park • St. Paul • Stadium Village • Uptown

Stop by Seward Co-op for breakfast, lunch, or dinner and find fresh, local, and organic food. We have many options for special diets and our Wellness department stocks a large selection of vitamins and supplements.

2823 E. Franklin Ave. | Minneapolis | 612-338-2465 FEBRUARY 2011 MINNESOTA HEALTH CARE NEWS

31

CARDIOLOGY

From “no options” to new options Heart patients improve with novel therapies

By Timothy D. Henry, MD, Mohammad Sarraf, MD, and Rachel E. Olson, RN

M

any patients with heart disease complain of angina pectoris— chest pain associated with coronary artery disease (CAD), an insufficient supply of blood to the heart because of blockages in the arteries. The term is derived from Latin (angere = to strangle or choke; pectus = chest). Thus, angina pectoris means a strangling feeling in the chest. An estimated 10 million to 12 million people in the United States have angina today. The majority of patients with CAD respond to medications, angioplasty, stenting, and, if required, coronary artery bypass graft (CABG) surgery. As the population ages and mortality improves, patients are living longer and longer with CAD. This has led to an increase in the number of patients who have exhausted all the medical and surgical options outlined above. These treatment-resistant patients are said to have “refractory angina pec-

A diagnosis of

Cancer is overwhelming news.

It raises many questions few of us are prepared to answer, such as: • How can I take time off from work?

• Can I get help paying bills?

• What is the difference between a health care directive and a power of attorney?

• Can I keep my health insurance even if I lose my job?

• And many others.

If you or a loved one is facing cancer, we are here to help.

We are a nonprofit organization funded entirely through grants and donations.

Your tax-deductible donations are welcome.

We provide free cancer related legal information on a wide range of topics.

Please visit our web site to find out more: www.cancerlegalline.org

educate.inform.empower

32

MINNESOTA HEALTH CARE NEWS FEBRUARY 2011

toris.” Often they are told they have no options remaining.

In an attempt to provide recourse for these patients, we developed the OPTions In Myocardial Ischemic Syndrome Therapy (OPTIMIST) program at the Minneapolis Heart Institute (MHI) at Abbott Northwestern Hospital in Minneapolis. A number of novel therapies are available in the OPTIMIST clinic with the goal of relieving the symptoms and improving the quality of life of patients with refractory angina.

Each patient meets with a select group of nurses and cardiologists to determine the best treatment suitable for that individual.

Every patient undergoes an extensive review of current and past medical problems, including previous surgeries, angioplasty and stent placements, medications, risk-factor modifications, and antianginal medications. After reviewing the conventional medical and surgical options, we consider a number of unique treatment options, including cutting-edge research treatments. Currently, the OPTIMIST program follows more than 1,400 patients with refractory angina. Nearly 90 percent of these patients have markedly improved symptoms and quality of life.

Novel medications

Of the few new medications recently developed in the United States and Europe, only one has U.S. Food and Drug Administration (FDA) approval for treatment of chronic angina—ranolazine (Ranexa), an extended-release tablet. We have observed improvement in symptom control for nearly 80 percent of patients with refractory angina when we added ranolazine to their previous medications. In addition, patients may improve with L-arginine, an overthe-counter supplement.

Enhanced external counterpulsation (EECP)

EECP is a noninvasive, outpatient approach to improve blood flow to the heart. EECP includes three pairs of pneumatic cuffs that are placed on the patient’s calves, thighs, and buttocks. When the setup is ready, it is synchronized with the patient’s heartbeat and the cuffs inflate sequentially from the calves up and then deflate in a manner to augment circulation to the heart, hence increasing the blood supply (Figure 1). Patients undergo 35 one-hour sessions over seven weeks. EECP leads to substantial improvement in symptoms for 75–80 percent of patients, is FDA-approved, and is covered by most major insurance.

Cases in point Enhancing angiogenesis

Jim, a 64-year-old farmer from northern Minnesota, had his first heart attack and triple bypass surgery 10 years ago. Five years later, he had a second heart attack and needed three stents in his coronary arteries. The following spring Jim was admitted to the hospital with chest pain and received two more stents. In 2008, admitted again to the hospital for chest pain, Jim was told, “There is nothing more to fix.”

He went home on maximum medical therapy and was referred to the OPTIMIST Clinic to manage his chest pain. Jim’s risk factors include hypertension, high cholesterol, obesity, and a history—no longer current—of smoking two packs of cigarettes a day. He could walk two blocks before he would get chest pain. He took up to five nitroglycerin tablets over a day.

Jim underwent EECP therapy and at his recent annual OPTIMIST Clinic visit noted he is now able to walk two miles on his treadmill without chest pain and has not needed nitroglycerin in the past six months.

Patients with severe CAD frequently grow their own new tiny blood vessels, called collaterals. Since patients with refractory angina have severe blockage of all the major vessels of the heart despite previous CABG surgery and/or angioplasty and stenting, protein and gene therapy have been used in attempts to enhance the natural process of blood vessel formation of the heart. This is called angiogenesis. While these initial efforts were promising, more convincing results have emerged recently by utilizing the patient’s own stem cells.

Injection of any stem cells directly into the heart stimulates the heart to grow collateral vessels around the blocked vessels, bypassing the diseased segment of the heart and increasing its blood supply.

The ethical and political concerns with stem cells frequently discussed in the media are related to embryonic stem cells. Scientists have overcome this issue in two ways: First, cells similar to embryonic stem cells can be reproduced from the patient’s own cells. The second solution uses adult stem cells. Current cardiology research uses only adult stem cells, which are abundant in the body. Every day the body renews itself by using these stem cells. A major source of stem cells is the bone marrow, where blood cells are produced every day. One specific population of these cells, in particular, is under examination for angiogenesis.

These cells (called CD 34+ cells) recently had very positive results in one carefully designed clinical investigation in patients with refractory angina. Patients treated with CD 34+ stem cells had improvement of more than two minutes in the time they were able to spend exercising on a treadmill and nearly 15 fewer episodes of chest pain a week. Further clinical trials are under way to illuminate the best approach for stem cell therapy in these challenging patients.

Patients are living longer and longer despite severe blockages in their coronary arteries.

Patricia, a 58-year-old former teacher from Fargo, N.D., was referred by her primary cardiologist to the OPTIMIST Clinic for possible enrollment in a stem cell trial. She had a bypass in 1998 and did well until 2004, when she had a heart attack. Two of her bypass grafts had closed and she had four stents placed in her coronary arteries. She did well for several years, but in 2008 noted symptoms of shortness of breath, fatigue, and chest pain with minimal activity, which forced her to take early retirement. Her risk factors include a strong family history of heart disease, hypertension, and high cholesterol. She was not a candidate for further surgery to re-establish blood supply to her heart.

Patricia enrolled in the CD 34+ stem cell study. At her baseline visit she was able to walk only four minutes on the treadmill and reported an average of 12 episodes of angina a week.

At her one-year final study visit, Patricia walked seven minutes on the treadmill and reported no angina at all. At her annual OPTIMIST Clinic visit this year, Patricia reported that she walks for 30 minutes four times a week and has only rare episodes of chest pain.

implanted electrical stimulator to deliver mild electrical signals to the area of the spinal cord that corresponds to the location of a From “no options” to new options to page 34

Don’t miss an issue...

Have you subscribed to Minnesota’s best source of health care information? To receive your personal copy of Minnesota Health Care News each month, complete and return the form below.

Name/Title ____________________________________________________________________ Company ______________________________________________________________________ Address ______________________________________________________________________ City/State/Zip _____________________________________________________ Phone (________)_______________________ Fax (________)_________________________ ANNUAL SUBSCRIPTION $36.00

Credit card orders may also be phoned in to (612)728-8600 or faxed to (612)728-8601

PAID BY CREDIT CARD I VISA I MC ________EXP. DATE I CHECK ENCLOSED I BILL ME CARD # _________________________________________________________

Neurostimulation

All pain pathways in the body cross the spinal cord to reach the brain and be felt. Spinal cord stimulation (SCS) is a surgically

SIGNATURE _______________________________________________________ MPP, Inc. • 2812 East 26th Street • Minneapolis, MN 55406 • www.mppub.com

FEBRUARY 2011 MINNESOTA HEALTH CARE NEWS

33

From “no options” to new options from page 33

patient’s angina. By modulating the pain pathways in the spinal cord, one may achieve significant improvement in control of the pain symptoms, including angina. This approach has been successfully tested in patients with refractory angina. Currently, it is the preferential non-pharma-cologic approach in Europe.

This intervention is FDA-approved for back pain, but not yet for angina.

Transmyocardial revascularization (TMR)

TMR is a complex technique in which a surgeon or cardiologist creates tiny channels in the heart muscle with a specialized laser. It is possible that the formation of small channels Figure 1: Mechanism of action of enhanced external counterpulsation (EECP). may stimulate new blood vessel formation and (With permission from www.iprogressivemed.com/therapies/eecp.html) also decrease the sensation of pain from the nerve endings of the heart. This technique can be used in the operating room or in the disease. Therefore, the major focus is to improve the patient’s sympcatheterization laboratory. Although this technique is FDAtoms and quality of life. Fortunately, the options for the “noapproved, the complexity of the procedure has limited its wideoption” patient are increasing, providing renewed hope for the spread use. patient with severe CAD. In summary, patients are living longer and longer despite severe blockages in their coronary arteries. Despite their high risk and Timothy D. Henry, MD, Mohammad Sarraf, MD, and Rachel E. Olson, complex heart disease, only about 2 percent of OPTIMIST patients RN, are on the staff of the Minneapolis Heart Institute Foundation’s die per year—a rate similar to age-matched patients without heart OPTIMIST Clinic at Abbott Northwestern Hospital in Minneapolis.

REGENCY

H OSPITAL

OF

M IN N EAPOLI S

Giving People Their Lives Back Regency Hospital of Minneapolis is an intensive critical care hospital serving the needs of medically complex patients that require acute level care for a longer period of time than traditional hospitals are set up to provide.

We are a national network of hospitals with a different way of thinking, a different way of caring, and a different way of treating, and it shows in everything we do.

R E G E NC Y PRO G R A M S A N D SE RV IC E S Pulmonary/ventilator program Medically complex/multi-system failure program Wound care program (stage III and IV decubitus) Low-tolerance rehabilitation services Regency Hospital of Minneapolis 1300 Hidden Lakes Parkway Golden Valley, Minnesota 55422 Main: 763.588.2750 Referral: 763.302.8340

34

MINNESOTA HEALTH CARE NEWS FEBRUARY 2011

A philosophy of caring is good. A history of it is better.

Caring. It would be nice if you could see it, like an amenity. Or tour it, like an apartment. But you can’t. All we can do is give you our definition: Caring is believing that everyone is someone who deserves to feel loved and valued, and be treated with dignity.

That’s not just something we say. As the nation’s largest not-forprofit provider of senior care and services, it’s what we’ve been doing for almost 90 years.

www.good-sam.com

To learn more about our communities in Minnesota, call 1-888-GSS-CARE.

;OL ,]HUNLSPJHS 3\[OLYHU .VVK :HTHYP[HU :VJPL[` WYV]PKLZ OV\ZPUN HUK ZLY]PJLZ [V X\HSPÄLK PUKP]PK\HSZ ^P[OV\[ YLNHYK [V YHJL JVSVY YLSPNPVU ZL_ KPZHIPSP[` MHTPSPHS Z[H[\Z UH[PVUHS VYPNPU VY V[OLY WYV[LJ[LK Z[H[\ZLZ HJJVYKPUN [V MLKLYHS Z[H[L HUK SVJHS SH^Z (SS MHP[OZ VY ILSPLMZ HYL ^LSJVTL *VW`YPNO[ ;OL ,]HUNLSPJHS 3\[OLYHU .VVK :HTHYP[HU :VJPL[` (SS YPNO[Z YLZLY]LK .

break a vial habit

Model is for illustrative purposes only.

With FlexPen®, your patients aren’t limited by a vial and syringe.

FlexPen® is a simple, patient-friendly insulin dosing option. And it’s available for the same copay as vial and syringe on most managed care plans.1* So, just add “FlexPen®” to your patients’ prescriptions and free both of you from the vial and syringe.

For formulary access specific to your area, visit www.novomedlink.com. *Intended as a guide. Lower acquisition costs alone do not necessarily reflect a cost advantage in the outcome of the condition treated because there are other variables that affect relative costs. Formulary status is subject to change.

Reference: 1. Data on file. Novo Nordisk Inc, Princeton, NJ.

FlexPen®, Levemir®, and NovoLog® are registered trademarks of Novo Nordisk A/S. © 2009 Novo Nordisk Inc. 139219

October 2009