Minnesota Health care News March 2012 by Minnesota Physician Publishing

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March 2012 â&#x20AC;˘ Volume 10 Number 3

Kidney stones Christopher Boelter, MD

Pediatric cardiology Joseph Dearani, MD

Dental health George Rizkalla, DDS

We Have Exciting News!

Our new breast cancer survivors support project of the African American Breast Cancer Alliance!

The African American Breast Cancer Alliance is excited to present its new Breast Cancer Survivors Support Project! A community-based project to connect African American breast cancer patients and survivors with a culturally specific support organization and resources. • COMMUNITY – Build a vibrant network of communitybased organizations, resources and services. • CONNECTIONS – Breast cancer survivors work with their family, friends and healthcare providers to combat the challenges of breast cancer. • Be a Connection • Be a Survivor • Build a Community of Hope and Support

• SUPPORT – The best breast cancer care includes emotional and social support. • HOPE – Inspire healing, health, empowerment, faith and a passion for life for patients and survivors.

Phone: (612) 486-2277 www.aabcainc.org info@aabcainc.org Funding for this project provided by

PO Box 8981, Minneapolis, MN 55408

(612) 825-3675

CONTENTS

4 7 8

MARCH 2012 • Volume 10 Number 3

16 20

NEWS

PEOPLE

PERSPECTIVE

CALENDAR Patient safety COMMUNITY CAREGIVERS 2012 Making a difference in Minnesota and the world By Scott Wooldridge

Susan Gunderson LifeSource

10 QUESTIONS George Rizkalla, DDS Comfort Dental

NEPHROLOGY Kidney stones

ONCOLOGY Facts about colorectal cancer

By Christopher W. Boelter, MD

By Matthew Flory

HOSPITALS Reducing hospital-acquired infections

CARDIOLOGY Pediatric cardiac surgery

SENTINEL

Laser Center Introducing a non-invasive treatment for Spine and Joint PAIN

By Joseph A. Dearani, MD

By Paul Youngquist, MD

SENTINEL Laser Center is a unique medical facility focused on the philosophy…

POLICY Health insurance options By Mike Rothman

“It is needless to do more when less will suffice” Call today for an appointment:

651-294-3232

www.mppub.com PUBLISHER Mike Starnes mstarnes@mppub.com EDITOR Donna Ahrens dahrens@mppub.com ASSOCIATE EDITOR Janet Cass jcass@mppub.com ASSISTANT EDITOR Scott Wooldridge swooldridge@mppub.com ART DIRECTOR Elaine Sarkela esarkela@mppub.com OFFICE ADMINISTRATOR Juline Birgersson jbirgersson@mppub.com

SENTINEL Laser Center

ACCOUNT EXECUTIVE John Berg jberg@mppub.com

Gallery Tower Office Building 514 St. Peter St., Suite 220 St. Paul, MN 55102

ACCOUNT EXECUTIVE Sharon Brauer sbrauer@mppub.com ACCOUNT EXECUTIVE Iain Kane ikane@mppub.com 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.

www.burtonreport.com

www.sentinellasercenter.com

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; email mpp@mppub.com. We welcome the submission of manuscripts and letters for possible publication. All views and opinions expressed by authors of published articles are solely those of the authors and do not necessarily represent or express the views of Minnesota Physician Publishing, Inc., or this publication. The contents herein are believed accurate but are not intended to replace medical, legal, tax, business, or other professional advice and counsel. No part of 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.

MARCH 2012 MINNESOTA HEALTH CARE NEWS

NEWS

Hospital Adverse Events Report Shows Mixed Results The state’s annual report tracking adverse events in hospitals finds that although the overall number of events increased, some improvements were also reported, including a decrease in the number of events leading to serious injury and death. The eighth annual report found that overall, Minnesota hospitals reported an increase in adverse events, from 305 in 2010 to 316 in 2011. Events resulting in serious injury or death dropped from 107 in 2010 to 89 in 2011. Officials with the Minnesota Department of Health (MDH) say that is the lowest level of harm since 2007. The past year saw an increase of adverse events in two categories: pressure ulcers and wrong procedures. The number of pressure ulcers rose to 141, an increase of 19 percent, while reports of wrong procedures

increased by 63 percent, to 26. Improvements were noted in the areas of serious falls, which decreased 11 percent; wrong-site surgeries, which decreased 23 percent; and medication errors, which decreased 38 percent. As they have noted in the past, safety experts say the work to reduce adverse events is a long-term effort that requires a culture of safety at health care facilities. Lawrence Massa, CEO of the Minnesota Hospital Association (MHA), says the new report shows that hospitals in the state are making significant improvement in patient safety efforts. “Our highest priority is the care and safety of our patients,” Massa says. “We are deeply sorry any time that care that’s intended to heal causes harm. Our goal, and the goal of the report, is to prevent adverse events by investigating what happened, putting systems in place to fix the problem, and sharing the lessons learned with all hospitals.”

Sports Participation Not Enough to Control Obesity A study from the University of Minnesota says that participating in sports may not be enough to keep young people from becoming overweight. Researchers with the U of M’s School of Public Health, along with researchers from the university’s Medical School and School of Kinesiology, found that nearly half the adolescents ages 12 to 17 who are overweight participate in organized sports. “Youth sport is encouraged as a way to help curb the obesity epidemic among young people, but the results of our review show that the activity alone might not be enough to prevent extra weight gain,” says School of Public Health researcher Toben Nelson, ScD, assistant professor within the Division of Epidemiology and Community Health. “The fact that many studies show that sport participants are as like-

ly as nonparticipants to be overweight is interesting because studies consistently show that participants are more likely to be physically active.” The researchers say a highcalorie diet may be canceling out the benefits of exercise. They found that youth sports participants consume more fast food and sugar-sweetened beverages than nonparticipating young people. The sports settings themselves often offer many unhealthy food options, the researchers note. Nelson and the other researchers are urging parents and sports officials to ensure that more healthy food and drink options are available to young people who participate in sports.

HealthPartners Changes Policy for Back Pain Patients HealthPartners is changing the way it covers back surgery, providing a new program designed to

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MINNESOTA HEALTH CARE NEWS MARCH 2012

help enrollees make decisions about the best course of treatment for spinal problems. Officials with the Bloomington-based health plan say that patients with back pain or spinal issues can be confused by the range of treatment options available, and that some may seek surgical solutions when there are other options that would provide similar or better outcomes at a lower cost. “With low back pain or spine pain, because there’s such variation, there really are options,” says Thomas Marr, MD, HealthPartners’ medical director of clinical relations. He adds that patients simply aren’t getting good guidance about what their options are. “We’ve heard over and over again from primary care physicians that they don’t know where to send these patients, so they send them to surgeons.” Under the new approach, primary care physicians will refer patients with spinal issues to a designated medical spine center, where a specialist will discuss the best options with patients. Specialists approved for the program will be rehabilitation physicians, occupational medicine physicians, or sports medicine physicians who meet certain standards, including a multispecialty approach that includes physical therapy and psychology. Marr says the inclusion of psychologists is important because for many patients, pain management has a psychological element. HealthPartners officials say that under the program, there will be 102 centers available in Minnesota and Wisconsin. The specialists at the centers will provide evaluations within 10 working days for most referrals; more urgent cases will be sent directly to surgeons. Marr notes that it will be the patient’s decision whether or not to pursue a surgical treatment for a spinal issue. “This is not a gatekeeper model,” he says. “The main goal is for the patient to know what all of their options are.”

WestHealth to Open Stand-Alone Emergency Facility WestHealth, an outpatient medical center owned by Allina Hospitals and Clinics, will open a standalone emergency department by the end of this year, officials announced recently. The new facility will be staffed by emergency medicine physicians from Abbott Northwestern and is part of an ongoing expansion at the site in Plymouth. The emergency department will be an 18,000-square-foot building adjacent and attached to the 180,000-square-foot campus. “This will be the outpatient health care campus of the future and another step toward Allina's commitment to achieving the Triple Aim of lower costs, higher quality, and improved patient experience,” says Ben Bache-Wiig, MD, president of Abbott Northwestern Hospital. Officials say the WestHealth campus is designed to meet a wide spectrum of needs at a location convenient to patents in the west metro area. The facility currently offers primary care, pharmacy, outpatient surgery, imaging, specialty care, and urgent care. Future plans for the site include a transitional care unit to provide care in a lower cost setting than a traditional hospital.

Swanson Files Suit Against Accretive Health Minnesota Attorney General Lori Swanson has filed suit against a New York-based company that provides revenue management services for failing to protect patient records, in a case involving a stolen laptop. Accretive Health provides “revenue cycle operations” services; in the lawsuit, Swanson refers to the company as a debt collection agency. The suit indicates that Fairview Health Services and North Memorial Health

MINNESOTA HEALTH CARE ROUNDTABLE

T H I R T Y- S E V E N T H

SESSION

Specialty pharmacy Controlling the cost of care Thursday, April 19, 2012 1:00 – 4:00 PM • Duluth Room Downtown Mpls. Hilton and Towers

Background and focus: Medications treating chronic and/or life-threatening diseases are frequently new products, which are often more expensive than generic or older, branded products that treat similar conditions. The term specialty pharmacy has come to be associated with these medications. Exponents claim the new technology improves quality of life and lowers the cost of care by reducing hospitalizations. Opponents claim the higher per-dose cost spread over larger populations does not justify the expense.

The cost of research, both failed and successful, is reflected in product pricing. Current federal guidelines allow generic equivalents marketplace access based on the patent date, not the release date, of a product. This considerably narrows the window in which costs of advances may be recovered. A further complicating dynamic involves the payers. Physician reimbursement policies sometimes reward utilizing lower-cost “proven” products and cast those prescribing highercost products as “over-utilizers,” placing them in lower-tiered categories of reimbursement and patient access. Objectives: We will discuss the issues that guide the early adoption of new pharmaceutical therapies and how they relate to medical devices. We will examine the role of pharmacy benefit management in dealing with the costs of specialty pharmacy. We will explore whether it is penny-wise but pound-foolish to restrict access to new therapies and what level of communication within the industry is necessary to address these problems. With the baby boomers reaching retirement age, more people than ever will be taking prescription medications. As new products come down the development pipeline, costs and benefits will continue to escalate. We will provide specific examples of how specialty pharmacy is at the forefront of the battle to control the cost of care. 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 Company Address City, State, Zip 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 04/12/2012

News to page 6 MARCH 2012 MINNESOTA HEALTH CARE NEWS

News from page 5 Services share significant amounts of patient data with the company and uses the company to manage revenue collection from patients. Swanson says that Accretive Health’s financial documents show that Fairview paid the company more than $75 million in the first three quarters of 2011. In the case of the stolen laptop, the suit says that on July 25, 2011, an Accretive employee left an unencrypted laptop containing sensitive information on 23,500 Minnesota patients from Fairview and North Memorial in a rental car in Minneapolis. The laptop was then stolen from the car. Swanson’s suit says that Accretive has violated state and federal health privacy laws, state debt collection laws, and state consumer protection laws. The state is seeking an order requiring Accretive to fully disclose what information it has about patients, what information has been lost, where it has sent patient information, and how the company uses

patient information. Swanson criticizes the company for its system of scoring patients for their risk of hospitalization and grading their frailty, based on data provided by the health systems. “The debt collector found a way to essentially monetize portions of the revenue and health care delivery systems of some nonprofit hospitals for Wall Street investors, without the knowledge or consent of patients who have the right to know how their information is being used and to have it kept confidential,” Swanson says.

Drug Report Shows Record-High Rate of Heroin Admissions A twice-yearly report on drug use in the Twin Cities showed a record-high rate of treatment admissions for heroin and opiates. The report, released by the Minnesota Department of Human Services (DHS), finds that heroin

accounted for 10 percent of addiction treatment admissions in the first half of 2011, a rate that has increased in the past decade from 3.3 percent in 2000. Other opiates, which include most prescription painkillers, accounted for 9.3 percent of treatment admissions in the first half of 2011, compared to 1.4 percent in 2000. Carol Falkowski, DHS drug abuse strategy officer, says the new data show the highest rate of heroin and opiate admissions since the report began tracking admissions in 1986. “Over the past decade, the public eye has been focused on methamphetamines,” Falkowski notes. “All those indicators, here as well as nationally, peaked around 2005 and have been declining ever since. But since 2000, we’ve seen this constant increase of heroin and other opiates among treatment admissions.” Falkowski calls the numbers for heroin treatment unprecedented. “We have never seen the extent of opiate addiction here that we are now seeing, and it’s

really created a learning curve for treatment professionals, for other health professionals, and for law enforcement in terms of how to best address it.” The report also notes the ongoing problems with synthetic drugs, which include synthetic THC, used as an alternative to marijuana; “bath salt” compounds; and 2C-E, a drug that drew headlines in 2011 when 10 young people at a party in Blaine were hospitalized and one died. Falkowski says one of the problems with the new generation of synthetic drugs is that they are marketed directly to consumers on the Internet. Despite the fact that these drugs are illegal in Minnesota, the products are advertised as legal online. “The area of online synthetic drug sales is an enormous challenge,” Falkowski says. “The public health dilemma is fairly urgent, especially with bath salts, which produce extreme psychotic reactions in people that can be very long-lasting.”

Now accepting new patients

A unique perspective on cardiac care Preventive Cardiology Consultants is founded on the fundamental belief that much of heart disease can be avoided in the vast majority of patients, and significantly delayed in the rest, by prudent modification of risk factors and attainable lifestyle measures.

Elizabeth Klodas, M.D., F.A.S.C.C is a preventive cardiologist. She is the founding Editor in Chief of CardioSmart for the American College of Cardiology www.cardiosmart.org, a published author and medical editor for webMD. She is a member of several national committees on improving cardiac health and a frequent lecturer on the topic.

We are dedicated to creating a true partnership between doctor and patient working together to maximize heart health. We spend time getting to know each patient individually, learning about their lives and lifestyles before customizing treatment programs to maximize their health. Whether you have experienced any type of cardiac event, are at risk for one, or

are interested in learning how to prevent one, we can design a set of just-for-you solutions. Among the services we provide • One-on-one consultations with cardiologists • In-depth evaluation of nutrition and lifestyle factors • Advanced and routine blood analysis • Cardiac imaging including (as required) stress testing, stress echocardiography, stress nuclear imaging, coronary calcium screening, CT coronary angiography • Vascular screening • Dietary counseling/Exercise prescriptions

To schedule an appointment or to learn more about becoming a patient, please contact: Preventive Cardiology Consultants 6545 France Avenue, Suite 125, Edina, MN 55435 phone. 952.929.5600 fax. 952.929.5610 www.pccmn.com

MINNESOTA HEALTH CARE NEWS MARCH 2012

PEOPLE Melanie Sullivan, EdD, has been appointed as chief executive officer of St. Croix Orthopaedics

NOW hear this!

(SCO). Sullivan, who has been an integral part of SCO for nearly 13 years, rose to the position of chief operating officer several years ago. The practice, which has corporate offices in Oak Park Heights, has clinics in Stillwater, Maplewood, Woodbury, Lake Elmo, and Wyoming, Minn., Melanie Sullivan, EdD

and in six locations in Wisconsin.

The 2011 Shotwell Award was presented to HealthPartners president and CEO Mary Brainerd in January on behalf of the West Metro Medical Foundation. Since 1971, the award has been presented annually to a person in the state of Minnesota who has made significant innovations and/or improvements in health care delivery. Brainerd has held her current position with HealthPartners since 2002, and previously served

Mary Brainerd

as the organization’s executive vice president and chief operating officer. Before joining HealthPartners in 1992, she held senior-level positions with Blue Cross and Blue Shield of Minnesota, and was senior vice president and chief executive officer of Blue Plus. In 2010 she accepted a leadership role as corporate champion for Honoring

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.

Choices Minnesota, an advance-care planning initiative of the Twin Cities Medical Society and its foundation. Brainerd also was given the 2011 Award for Outstanding Citizenship by the Caux Round Table, an international group based in St. Paul that promotes ethical busi-

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

ness practices. Cindra Kamphoff, PhD, MS, has received the Dorothy V. Harris Memorial Award from the Association for Applied Sport Psychology (AASP). Kamphoff, an AASP-certified consultant, is an associate professor at Minnesota State University, Mankato, where she coordinates the master’s program in sport and exercise psychology and also serves as the department’s graduate coordinator. Kamphoff is

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be b ew worry-free. or r y-f re e.

the current head of the AASP’s Research and Practice Division, section editor for Women in Sport and Physical Activity Journal, and serves on the editorial board of the International Journal of Sport Science and Coaching. Northwest Family Physicians (NWFP) has announced additions to its medical staff. Daniel Hanson, MD, FAAOS, a spine surgeon with Midwest Spine Institute, will see patients at NWFP’s clinics in Crystal and Rogers, Minn. Hanson provides clinical assessment and treatment for all patients with spine pathology. Jonathan Tallman, MD, will practice at the Crystal clinic. He has more than 14 years of experience and is board-certified in family medicine. Hennepin County Medical Center nurse David Groves won a Diseases Attacking the Immune System (DAISY) Award recently for

IIt’s t ’s Medicare Medicare with with a plan plan you you can can trust. trust. HealthPartners F HealthPartners Freedom reedom iiss tthe he ttop-rated* op-rated* Medicare M edicare plan plan in in Minnesota, Minnesota, and and the the only only plan plan in in tthe he sstate tate tto o rreceive eceive the the highest highest accreditation accreditation ffrom rom National for tthe he N ational Committee Committee fo or Quality Quality Assurance.** Assurance.** healthy. So yyou ou ccan an feel feel confident, confident, supported supported aand nd h ealthy. Shop plans Orr call uss aatt S hop aand nd ccompare ompare p lans online. online. O call u 952-883-5601 800-247-7015, 9 52-883-5601 oorr 8 00-247-7015, 8 aa.m. .m. tto o8 p.m., days TTY p .m., sseven even d ays a week. week. T TY users users 952-883-6060 800-443-0156. ccall all 9 52-883-6060 oorr 8 00-443-0156. healthpartners.com/medicare healthpartners.com/ com// medicar e

contributions he has made under the hospital’s implementation of the Transforming Care at the Bedside (TCAB) program. The DAISY Foundation’s national awards program recognizes “extraordinary nurses” and the “superhuman work nurses do every day at the bedside.” As part of the hospital’s TCAB team, Groves helped implement clearer protocols for the use of insulin at patients’ bedtimes. Groves and the team also moved supplies for drawing blood closer to the areas where they are needed, thereby increasing the time nurses have to care directly for patients.

A health plan with a Medicare edicare contract. *NCQA *NCQA’s A’s Health Insurance Plan Rankings 2010-11 – Private. ate. HealthPartners is also known as Group Health Inc. c. Released October 18, 2010. **NCQA **NCQA’s ’s Accreditation ation Survey.. Released May 15, 2011. H2462_AdRating_164 Survey ng_164 File & Use 10/08/2011 © 2011 HealthPartners MARCH 2012 MINNESOTA HEALTH CARE NEWS

PERSPECTIVE

Are you an organ donor? “You and $2” supports a critical need

Susan Gunderson LifeSource

Susan Gunderson is CEO of LifeSource, the nonprofit, federally designated organization that manages organ and tissue donation in Minnesota, North Dakota, South Dakota, and western Wisconsin. LifeSource works with hospital and community partners to support donor families, to facilitate organ and tissue donations, and to encourage people to register as donors. Each year, LifeSource works with approximately 150 organ donors and more than 450 tissue donors, resulting in more than 500 organ transplants and thousands of tissue transplants.

f given the chance to save a life, most Minnesotans will want to do so. It’s just the way we are. Now we can help others learn how easy it is to be a lifesaver. Legislation that took effect in January makes it easy for Minnesotans to support education about organ, tissue, and eye donation by donating two dollars when they apply for or renew their driver’s license or state ID card. Money raised will be used to educate Minnesotans about the need for lifesaving organ donation, with the goal to increase the number of registered organ donors in the state. This fundraising program, known as “You and $2,” was made possible by passage of a bipartisan bill during the 2011 legislative session.

and/or eye donors. More than 2.4 million Minnesotans have already done so. That’s about 60 percent of adults in the state, exceeding the national average of 42 percent of people who are registered donors. But while six in 10 Minnesotans have joined the state donor registry, we are far from the top. In the Upper Northwest, for example, more than 70 percent of adults are registered as donors across four states: Alaska, Montana, Washington, and Oregon. With more education about donation, we can increase the number of registered donors in our state, thereby saving more lives and restoring more shattered families.

Critical need Thousands of Minnesotans The number of people who are registered donors Organ, tissue, and eye donations are gifts that in Minnesota continues to rise, but the rate of provide hope, healing, and a chance for continued growth in registration has slowed significantly. life to those in need of transplantation. One per- This is of critical concern, as the need for organ son can save and heal as many as 60 lives through donors is expected to increase. Now, the “You and organ, tissue, and eye donation. In 2010, more $2” program allows Minnesotans to easily conthan 28,000 men, women, and children in the tribute $2 to education about United States received a lifesavorgan, tissue, and eye donation. ing organ transplant. For these The Commissioner of Public The need for organ individuals, a transplant granted Safety will disburse funds raised them the opportunity to enjoy donors is expected through this program via grants time with their families, return to to nonprofit organizations dedito increase. work or school, and live a full cated to advocacy for organ, tislife. However, they represent sue, and eye donation. just one-fourth of the more than Research shows that about half of Minnesotans 112,000 people nationwide who need transplants. who are not registered donors do, in fact, support That includes nearly 3,000 people in Minnesota. donation. Commonly cited reasons for not regisWe can help those in need by increasing the numtering are misconceptions that individuals are too ber of people who are registered to donate. old to donate or that a preexisting medical condiTransplantation is a highly successful medical tion precludes donation. Contributions to “You therapy, limited not by technology or science but and $2” will help develop education programs to by a lack of available organs, tissues, and eyes. As correct these misconceptions through high school a community, we have a long tradition of lending and driver’s education, community outreach, a helping hand when needed. The “You and $2” events, and the media. program builds on this spirit of giving to help the We encourage all Minnesotans to register as men, women, and children awaiting that gift of life donors, and to consider making a $2 contribution or sight. to support donation education.To find information Check a box about donation and register online to be a donor, The way it works is that Minnesotans applying for visit www.DonateLifeMN.org. Information about or renewing their driver’s licenses or state ID the “You and $2” program is available at cards fill out a form, and can check a box on the www.Life-Source.org. form to designate themselves as organ, tissue,

MINNESOTA HEALTH CARE NEWS MARCH 2012

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10 QUESTIONS

& George Rizkalla, DDS George Rizkalla, DDS, completed postgraduate training at the University of Minnesota School of Dentistry and has been practicing general dentistry since 2000. His solo practice, Comfort Dental, in New Hope, is unaffiliated with any other dental clinic. What criteria should a person use to select a dentist? Cost and insurance: All in-network providers should charge you the same amount, no matter which dentist you go to—you don’t have to go to a chain clinic to receive affordable care. Quality: “You get what you pay for” is true in dentistry as in other situations. This comes through in the quality of the lab work and the skill of the dentist. Technology: Some dental care providers may not invest in the latest technology, like digital imaging, intra-oral cameras, CAD/CAM crowns (computer-aided design/computer-aided manufacturing), and lasers. Ask any potential dental care provider what their practice does to stay on the leading edge of dental technology. One way to find out quickly is to ask if the office is “paperless.” If it is, then it likely has embraced technologic advances in dentistry. What can you tell us about gum disease? Fifty percent of adults in the U.S. have gingivitis, the mildest form of gum disease. Another 35 percent have more advanced gum disease, called periodontal disease or periodontitis. Untreated periodontitis increases your risk of stroke, heart attack, diabetes, and several other serious health problems, and can directly affect bone health and tooth loss. If your health care provider detects the early stages of periodontitis, often described as “pockets” around your teeth, you should take it seriously. Treatment may include cleaning below the gums, treatment with locally applied antibiotics, and laser treatment to eliminate bacteria and infection. What are some new advances in dentistry? Digital x-rays expose the patient to 90 percent less radiation and, because they can be enlarged on a computer screen, allow dentist and patient to look at dental problems together. New restorative materials include metal-free options for fillings and crowns. New resins bond to teeth better and last longer than amalgam fillings and metalbased crowns. Quick crowns: CAD/CAM equipment allows the dentist to custom design and manufacture crowns and veneers on site, often in one visit. This is more convenient for the patient than traditional crowns and veneers, which typically require multiple visits.

Photo credit: Bruce Silcox

MINNESOTA HEALTH CARE NEWS MARCH 2012

What conditions do you see most? Gum disease, because it is common, often underdiagnosed, and underemphasized in our culture. This shows up as a local bacterial infection between your teeth and gums that is described as a “pocket.” Pockets that are 4 millimeters deep or deeper may indicate periodontitis. This condition can often be treated with deep-cleaning procedures and localized application of antimicrobial medication. However, because insurance does not always cover periodontal cleanings at the same level as regular cleanings, many patients decline treatment. What results is a worsening condition that can lead to tooth decay, loss, and systemic problems. If your dental provider detects periodontitis, it may be time to change your dental routine and pursue any recommended deep cleanings and follow-up treatment.

“

Fifty percent of adults in the U.S. have gingivitis.

What are reasons not to ignore tooth pain? It is critical not to ignore tooth pain. Pain can be caused by many different reasons, including tooth decay that has reached a nerve, periodontitis, local infection, and trauma. Typically, once tooth pain has started it never goes away. It may subside for a time, but damage has occurred and will worsen. Additionally, the sooner you see your dentist for diagnosis and treatment of tooth pain, the more that can be done to save the tooth. When you consider that replacing teeth with bridges, implants, or dentures can be costly, saving a tooth to begin with may be the healthiest and most cost-effective route. What can you tell us about halitosis (bad breath)? Halitosis can indicate underlying dental issues. If brushing your teeth, flossing, and using mouth rinse doesn’t get rid of halitosis, you may need to make an appointment for diagnosis and treatment. Treatment may include prescription medication, gum therapy, or addressing decay and infection. What can you tell us about dental implants? A dental implant is a post, usually titanium, anchored in the jawbone to replace a missing tooth. Bone eventually grows around and through the implant, which can function as a single tooth or as an anchor to support partial or full dentures. Implant-supported dentures fit better and provide more comfort and functionality than dentures that aren’t supported by implants. Implant procedures are increasingly incorporated into general dentistry.

”

What is sedation dentistry? This involves using options that reduce patient anxiety. Sedation dentistry options include taking prescription medication before a dental appointment, having your dentist give you “relaxing gas” (nitrous oxide), and intravenous sedation. Sedation dentistry may help patients who have a history of traumatic dental experiences, difficulty becoming numb, extremely sensitive teeth, or complex dental problems; those who experience sweaty palms or grip the armrests of the dental chair; or those whose treatment requires lengthy dental appointments.

What should a parent know about a child’s first visit to the dentist? Before your child’s first visit, it’s a good idea to make an appointment for yourself and invite your child to attend. Your child can sit on your lap for most routine dental visits, which reassures them that they are in a safe environment. To ensure your child has a positive first visit, your dentist should introduce the child to equipment in the room using child-friendly language. What are the most important things to know about taking care of your teeth? Find a dental care provider you trust and who shares your vision for your dental goals. Schedule cleanings every six months if you have healthy gums; every four months if you have periodontal issues. Regular checkups will help you detect problems before they occur and save your teeth, overall health, and finances in the long run.

MARCH 2012 MINNESOTA HEALTH CARE NEWS

H O S P I TA L S

cynic might wonder if it’s possible to improve patient health while lowering health care costs. But my work as an intensivist at Mercy Hospital in Coon Rapids—an intensivist is a physician who specializes in the care and treatment of patients in intensive care— has convinced me that preventing hospitalacquired infections and reducing the cost of health care are not only simultaneously achievable but are interconnected.

The problem Two of the most common hospital-acquired infections are ventilator-associated pneumonia (VAP) and central line–associated bloodstream infections (CLABSI). VAP may occur in a patient who uses a ventilator to breathe. CLABSI may occur in a patient who has a central line (a tube called a catheter) inserted into a large vein, typically in the neck or near the heart, which is used to administer medicine or fluid or to collect blood. Both VAP and CLABSI can lead to death. When patients do survive, they endure pain and suffering, time in the intensive care unit (ICU), and expense. Our hospital’s ICU, which cares for approximately 2,400 critically ill patients each year, wanted to see if it could implement changes that would reduce or eliminate these infections.

The solution Instances of both of these hospital-acquired infections have been virtually eliminated in our ICU. There have been no cases of CLABSI

REDUCING red i u q c a l a t i p s ho infecsptitioal’ns ssuccess story One ho

quist, MD By Paul Young

for more than three years and only one to two cases of VAP per year during that time These results recently garnered our hospital an Outstanding Leadership Award from the U.S. Department of Health and Human Services (HHS) and the designation of “Mentor Hospital” from the Institute for Healthcare Improvement, a The key to Massachusetts-based nonprofit organizasuccess has tion that promotes best practices and been ... effective innovations in health care. teamwork. Eliminating these infections required changes in complex clinical practices and a focus on teamwork among hospital personnel. Different changes were designed and implemented for each of the two types of infections.

Eliminating VAP includes • Elevating the head of the patient’s bed to reduce aspiration pneumonia, which occurs when foreign materials (usually food, liquids, vomit, or fluids from the mouth) are breathed into the lungs or airways leading to the lungs. • Daily sedation vacations—periodic pauses in constantly administered sedatives—and readiness-to-wean assessments, to ensure patients are weaned off ventilators as quickly as possible

MINNESOTA HEALTH CARE NEWS MARCH 2012

• Stress ulcer prophylaxis to suppress production of stomach acid, to reduce complications that would extend a patient’s stay in the ICU • Deep vein thrombosis prophylaxis to prevent blood clots and related complications that would extend a patient’s stay in the ICU

Our ICU safety culture ranks in the top 10 percent of U.S. hospitals.

Eliminating CLABSI includes changes in the way the central line is inserted and changes in the way it is maintained. Insertion changes • Improved hand hygiene practices • Maximal barrier precautions (methods and/or devices used to decrease contact with potentially infectious body fluids) • Using antiseptic solution for insertion and site care • Optimal site selection for the central line Maintenance changes • Changing the location of the central line if the patient arrives with a line in the femoral artery or if the line was initially inserted using inappropriate hygiene • Daily, documented review of the need to keep the line inserted • Daily bathing of patients with a chlorhexidine gluconate-impregnated cloth; chlorhexidine gluconate has been shown to reduce infection. • Standardized techniques for site care and line maintenance

Teamwork The key to success has been not just the infection-reducing clinical practices but also the teamwork practices that help engage all clinicians in doing the work. • Information on infection prevention practices is provided to all clinicians who are new to Mercy. • Peer coaching by trained colleagues helps provide immediate, bedside feedback. • A critical event analysis of every infection is conducted to learn from it. This involves a review of the patient’s risk factors, the symptoms and progression of the infection, checking to see if personnel are following best practices, and determining the root cause of the infection. Specific bullet points that address what was done correctly and what could be improved are shared widely and are regularly posted in areas that staff members, patients, and family members can access.

Sharing knowledge Articles about our success at reducing hospital-acquired infection were published throughout the Allina health care system and resulted in these interventions being adopted by new units and hospitals within the system. Articles also were published in national medical journals, allowing us to add our knowledge to a national conversation about infection prevention.

Data now show that we achieved our aim of improving the care of ICU patients while eliminating the costs that hospitalacquired infections can add to patients’ medical bills. Data from Allina-wide 2010 and 2011 “safety culture” surveys, which are validated and benchmarked through the Agency for Healthcare Research and Quality, revealed that our ICU safety culture ranks in the top 10 percent of U.S. hospitals.

Making it better for patients Data show that eliminating CLABSI resulted in a total of 96 fewer days in our ICU for all patients treated between 2007 and 2010. Preventing VAP saved approximately $18,000 per patient. These achievements have helped us exceed Minnesota and HHS quality measure thresholds and have helped establish Mercy Hospital’s overall quality performance in the top 10 percent of Minnesota hospitals. Most important, patients have experienced less suffering, fewer days, lower costs, and higher-quality care while in our ICU. Paul Youngquist, MD, is an intensivist at Mercy Hospital in Coon Rapids.

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MARCH 2012 MINNESOTA HEALTH CARE NEWS

POLICY

Health insurance options A market-driven health insurance solution By Mike Rothman

ealth insurance isn’t something we think about every day. But sitting in the waiting room at the doctor’s office about to make that copay, we can’t help but think about it. That is the moment we sometimes wonder: Am I getting the best value for my dollar? Is this really the best health coverage for my family? Isn’t there a more affordable option? Two years from now, in January 2014, all Minnesotans will have access to a user-friendly consumer tool that will help us answer those questions more easily. At the click of a mouse or with the swipe of a finger on a personal mobile device, a Minnesota-Made Health Insurance Exchange will help consumers compare specific insurance policies. In an apples-to-apples format, this new shopping tool will empower Minnesotans to make the best health insurance choices for ourselves, our families, and our businesses.

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MINNESOTA HEALTH CARE NEWS MARCH 2012

What is a health insurance Exchange?

to expand their businesses in Minnesota or to hire new workers. A Minnesota-Made Health Insurance Exchange will help small businesses provide affordable coverage choices for their workers. It will also simplify the administration of health insurance for small businesses and allow business owners to focus on growing their business instead of managing the rising cost of health insurance.

Envision for a moment a user-friendly website like Priceline.com or Orbitz.com. Websites like these have made it much easier to buy affordable airline tickets and pick the right hotel room. From the comfort of your personal computer, you can compare flights by price and availability, complete with consumer reviews to help make the best decision for your travel plans. So, if planning your next vacation is that We sometimes wonder: Am I getting easy, shouldn’t it be a little easier to buy health insurance? With a Minnesota-Made Health the best value for my dollar? Insurance Exchange, it will be. In fact, a website tool much like Priceline.com will be an integral part of a new Exchange. Employers both large and small need the more competitive, The concept of an Exchange is simple: provide Minnesotans with affordable health care choices that an Exchange would provide. the information and ability to choose their own affordable, quality That’s why the Minnesota Chamber of Commerce and the Minnesota health care. From your PC, tablet, or smart phone, the Exchange will Business Partnership agree that an Exchange will be an important provide you with numerous health insurance choices available in the private market or through public programs. Based on your needs and cost-saving tool for Minnesota’s business community. what you wish to pay, the Exchange will help you easily compare I can’t afford insurance—how can an Exchange help? your coverage options by cost, quality, and consumer satisfaction. It A Minnesota-Made Health Insurance Exchange will help consumers will be a simple, one-stop shop that provides all the information you determine whether they are eligible for Medical Assistance or other need to make an informed decision. The Exchange will also give public programs. Eligible Minnesotans will then be able to enroll in insurance companies market-driven incentive to compete for your those public programs more easily through the Exchange. Consumers business. will also be able to determine whether any subsidies and tax credits are available to help lower their premium costs for private coverage What if I have health insurance through my employer? for themselves, their families, or their businesses. An Exchange can allow workers who already have coverage through a small employer to choose the plan that is best for them and their families. This is how it will work. First, the employer determines how much it wants to contribute financially to cover an employee’s health benefits. The employer can either offer an insurance plan or a stipend. Next, the employee—not the employer—picks the plan that best meets his or her individual and family needs based on cost, quality, and consumer satisfaction. Then, the employer contributes the amount it has chosen to pay, in the form of a stipend to the employee or by contributing to the insurance plan that the employee selected using the information provided by the Exchange. The Exchange will enable employers to offer more affordable options to their workers, and will give employees the flexibility and independence to choose their own coverage. Employees will be able to keep that coverage if they become self-employed, lose their job, or change jobs. In that way, Minnesotans will have more choice, more flexibility, and more confidence that their insurance policy is the right fit for their needs.

How will an Exchange help business owners? For the estimated 150 million American workers with employer-based health coverage, the average annual cost of family health insurance is more than $15,000. Employers pay almost three-quarters of that cost for their employees—an average $11,000 per family policy. That is an enormous price for both large and small businesses to pay. But small businesses are carrying a disproportionate burden of rising health care costs. This stifles competition and slows Minnesota’s recovery efforts. In fact, small businesses pay, on average, 18 percent more than large businesses to provide health insurance for their employees. That is money that small employers could be using

Health insurance exchange to page 17

Need help to plan for aging at home?

Create a plan to stay at home for yourself, your aging parents, your partner or a friend. Get step-by-step help to find out how to stay in your home longer and find services near home. Who uses the navigator tool? People who are thinking about staying in their home while they get older. People who are trying to figure out how to handle yard work, groceries, help for an older parent, or assisting their partner and friends.

What areas does it assist with? t Home maintenance t Medications t Safety t Housing

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Who can I call for assistance? Senior LinkAge Line® at 1-800-333-2433 Monday–Friday 8 a.m. to 4:30 p.m.

To get started visit www.longtermcarechoices.minnesotahelp.info MARCH 2012 MINNESOTA HEALTH CARE NEWS

March Calendar 8

Down Syndrome Parent Group You’ll find support, information, new ideas, and other parents of children with Down syndrome who understand. New members are always welcome. Call Down Syndrome Association of Minnesota (DSAM) at (651) 603-0720 or visit www.dsamn.org for more information about this group or other DSAM meetings in Minnesota. Thursday, March 8, 6:30–8 p.m., St. John’s Lutheran Church, 300 E. 4th St., Chaska Budget Meals Demonstration If you are shopping on a budget, providing a healthy meal for your family can be easy. Every Monday we demonstrate one hearty, healthy meal that is simple to make and tastes great! Please stop in; no registration required. For more information and class listings, visit www.valleynaturalfoods.com or call (952) 891-1212. Monday, March 12, 3–6 p.m., Valley Natural Foods, 13750 County Rd. 11, Burnsville Concerned Persons Group for Addiction and Mental Health Come and talk with others about how substance abuse and/or mental health issues affect you or your family. We offer education and time for discussion about current family issues. Free. You may come as often and stay as long as you choose. We meet the first and third Monday of each month. For more information, call (320) 251-2700, ext. 79920, or email voigtj@centracare.com. Monday, March 19, 6–8 p.m., Clara’s House, 1564 County Rd. 134 St. Cloud Living Well Series: Legal Issues for Ovarian Cancer Survivors Minnesota Ovarian Cancer Alliance invites you to join several financial and legal experts who will speak about the legal issues that ovarian cancer survivors can face. Small-group sessions follow the presentations. Pre-registration is requested for seating. Meetings are free and open to the public. Walk-ins are welcome. Call Becky Lechner at (612) 822-0500 for more information.

Tuesday, March 20, 7–9 p.m., MOCA, One Corporate Ctr., 7401 Metro Blvd., Suite 350, Third Fl., Edina Patient Safety Awareness Week: Be Aware for Safe Care, March 4–10, 2012

Colon Cancer Update Colon cancer is diagnosed in 130,000 Americans each year, but it is highly treatable—even curable—if caught early. Timothy Kinney, MD, gastroenterologist, addresses new tests for detection, newly approved drugs, and treatment options. He will also discuss the importance of colonoscopies and healthy lifestyles in preventing this disease. Questions? Call (952) 442-8083. Thursday, March 22, 6:30–7:30 p.m., Ridgeview Medical Center, 500 S. Maple St., Waconia

Kimchi Making Kimchi is a traditional fermented Korean dish made of vegetables and varied seasonings. Learn how to make basic kimchi in a crock pot and ferment it in glass jars. Kimchi promotes health, as it contains enzymes and probiotics that help digest food. Instructor Angelica Hollstadt produces fermented vegetable products for area co-ops. Cost: $22/members, $25/nonmembers. Register in person at customer service, by phone at (952) 891-1212, ext. 221, or online at www. eventbee.com/v/valleynaturalfoods/ boxoffice. Thursday, March 28, 6:30–8 p.m., Valley Natural Foods, 3750 County Rd. 11, Burnsville

The“Be Aware for Safe Care” campaign of the National Patient Safety Foundation (NPSF) emphasizes that safety issues affect everyone. NPSF suggests you: Become an informed health care consumer. • Research treatment plans for your condition; seek more than one opinion. • Choose a doctor, clinic, pharmacy, and hospital experienced in the type of care you require; ask questions of your care team. Keep track of your history. • Write down your medical history: medical conditions, illnesses, immunizations, allergies, hospitalizations, medications, dietary supplements, and reactions or sensitivities. Be a member of your health care team. • Share your health history and up-to-date health information with your health care team; understand your treatment plan. • If something doesn’t seem right or you have concerns about your safety, tell your doctor or health care professional. Involve family or a friend in your care. • Ask someone to accompany you to appointments, stay with you, help you ask questions, understand care instructions, and suggest your preferences. Follow the treatment plan agreed upon by you and your doctor. • Take medication exactly as prescribed and report anything unusual to your doctor. For more patient safety info, visit www.npsf.org or call (617) 391-9900.

28 Managing Your Medications More than one-third of medicine-related hospitalizations occur because medicine wasn’t taken properly. Learn about how medicines work, side effects, etc. Free; advance registration required. Call (651) 430-4697. Wednesday, March 28, 6:30–7:30 p.m., Lakeview Hospital, 927 Churchill St. W., Stillwater

Send us your news: 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 email 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 MARCH 2012

Health insurance exchange from page 15

Donâ&#x20AC;&#x2122;t have a computer? Need help using an Exchange? Resources will be available to help consumers, including one-on-one assistance navigating the Exchange. If you need assistance using the Exchange, your insurance agent or other designated professionals will be available to help you use this tool effectively and to make an informed decision.

The average annual cost of family health insurance is more than $15,000.

How is Minnesota developing an Exchange? In 2011, Gov. Mark Dayton signed Executive Order 11-30 to create a Minnesota-Made Insurance Exchange. This Exchange is currently being developed by the Minnesota Department of Commerce in coordination with the Minnesota Department of Human Services and the Minnesota Department of Health, with assistance from the Minnesota Health Insurance Exchange Advisory Task Force. When the federal Patient Protection and Affordable Care Act (PPACA) was signed into law in March 2010, states like Minnesota were given the option and the resources necessary to create their own insurance exchangesâ&#x20AC;&#x201D;consumer-friendly market tools designed to meet the unique demands of each stateâ&#x20AC;&#x2122;s consumers, economy, and health care system. Minnesota has the opportunity to craft its Exchange however we see fit, tailoring it to the needs of our stateâ&#x20AC;&#x2122;s families, employers, and health care system. If our state does not build its own Exchange, the federal government will do it for us, and we will have lost an oppor-

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tunity to adopt a solution to the rising cost of health insurance that is built by Minnesotans, for Minnesotans.

Learn more

Visit the Minnesota Department of Commerce website at http://mn.gov/commerce/insurance to find more information, including examples of how an Exchange might work and how it can help your family or business. You can also use this website to provide feedback on what you want and expect from an Exchange. Additional information about the Exchange is available on the Minnesota Health Reform website at http://mn.gov/health-reform or by calling the Department of Commerce at (651) 296-4026. We encourage your questions, and want to hear your concerns as our state works to build a Minnesota-Made Health Insurance Exchange. It is important that we work together and that we consider all perspectives as we build an Exchange that meets the unique demands of Minnesotaâ&#x20AC;&#x2122;s consumers, economy, and nation-leading health care system. Mike Rothman was appointed by the governor in 2011 to serve as commissioner of the Minnesota Department of Commerce. Prior to his appointment as commissioner, Rothman was an attorney with Winthrop & Weinstine, PA, Minneapolis, where he co-chaired the Insurance and Financial Services practice group. In addition to his experience in private practice and state government, Rothman has served as an adjunct professor at the University of Minnesota Law School.

Health care â&#x20AC;Śnaturally The clinics of Northwestern Health Sciences University offer natural health care solutions at three Twin Cities locations. We also partner to provide free services at community clinics. â&#x20AC;˘ Acupuncture and Oriental medicine

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Visit our website or call to find out more about locations, hours and services:

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MARCH 2012 MINNESOTA HEALTH CARE NEWS

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Fungal Infections Fluconazole 150mg tab ........................................................1 Nystatin/Triamcin cream* (15gm tube)† .........................1 Nystatin/Triamcin cream* (30gm tube)† .........................1 Nystatin/Triamcin ointment* (15gm tube)†...................1 Nystatin cream* (15gm tube)† ...........................................1 Nystatin cream* (30gm tube)†.............................................1 Terbinafine 250mg tab*.......................................................30

..........3 ..........3 ..........3 ..........3 ..........3 ..........3 .......90

Gastrointestinal Health Belladonna Alkaloid/PB tab*.............................................60 .....180 Cimetidine 800mg tab* ......................................................30 ........90 Cytra2 solution ...............................................................180ml 540ml Dicyclomine 10mg cap .......................................................90 .....270 Dicyclomine 20mg tab .......................................................60 .....180 Famotidine 20mg tab ..........................................................60 .....180 Lactulose syrup ..............................................................237ml 711ml Metoclopramide 10mg tab ...............................................60 .....180 Metoclopramide syrup ..................................................60ml 180ml Promethazine 25mg tab*...................................................12 ........36 Promethazine plain syrup*.........................................180ml 540ml Ranitidine 150mg tab .........................................................60 ......180 Ranitidine 300mg tab .........................................................30 ........90

Revised 1/4/12

Heart Health & Blood Pressure Amiloride-HCTZ 5mg-50mg tab .....................................30 ........90 Atenolol-Chlorthalidone 100mg-25mg tab ................30 ........90 Atenolol-Chlorthalidone 50mg-25mg tab ..................30 ........90 Atenolol 25mg tab ...............................................................30 ........90 Atenolol 50mg tab ...............................................................30 ........90 Atenolol 100mg tab ............................................................30 ........90 Benazepril 5mg tab ..............................................................30 ........90 Benazepril 10mg tab ...........................................................30 ........90 Benazepril 20mg tab ...........................................................30 ........90 Benazepril 40mg tab ...........................................................30 ........90 Bisoprolol-HCTZ 2.5mg-6.25mg tab ..............................30 ........90 Bisoprolol-HCTZ 5mg-6.25mg tab .................................30 ........90 Bisoprolol-HCTZ 10mg-6.25mg tab ...............................30 ........90 Bumetanide 0.5mg tab ......................................................30 ........90 Bumetanide 1mg tab ..........................................................30 ........90 Captopril 12.5mg tab ..........................................................60 ......180 Captopril 25mg tab ..............................................................60 ......180 Captopril 50mg tab ..............................................................60 ......180 Captopril 100mg tab ...........................................................60 ......180 Carvedilol 3.125mg tab ......................................................60 ......180 Carvedilol 6.25mg tab .........................................................60 ......180 Carvedilol 12.5mg tab ........................................................60 ......180 Carvedilol 25mg tab* ..........................................................60 ......180 Clonidine 0.1mg tab ............................................................30 ........90 Clonidine 0.2mg tab ............................................................30 ........90 Digoxin 0.125mg tab ..........................................................30 ........90 Digoxin 0.25mg tab .............................................................30 ........90 Diltiazem 30mg tab .............................................................60 .....180 Diltiazem 60mg tab .............................................................60 .....180 Diltiazem 90mg tab*............................................................60 .....180 Diltiazem 120mg tab ..........................................................30 ........90 Doxazosin 1mg tab ..............................................................30 ........90 Doxazosin 2mg tab ..............................................................30 ........90 Doxazosin 4mg tab ..............................................................30 ........90 Doxazosin 8mg tab ..............................................................30 ........90 Enalapril-HCTZ 5mg-12.5mg tab ....................................30 ........90 Enalapril 2.5mg tab ..............................................................30 ........90 Enalapril 5mg tab .................................................................30 ........90

Need to change your Pharmacy? Many large employers have recently dropped Walgreens and other Pharmacies from their Prescription Drug Benefit Plan, impacting where you can pick up your prescriptions. If this has happened to you please contact your local Walmart for assistance on our easy prescription transfer. $4, 30-day $10, 90-day

Enalapril 20mg tab ..............................................................30 Furosemide 20mg tab ........................................................30 Furosemide 40mg tab ........................................................30 Furosemide 80mg tab ........................................................30 Guanfacine 1mg tab ............................................................30 Hydralazine 10mg tab ........................................................30 Hydralazine 25mg tab ........................................................30 Hydrochlorothiazide(HCTZ)12.5mg cap*.....................30 Hydrochlorothiazide (HCTZ) 25mg tab ........................30 Hydrochlorothiazide (HCTZ) 50mg tab ........................30 Indapamide 1.25mg tab ....................................................30 Indapamide 2.5mg tab .......................................................30 Isosorbide Mononitrate 30mg ER tab ...........................30 Isosorbide Mononitrate 60mg ER tab ...........................30 Lisinopril-HCTZ 10mg-12.5mg tab ................................30 Lisinopril-HCTZ 20mg-12.5mg tab*................................30 Lisinopril-HCTZ 20mg-25mg tab* ..................................30 Lisinopril 2.5mg tab .............................................................30 Lisinopril 5mg tab ................................................................30 Lisinopril 10mg tab ..............................................................30 Lisinopril 20mg tab ..............................................................30 Methyldopa 250mg tab*....................................................60 Methyldopa 500mg tab*....................................................30 Metoprolol Tartrate 25mg tab..........................................60

........90 ........90 ........90 ........90 ........90 ........90 ........90 ........90 ........90 ........90 ........90 ........90 ........90 ........90 ........90 ........90 ........90 ........90 ........90 ........90 ........90 .....180 .......90 .....180

Metoprolol Tartrate 50mg tab..........................................60 .....180 Metoprolol Tartrate 100mg tab* .....................................60 .....180 Nadolol 20mg tab ................................................................30 ........90 Nadolol 40mg tab ................................................................30 ........90 Prazosin HCL 1mg cap ........................................................30 ........90 Prazosin HCL 2mg cap ........................................................30 ........90 Prazosin HCL 5mg cap ........................................................30 ........90 Propranolol 10mg tab .........................................................60 ......180 Propranolol 20mg tab ........................................................60 ......180 Propranolol 40mg tab .........................................................60 ......180 Propranolol 80mg tab .........................................................60 ......180 Sotalol HCL 80mg tab*........................................................30 ........90 Spironolactone 25mg tab*................................................30 ........90 Terazosin 1mg cap ...............................................................30 ........90 Terazosin 2mg cap ...............................................................30 ........90 Terazosin 5mg cap ..............................................................30 ........90 Terazosin 10mg cap .............................................................30 ........90 Triamterene-HCTZ 37.5mg-25mg cap ..........................30 ........90 Triamterene-HCTZ 37.5mg-25mg tab ..........................30 ........90 Triamterene-HCTZ 75mg-50mg tab ..............................30 ........90 Verapamil 80mg tab ............................................................30 ........90 Verapamil 120mg tab .........................................................30 ........90 Warfarin 1mg tab .................................................................30 ........90 Warfarin 2mg tab .................................................................30 ........90 Warfarin 2.5mg tab ..............................................................30 ........90 Warfarin 3mg tab .................................................................30 ........90 Warfarin 4mg tab .................................................................30 ........90 Warfarin 5mg tab*.................................................................30 ........90 Warfarin 6mg tab ..................................................................30 ........90 Warfarin 7.5mg tab ..............................................................30 ........90 Warfarin 10mg tab ...............................................................30 ........90

$4, 30-day $10, 90-day

Men’s Health

$9/30-day

Finasteride 5mg ...................................................................................30 $9/tablet

Levitra 20mg (limit 10 per customer per month) ......................1

Mental Health

$4, 30-day $10, 90-day

Amitriptyline 10mg tab .....................................................30 .......90 Amitriptyline 25mg tab ......................................................30 ........90 Amitriptyline 50mg tab .....................................................30 ........90 Amitriptyline 75mg tab ......................................................30 ........90 Amitriptyline 100mg tab ...................................................30 ........90 Benztropine 2mg tab ..........................................................30 ........90 Buspirone 5mg tab ..............................................................60 ......180 Buspirone 10mg tab*...........................................................60 ......180 Carbamazepine 200mg tab*.............................................60 ......180 Citalopram 20mg tab ..........................................................30 ........90 Citalopram 40mg tab .........................................................30 ........90 Fluoxetine 10mg tab*..........................................................30 ........90 Fluoxetine 10mg cap ..........................................................30 ........90 Fluoxetine 20mg cap ..........................................................30 ........90 Fluoxetine 40mg cap ..........................................................30 ........90 Fluphenazine 1mg tab .......................................................30 ........90 Haloperidol 0.5mg tab ......................................................30 ........90 Haloperidol 1mg tab ...........................................................30 ........90 Haloperidol 2mg tab ...........................................................30 ........90 Haloperidol 5mg tab ...........................................................30 ........90 Lithium Carbonate 300mg cap* ......................................90 ......270 Nortriptyline 10mg cap .....................................................30 ........90 Nortriptyline 25mg cap ......................................................30 ........90 Paroxetine 10mg tab* .........................................................30 ........90 Paroxetine 20mg tab*..........................................................30 ........90 Prochlorperazine 10mg tab .............................................30 ........90 Thioridazine 25mg tab .......................................................30 ........90 Thioridazine 50mg tab .......................................................30 ........90 Thiothixene 2mg cap ..........................................................30 ........90 Trazodone 50mg tab ...........................................................30 ........90 Trazodone 100mg tab .........................................................30 ........90 Trazodone 150mg tab ........................................................30 ........90 Trihexyphenidyl 2mg tab ..................................................60 ......180

Thyroid Conditions Levothyroxine 25mcg tab .................................................30 Levothyroxine 50mcg tab .................................................30 Levothyroxine 75mcg tab .................................................30 Levothyroxine 88mcg tab .................................................30 Levothyroxine 100mcg tab ...............................................30 Levothyroxine 112mcg tab ...............................................30 Levothyroxine 125mcg tab ...............................................30 Levothyroxine 137mcg tab ...............................................30 Levothyroxine 150mcg tab ...............................................30 Levothyroxine 175mcg tab*..............................................30 Levothyroxine 200mcg tab*..............................................30

........90 ........90 ........90 ........90 ........90 ........90 ........90 ........90 ........90 ........90 ........90

Viruses Acyclovir 200mg cap ...........................................................30 .......90

Vitamins & Nutritional Health Folic Acid 1mg tab ...............................................................30 Mag 64 64mg tab* ................................................................60 Magnesium Oxide 400mg tab0 ......................................30 Prenatal Plus qty 30*.............................................................30 Potassium Chloride 10% liquid ................................470ml Sodium Fluoride .25mg chewable (120ct bottle) †* ....1

........90 ........90 ........90 ........90 1419ml .....N/A

Women’s Health Estradiol 0.5mg tab .............................................................30 Estradiol 1mg tab .................................................................30 Estradiol 2mg tab .................................................................30 MedroxyprogesteroneAcetate 2.5mg tab ...................30 Medroxyprogesterone Acetate 5mg tab .....................30 Medroxyprogesterone Acetate 10mg tab ...................10

........90 ........90 ........90 ........90 ........90 ........30

$9, 30-day $24, 90-day

Alendronate SOD 35mg tab . ..............................................4 ........12 Alendronate SOD 70mg tab ...............................................4 ........12 Clomiphene 50mg tab ..........................................................5 ........15 Sprintec 28-day tab ..............................................................28 .....N/A Tamoxifen 10mg tab ............................................................60 ......180 Tamoxifen 20mg tab ...........................................................30 ........90 Tri-Sprintec 28-day tab .......................................................28 ....N/A

Skin Conditions

Other Medical Conditions

Fluocinonide 0.05% cream* (15gm tube)†......................1 ...........3 Fluocinonide 0.05% cream* (30gm tube)† .....................1 ...........3 Gentamicin 0.1% cream (15gm tube)†.............................1 ...........3 Gentamicin 0.1% ointment (15gm tube)† ......................1 ...........3 Hydrocortisone 1% cream (28.35-30g tube)†................1 ...........3 Hydrocortisone 2.5% cream (30gm tube)†.....................1 ...........3 Silver Sulfadiazine 1% cream* (50gm tube)† .................1 ...........3 Triamcinolone 0.025% cream (15gm tube)† ..................1 ...........3 Triamcinolone 0.025% cream (80gm tube)† ..................1 ...........3 Triamcinolone 0.1% cream (15gm tube)† .....................1 ...........3 Triamcinolone 0.1% cream (80gm tube)† .......................1 ...........3 Triamcinolone 0.1% ointment (15gm tube)† ................1 ...........3 Triamcinolone 0.1% ointment (80gm tube)†.................1 ...........3 Triamcinolone 0.5% cream (15gm tube)† .......................1 ...........3

Chlorhexidine Gluconate 0.12% soln (473ml bottle)† ...1 ...........3 Hydrocortisone AC 25mg suppositories* ....................12 ........36 Isoniazid 300mg tab ............................................................30 ........90 Lidocaine 2% viscous solution (100ml bottle)† .............1 ..........3 Megestrol 20mg tab*...........................................................30 ........90 Oxybutynin 5mg tab*..........................................................60 ........90 Phenazopyridine 100mg tab.............................................60 .....180 Phenazopyridine 200mg tab ............................................30 ........90 Prednisone 2.5mg tab .........................................................30 ........90 Prednisone 5mg tab ............................................................30 ........90 Prednisone 10mg tab .........................................................30 ........90 Prednisone 20mg tab .........................................................30 ........90

Revised 1/4/12

*Prices may be higher due to State restrictions. † Prepackaged drugs are covered only in unit sizes specified on Drug list. See Program Details or your Walmart Pharmacist for details. Prescription Program includes up to a 30-day supply for $4 and a 90-day supply for $10 of some covered generic drugs at commonly prescribed dosages. Higher dosages cost more and some restrictions may apply. PHARMACIES ARE CONVENIENTLY LOCATED IN EVERY MINNESOTA WALMART LOCATION

FOR MORE INFORMATION AND THE MOST CURRENT LIST OF DISCOUNTED DRUGS VISIT

WALMART.COM/pharmacy

COMMUNITY CAREGIVERS 2012

Making a difference in Recognizing Minnesota’s volunteer physicians

“There’s no shortage of patients; we just try to get as much done as we can while we’re there.” Rod Brown, MD

Each year, Minnesota Physician Publishing honors physicians

Providing care on the mosquito coast

who have volunteered medical services in recent years. Through volunteer medical activities that span the globe, Minnesota’s volunteer physicians have provided medical care and medical education and expanded cross-cultural skills and understanding. Their compassion, commitment, and generosity reflect deeply held values of Minnesota’s medical community. Story by Scott Wooldridge

When Rod Brown, MD, first traveled to Puerto Lempira 14 years ago, he was struck by how undeveloped the port town was. No electricity. The only way into the town, located on Honduras’ isolated Atlantic coast region, was by airplane or boat. Other than the local priest’s dilapidated truck, the only things with wheels were wheelbarrows. A lot has changed since that time, Brown says. “Everybody has cell phones. There are cars and trucks and motorcycles, even taxis,” he says. “It’s just a dramatic transformation from this very remote, sleepy little village to a kind of bustling small town.” Still, the region, commonly called the Mosquito Coast, has a ways to go. The hospital that Brown works from on his yearly medical missions had running water for the first time last year. Electricity is supplied by generators and is sometimes intermittent. Some of the X-ray equipment dates from the Vietnam War era. “It’s pretty primitive,” Brown says. “The facility is quite poor so anything you can do to get patients in and out of the hospital is better. They have a nursing staff and beds for patients, but linen and food and those types of things have to be brought by the patients’ families. Brown has traveled every year for 14 years to Puerto Lempira as part of missions with International Health Service (IHS), a nonprofit relief organization that is based in Eden Prairie. Brown is past president of the group and has served as medical director. IHS sends large missions twice a year to the Honduran town. The main medical mission takes place in February, and can consist of as many as 120 medical, dental, and support staff. Brown, an internist with Glacial Ridge Medical Center in Glenwood, travels to Puerto Lempira as part of the February missions, and works

MINNESOTA HEALTH CARE NEWS MARCH 2012

with a surgical team of eight to 12 people. He says his team will address a wide range of issues on any given mission, including removing tumors, fixing hernias, taking out tonsils, and repairing wounds from machetes or bullets. The hospital does have laparoscopic gear, so the visiting physicians also do some laparoscopic work, he adds. On a typical trip, Brown estimates, the surgical team will do 50 to 70 procedures over a 10-day period. “There’s no shortage of patients; we just try to get as much done as we can while we’re there,” he says. The missions also bring equipment and medical supplies with them. “The hospital has some supplies, but we don’t want to use them all up. We’re there to work with them and support them; what we don’t use we leave for their use,” Brown says. He notes that Standard Fruit, which owns the Dole brand, works with IHS to bring two container loads of supplies to the hospital every year. Having made so many trips, Brown has become good friends with some physicians in Puerto Lempira and he says his familiarity with the town has advantages. “You can step right in and know what to expect,” he says. “You know the staff, and they know you, so you don’t have to recreate the wheel each time. It makes for a smoother operation.” The trips have also allowed him to show his children what medical missions are like, Brown notes. “My son is now a physician in training … and he got interested in medicine and surgery from going down there as a high school student,” Brown says. “My daughter likewise had an interest and she’s in her fourth year of dental school at the University of Minnesota. That was a great opportunity and motivator for her.”

Minnesota and the world Outside the comfort zone Loree Kalliainen, MD, recently made her third trip to India to do medical mission work. Unlike her first two trips, Kalliainen organized the latest mission herself, taking five other medical professionals from Minnesota deep into one of India’s poorest regions, to a hospital that had never seen an American physician before. “It’s seven hours northwest of Calcutta in a very rural area called Jharkhand. No tourists ever go up there,” says Kalliainen. “It’s very impoverished, even for India.” Kalliainen, a plastic surgeon who is chief of staff past at Regions Hospital in St. Paul, planned the trip after meeting an Indian physician, Sister Victoria Aind, MD. Aind had asked Kalliainen to come and do a plastic surgery mission at the hospital Aind runs, Holy Cross Belatanr. The small convent hospital has one floor and 25 beds. It is located in a compound that holds the hospital and a leprosarium— Kalliainen notes that leprosy is still seen on a regular basis in the area. After raising the money—Kalliainen estimates it cost each member approximately $5,000 for the entire trip—and doing planning and preparation, the team left for India in February 2011.

Kalliainen describes the trip as a fascinating experience. “Everything about India is a massive sensory assault,” she says. “It’s loud and noisy and smelly and colorful. It just took

“Everything about India is a massive sensory assault.” Loree Kalliainen, MD me right out of my comfort zone.” But Kalliainen enjoyed the challenge, and she says her team did as well. “I’ve been lucky because the people I’ve chosen to bring with me on trips are of like mind. I don’t want anybody whining about the food or making comments about having to bathe with a bucket of water poured over our head. It’s an amazing opportunity ... I try to never be the ugly American.” Aind had asked Kalliainen to bring a team for a plastic surgery camp in part because rural India has a high number of burn cases. People in the region use open fires to cook and commonly use kerosene lanterns, and

simple accidents often lead to serious buns. “There are still a few cases where people will set each other on fire, “ she adds. “Women will set each other on fire if one was looking at another women’s husband.” Burn treatments and cleft lip repair were the vast majority of the mission’s work, and Kalliainen says those treatments can make a big difference. “If their lips weren’t fixed, these kids would be outcasts forever,” she notes. “If I do a relatively simple hand surgery or scar release on an arm, now they can work.” Despite the primitive conditions—“I don’t bring any electrical equipment because it will just be blown apart by the Indian power grid; what little there is of it,” Kalliainen says—the team was productive, doing more than 60 operative procedures in one week. “We just have some flashlights in the room, and when the power goes out … you just keep operating under flashlight,” she says. Kalliainen speaks fondly of the local community. “I think it’s wonderful to see that people are the same everywhere; you hear that all the time and it really is true,” she says. “Even with the immensity of the poverty, people are content, happy, and very pleasant. It’s just really an amazing experience.” Caregivers to page 22

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COMMUNITY CAREGIVERS 2012 The program has been recognized for its efforts to overcome barriers to care. In 2010, it was given the Governor’s Council on Faith and It’s not a major commitment of time, Patrick Heller, MD, says; just a few Community Service Initiatives Best Practices Award. The award is a hours a month. The facilities are modest; a basement of a church, with recognition of faith and community organizations that create best praca physician, a nurse, and a few volunteers. The service provides only tice models for bringing together private and government resources to basic screening and primary health care services. address community needs. Project H.E.A.L. has also received a Federal Yet Project Health, Education, Access, Link (H.E.A.L.) serves a popuCommunity Access Program grant in recent years to assist with outlation that may not have any other regular access to health care. The reach efforts in the St. Cloud metro area as well as the surrounding program was launched after local churches asked CentraCare Health rural areas. System to help provide basic health services for the homeless and uninHeller says the scope of practice is limited but helpful. “Maybe a sured people in St. Cloud. Since then, the health system has partnered 2-year-old has an ear infection, and we can see him, so they don’t have with many groups, including Catholic Charities, to go the ER,” he says. “Even just a clinic visit or an the Boys & Girls Club, the Robert Wood Johnson urgent care visit is going to be pretty expensive for Foundation, and United Way St. Cloud, to fund and them if they don’t have insurance.” maintain health care clinics in Cold Spring, Long Other issues the clinic treats includes upper respiraPrairie, Melrose, St. Cloud, and Waite Park. tory infection, back pain, and minor injuries. Patients The program began in 1999, and now has more with more serious conditions can be referred to other than 70 volunteers. The CentraCare Health Founfacilities. Heller notes in one case where a cancer was dation and Mid-Minnesota Family Medicine Center diagnosed, the clinic was able to send the patient on to supply equipment, and pharmaceutical companies a specialist. Other resources are available too—for donate medical supplies and sample medications. example, at Heller’s clinic a nutritionist is often avail“It’s a program to try to get care to people who able to talk to patients about healthy eating. don’t have insurance,” Heller says. “There’s a popula“ Some of what they Delivering health care can be as much about protion of people who don’t come in because they don’t viding moral support as administering medicine or need is reassurance, have insurance and maybe aren’t in a position where treatments, Heller notes. “There are some people that they can go through all the paperwork. But being part and they feel better just come frequently with fairly minor issues,” he says. of the community, you want to serve those people’s from the reassurance “Some of what they need is reassurance, and they feel needs too.” better just from the reassurance you give.” you give.” Heller says that most of the people he sees are The program is rewarding and also eye-opening, Hispanic and he guesses that a good number of them Patrick Heller, MD Heller says. “It just give you a little more insight into are undocumented. He says that he doesn’t ask—his other people who are out there; the people you don’t emphasis is on giving care. “If I can use my professee in the [regular] clinic. And it gives you a little more sional skills in that way, it makes sense,” he says. “We insight into what immigrants are dealing with.” don’t restrict it in any way.”

Overcoming barriers to care

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One new area for his group in building local capacity is the use of interactive training videos. With the help of a software developer, CSI is As medical director of Children’s Surgery International (CSI), Peter producing a series of DVDs that feature real surgeries, with interactive Melchert, MD, takes a big-picture approach to medical missions. Not “hot spots” placed over relevant areas of anatomy that users can click only does his Minneapolis-based group help needy children—with a on to choose the right instrument or procedure. The program will focus on fixing cleft palates—but under Melchert’s leadership it works assess mistakes or confirm proper decisions. to help the communities it visits improve their ability to provide their “The trainees can do that at home or at the hospital before we own medical services. ever come, and they’re miles ahead in terms of preparation,” Melchert “The question we ask ourselves is, are we fostering independence says. “Even the most low-resource hospital in Africa without electricity by building local capacity?” Melchert says. “Are we going to a place will have a computer for its physicians for continuing medical education where there's need and where our skills can be applied meaningfully, and communicating. It may be run by a little gas-powered generator, without taking away the job of a local physician?” but everyone has a computer. We can make this tool that runs on a Melchert began working with CSI in 2003, and he became its med- simple personal computer and broadly expand our trainee pool and ical director in 2004. In Minneapolis, Melchert is an internal medicine train faster and at less cost.” and pediatric hospitalist at Abbott Northwestern Hospital and In addition to fixing cleft palates, many of the missions include Children’s Hospitals and Clinics, but he describes his pediatric surgeons or pediatric urologists. Melchert work with CSI as a second full-time job. He makes as notes that hernias are a big problem in the developmany as three trips a year for the group, often ing world but that medical groups find it easier to assessing sites for future missions. fundraise for facial deformities than genital anomThat attention to detail and preparation is a key alies. By including surgical teams that can handle a part of his group’s philosophy, Melchert says. “Our range of problems, the group greatly increases the assessment is so comprehensive, I’m in the operatgood it can do. “Very simple treatments can have a ing room counting the number of outlets,” he says. great impact,” Melchert says. “I meet all the people we’ll be working with side-byAccording the Melchert, CSI is seeing an side … That’s really the only way to be effective.” increase in the number of physicians and medical Melchert, who also teaches as an assistant prostaff who volunteer for the overseas work. He says fessor for the University of Minnesota’s Global “Very simple treatments physicians tell him the work revitalizes their practices Health Course, says he has seen warehouses full of at home. “I find that when I’m working overseas, donated equipment that will never be used because can have a great impact.” I’m doing the things I thought I would be doing, facilities don’t have electricity or local physicians back when I was a medical student. All the doctors Peter Melchert, MD aren’t trained on the equipment. His group believes and nurses that come on these trips tell me the in working closely with local physicians, training same thing: ‘This is why I went into medicine.’” them to do the work so that further missions from Caregivers to page 24 U.S. doctors won’t be needed.

Healing patients, building capacity

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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

www.mppub.com MARCH 2012 MINNESOTA HEALTH CARE NEWS

COMMUNITY CAREGIVERS 2012 Recently, Slusher has been doing research on phototherapy using natural sunlight, and she notes her work has become a mix of research, training, and patient care. “There are a lot of blurred lines there. There’s Tina Slusher says medical mission work changes lives. She is an example a lot of teaching with the research, and there’s a lot of patient care in the teaching and in the research. It’s not a clear delineation.” herself—having gone from a general pediatric practice in eastern In addition to her work in Africa, Slusher has done teaching in Kentucky to a career where she devotes three to four months a year Thailand, which she says has significant cultural differences compared overseas, treating children and doing research. to Africa. “Generally speaking, Asia is more resourced and more highFor the past 22 years, Slusher has gone to Africa or Thailand every tech than Africa, of course excluding South Africa. Sub-Saharan Africa is year for extended medical missions, a devotion that has shaped the generally struggling a lot more with resources and basics like electricikind of practice she can do here in the United States. “It’s been a varity,” she says. “It’s a very different world. Asian culture moves a lot ety of arrangements,” she says. “I refuse to take a job where [overseas faster. African culture is much slower; relationships are important, time work] couldn’t be a significant part. The least I’ve negotiated is three is not important.” months; that’s the bare minimum I will agree to.” The lack of resources and high mortality among children can be Slusher works with a number of organizations, sometimes as a voldiscouraging, Slusher says. But she says she finds unteer and sometimes for varying amounts of pay. inspiration in the passion and hard work of her She says her devotion to mission work comes from African colleagues, who carry on despite huge chalseeing the challenges that both patients and physilenges. She adds that her faith also plays a role. “I cians face in developing nations. “I work with some see my faith as part of what I do every day. I really absolutely wonderful African doctors,” she adds. think God expects us to do what we do and do it “They need U.S. colleagues, to be able to do what very well.” they do for their kids. They need our collaboration.” Slusher is on staff at Hennepin County Medical Slusher’s main area of focus in Africa has been Center and a faculty member of the Global newborn jaundice, an easily treated condition in the Pediatrics program at the University of Minnesota. U.S. that is a major killer of newborn children in She says her teaching position gives her an excelcountries like Nigeria, where she has done much of lent opportunity to promote overseas medical work “It completely changes her work. to medical students. “I encourage every medical “Many of the places in Nigeria that are trying how you practice medicine student or resident to go at least once because it to take care of newborn jaundice don’t have consiscompletely changes how you practice medicine in in the United States.” tent electricity or don’t have electricity at all. They the United States, even if you never go back,” don’t have good phototherapy units even if they Tina Slusher, MD Slusher says. “It makes you more conscious and less happen to have electricity,” she says. “That’s part of wasteful. I believe that you’re a better physician [if the reason that so many children are dying or disyou take part in a medical mission].” abled from jaundice.”

A lifelong devotion to medical missions

WHO’S A BIGGER BASEBALL FAN, YOU OR ME? You’ll find that people with Down syndrome have a passion for knowledge and learning that can rival anyone you’ve met before. To learn more about the rewards of knowing or raising someone with Down syndrome, contact your local Down syndrome organization. Or visit www.dsamn.org today. It is the mission of the Down Syndrome Association of Minnesota to provide information, resources and support to individuals with Down syndrome, their families and their communities. We offer a wide range of services, programs and materials at no charge. If you are interested in receiving one of our information packets for new or expectant parents, please email Kathleen@dsamn.org or For more information please call:

(651) 603-0720 • (800) 511-3696 24

MINNESOTA HEALTH CARE NEWS MARCH 2012

funds for equipment and travel expenses. A typical trip, Treacy says, includes approximately 10 volunteers, including two physicians. In addition to providing laser treatments at Milton Cato Memorial Hospital in Kingstown, they often travel to medMany medical missions involve large organizations and impressive ical sites around the islands, visiting clinics with primitive facilities. Each amounts of logistics, but medical volunteer work in developing countrip lasts a week and the medical team typically treats 400 to 600 tries can exist on a smaller scale as well. Kevin Treacy, MD, an ophthalpatients in that time period. The staff works long hours, Treacy notes. mologist from Duluth, has proved that with his Project SCENE. “I’ve never brought sunscreen because I’ve been inside pretty much The project’s name reveals its roots: Sister Congregations Enjoying sunup to sundown,” he says. “There’s that much work to do.” New Eyesight (SCENE) was born when Treacy traveled to his church’s The SCENE program is also training local physicians to do eye prosister diocese in Kingstown, the capital of St. Vincent and the Grenacedures so patients can continue to be treated on a regular basis. Treacy dines. The Caribbean nation consists of 32 islands says he has cut back on cataract surgery because north of Venezuela and near Grenada. some patients told local surgeons they wanted to wait St. Vincent, with a population of 125,000, is for the American doctors. “You can become counterpoor and has traditionally had a high rate of diabetes productive in terms of our goal of trying to support and related conditions such as diabetic retinopathy. local doctors and their practices,” he says. “That can That condition is a leading cause of blindness cause a threat to their livelihood and a threat to the throughout the world for people aged 25 through permanent care that we want to see in place.” 65, Treacy notes. To support the local health care system in St. Treacy first visited Kingstown in 1999, and began Vincent, Treacy donated a cash award he received in laying the groundwork for regular ophthalmology 2004 from the Minnesota Academy of Ophthalmolmissions to treat diabetic retinopathy and other eye ogy toward training a physician from St. Vincent. The conditions. With the help of groups such as the physician has since begun offering cataract surgery in Rotary Club and the Lions Club in Minnesota, he his clinic, Treacy notes. “That’s our goal, to give them raised enough money to purchase two lasers for the tools they need, the education to do the work. treating eye conditions. Before Treacy’s efforts, no Basically, I’d love to put myself out of business.” such technology was available in St. Vincent. Treacy says he’s found work very rewarding “There was no real funding available for that “That’s our goal, to give and has enjoyed taking his the family along to help with care,” Treacy says. “Either a family could come up them the tools they need.” the medical missions. “It’s been very fulfilling effort,” with money [to fly to another country for treatment], he says. “Eye care is universally appreciated, so even Kevin Treacy, MD or they would basically lose their vision.” when there are political or cultural differences, it’s Since his first trip in August 2000, Treacy has something that we can all enjoy.” visited the island nation 18 times. In addition, he has

Project SCENE brings eye care to Caribbean island

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The outsider experience

something that Doctors Without Borders took very seriously. “We would get into our Land Rovers behind a locked gate, and Patrick Ebeling, MD, a surgeon with Twin Cities Orthopedics, is relathey would open the gate and we’d drive to the hospital, then we tively new to medical missions. His first, to Haiti, came just months after would get out behind another locked gate,” he says. “They wanted us the devastating earthquake that destroyed much of the nation’s capitol, to be careful to wear our Doctors Without Borders shirt at all times, so Port-au-Prince. His second was to Port Harcourt in Nigeria, a city so they know you’re a doctor and not an oil worker, because that’s who plagued by kidnappings of westerners that the group sponsoring the they are usually looking to kidnap.” mission, Doctors Without Borders, required Ebeling to sign a proof-ofAs part of an international team sponsored by the Paris-based life document in case he was abducted. group, Ebeling provided surgical care at a free trauma center at a hospi“Filling out that form was definitely a moment where I thought, tal in Port Harcourt. The port town was a rough place, and Ebeling ‘What am I doing here?’” Ebeling says. notes that the lack of traffic controls leads to many auto accidents and But despite the eye-opening circumstances of his first two medical injuries. “There’s an unbelievable number of cars hitting pedestrians, missions, Ebeling admits that he has “caught the bug” and that was a lot of what we saw,” he says. “In a place and is looking forward to doing more. And he says even where everybody’s scraping for what they can get, there the discomfort of working in a very different culture can are a lot gunshot wounds and machete injuries. A lot of be seen in a positive light. interpersonal violence.” “You definitely feel unsettled,” he says. “That unsetAlthough physicians with the program were retled feeling is one of the benefits. I think being able to stricted in where they could travel because of safety recall that feeling of being so unsettled and being so concerns, Ebeling said he never felt he was in any danmuch the outsider makes you a more empathetic person, ger. “I felt safe the whole time, and I think that’s a testanot just in your job but in your daily life.” ment to how they run the program.” Ebeling first traveled to Port-au-Prince with Project Ebeling said the African trip was a little stressful on Medishare in May 2010, where he worked in a tempohis family, but he was surprised at how quickly things rary hospital offering follow-up care for people who had got back to normal when he returned. “Even after a been in injured in the January earthquake. He traveled month away, after two or three days of being back “That unsettled there again in September 2011 for a week, again seeing you’re kind of back into your routine. You definitely feeling is one of earthquake victims but also treating congenital condihave a different perspective on how much you can get tions and common, day-to-day injuries. done with different equipment and how much you can the benefits.” In May of 2011 Ebeling went on a longer, onedo in a rough situation,” he notes. “But it is possible to Patrick Ebeling, MD month mission to Port Harcourt with Doctors Without be gone for a month and experience something like this Borders. The city, with a metro population of approxiand help some people, and then get back to normal life mately 1.5 million people, is the center of Nigeria’s oil when you come back.” industry, and kidnappings of westerners for ransom is

Minnesota

Health Care Consumer February survey results... Association

19.1%

20 15 10

6.4%

5 0.0% Strongly agree

Agree

Does Disagree not apply

21.3%

20 15 10.6%

Strongly agree

Agree

Does Disagree not apply

Strongly disagree

MINNESOTA HEALTH CARE NEWS MARCH 2012

17.0% 15 10

8.5%

5 Strongly agree

Agree

Does Disagree not apply

73.6%

70 60.8%

50 40 30

22.3%

19.1%

2.1%

27.7%

5. My physician and I discuss different medication options before I am given a prescription.

Percentage of total responses

27.7%

Strongly disagree

70 Percentage of total responses

Percentage of total responses

38.3%

36.2%

4. I can tell the medications I take on a regular basis are improving my health and quality of life.

38.3%

3. I now take prescription medications that were not available for my specific condition when I began treatment.

2. The cost of medications I take regularly has increased significantly in the past three years.

1. I have had difficulty finding medications my doctor has prescribed for me.

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 February survey.

12.8%

50 40 30 20 10

3.4% Strongly agree

0.7% Agree

Does Disagree not apply

Strongly disagree

8.8%

10.8%

4.1% Strongly agree

2.7% Agree

Does Disagree not apply

Strongly disagree

Minnesota

Health Care Consumer Association

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.

â&#x20AC;&#x153;A way for you to make a differenceâ&#x20AC;? MARCH 2012 MINNESOTA HEALTH CARE NEWS

NEPHROLOGY

Kidney stones

idney stones have plagued the human race for a long time. Case in point: In 1901, a 7,000-year-old Egyptian mummy was found to have traces of them. Kidney stones continue to be a painful fact of life for many people, with their prevalence increasing in recent years. Roughly one in 10 Americans will have a kidney stone during their lifetime. What causes them, how are they treated, and how can you prevent them from recurring? What are they?

Diagnosis, treatment, and prevention By Christopher W. Boelter, MD

In the next issue.. • Breast-reduction surgery • Pediatric behavioral health • Speech-language pathology 28

MINNESOTA HEALTH CARE NEWS MARCH 2012

A kidney stone is a collection of crystals formed from minerals that are normally present in the urine. To understand why those minerals sometimes form crystals that stick to each other to form stones, it helps to understand how urine is formed. The urinary tract consists of the kidneys, ureters, bladder, and urethra. The job of the kidneys is to filter extra water and waste from the blood. Urine is the byproduct produced by that filtration, and passes out of the body though the ureters, bladder, and urethra. In addition to getting rid of waste and extra water, the kidneys balance the body’s water and electrolytes. These electrolytes include salt, potassium, and calcium, all of which can form crystals. When the relative amounts of these components in the blood are imbalanced, urine contains more crystal-forming substances and less of the substances that keep crystals from sticking together. Eventually, the crystals accumulate to form a kidney stone, which can be located anywhere along the urinary tract. Who gets them? Kidney stones affect both men and women, with males three times more likely than females to develop a stone. They are diagnosed in people of all ages but are most likely to occur between the ages of 30 and 60. Age, gender, family history, dietary habits, water consumption, and the presDehydration ence of certain other medical conditions is a leading can all play a role in the formation of stones. cause of People with stones may have them for kidney stones. many months or even years before they become aware of them. Symptoms may strike with little to no warning once the stone has moved into the ureter, the tube connecting the kidney and the bladder. Symptoms vary, but can include nausea and vomiting; severe pain in the side, back, abdomen, or groin; and painful or bloody urination. Diagnosis Diagnosis is confirmed by lab tests, imaging studies, and patient history. Lab tests include those that assess the levels of calcium and uric acid in the blood, which allow your doctor to check for related medical conditions. A 24-hour urine collection may be done to determine if a patient’s water and electrolyte levels are imbalanced and are causing the passage of too many stone-forming minerals or too

few stone-inhibiting substances. A cent. The chance of recurrence rises to 50 CT scan may be done to check for percent within 10 years after diagnosis. Dehydration is a leading cause of kidney kidney stones in the urinary tract. stones. It is recommended that people with a A person may also be asked to uriRoughly one in 10 Americans history of stones drink 48 ounces of water daily. nate through a strainer designed to will have a kidney stone during Not surprisingly, the incidence of kidney stones collect any stones that are passed. their lifetime. increases from July to September. Those who Collected kidney stones are analive in hot, dry climates or who exercise a great lyzed in a lab to determine the type deal may need to drink even more to prevent recurring of minerals in the stone. The physician uses all this informastones. tion to determine a treatment and prevention plan. Dietary choices are also important in the prevenAn individual’s treatment plan is tion of kidney stones. Foods high in oxalate, including based on the size, shape, composition, spinach, sweet potatoes, tea, chocolate, and soy prodand location of the stone along the ucts, can promote formation of calcium oxalate urinary tract, in addition to how well stones. Take steps to reduce your intake of high oxalate symptoms are tolerated. foods as well as to reduce the amount of salt and animal Although stones can be uncomfortprotein in your diet. While calcium-rich foods don’t promote able, many stones are passed spontaformation of kidney stones, consult your physician before neously in urine. Increasing your water taking calcium supplements, as these have been shown to consumption and using pain- and muscle-relaxing medication increase the likelihood of stones. Additionally, a high body can help this process along. Additionally, for stones composed of mass index (BMI), increased waist size, and weight gain have uric acid, stone-dissolving medications may be prescribed. If a stone is too large to pass on its own, is growing, or is causing been linked to an increased risk of stones. By following these lifestyle guidelines, you’ll be taking important an infection, or if pain cannot be controlled, one of the following steps toward guarding the health of your urinary tract. treatments may be needed. Treatments Extracorporeal shockwave lithotripsy (ESWL) is one of the most common treatments used today. ESWL is used to remove stones that are smaller than one-half inch and are located near the kidney or ureter. This noninvasive technique uses a machine that produces sound waves that shatter stones into pieces small enough to pass during urination. Percutaneous nephrolithotomy (PCNL) is a minimally invasive treatment used to remove medium or large stones that are in or near the kidney. In PCNL, stones are removed using a specialized fiber optic telescope inserted through the urethra and up to the kidney or through the patient’s side directly into the kidney. Larger stones may be broken into smaller pieces by a laser before removal by PCNL. Ureteroscopy may be used to remove stones located in the lower urinary tract. As with many of today’s less invasive treatments, no incision is required for this procedure. A urologic surgeon inserts a thin viewing tool called a ureteroscope into the urethra. The ureteroscope is then passed through the bladder and the ureter until the kidney stone is located. At that point, the urologist removes the stone by catching it with a small wire basket attached to the ureteroscope. Larger stones may be broken into smaller pieces by a laser before removal by ureteroscopy. Certain factors such as urinary infection, pregnancy, or the use of blood-thinning medication may delay treatment and necessitate the use of specialized tubes called stents to temporarily allow urine to flow until the obstructing stone can be safely removed. Rarely, surgery may be needed if other methods do not work or cannot be used for various reasons. Prevention

Christopher W. Boelter, MD, is managing partner at Adult and Pediatric Urology (APU) and treats patients at APU’s Sartell and Buffalo locations. He has special interests in urological cancers and women's health, as well as in laparoscopic and minimally invasive surgery.

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The best treatment for kidney stones is prevention. People who have a history of stones need to be particularly diligent, as the chance of recurrence within one year after diagnosis of kidney stones is 10 perMARCH 2012 MINNESOTA HEALTH CARE NEWS

ONCOLOGY

FACTS about colorectal cancer Screening tests save lives By Matthew Flory March is National Colorectal Cancer Awareness Month, so there couldnâ&#x20AC;&#x2122;t be a better time to learn the facts about colorectal cancer and to get screened. Nearly 850 Minnesotans lose their battle with colorectal cancer each year. If people got screened regularly starting at age 50 or earlier, half these deaths could be prevented. What do screening tests do? There are two types of screening tests. One type detects colorectal cancer. The other detects both colorectal cancer and polyps, which are growths that sometimes develop into colorectal cancer. Testing that detects polyps before they become cancerous allows the polyps to be removed, and most people who have polyps removed never get colorectal cancer. Even if cancer is found, you have a good chance of beating it with treatment if it is found early. And testing can find it early.

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

EXERTstudy.org 30

MINNESOTA HEALTH CARE NEWS MARCH 2012

Screening tests offer a powerful opportunity for the prevention, early detection, and successful treatment of colorectal cancer, but only twothirds of Minnesotans report getting screened as recommended. Fewer still understand the importance of family history and personal medical history in deciding when to begin screening. When should I get screened? People who have no identified risk factors other than age (incidence of colorectal cancer rises with increasing age) should have their first screening test at age 50. Those who have a family history of cancer or colorectal polyps, or who have other risk factors such as inflammatory bowel disease, should talk with their doctor about starting screening at a younger age, getting screened more frequently, or both. If you have a relative with cancer Half of these or colorectal polyps, talk with your doctor about genetic counseling to deaths could review your family medical tree. be prevented. This review determines your chance of developing colorectal polyps or cancer, and can help you decide about taking preventive steps, like beginning screening before age 50. Genetic counseling may recommend genetic testing to determine if members of certain families have inherited a high risk for developing colorectal cancer due to syndromes such as familial adenomatous polyposis (FAP) or hereditary nonpolyposis colorectal cancer (HNPCC), also called Lynch syndrome. Without genetic testing, all members of a family known to have an inherited form of colorectal cancer should start screening before age 50, and should get screened frequently. If genetic testing is done

For more information on colorectal cancer American Cancer Society www.cancer.org or call 800-227-2345

test, before they have a chance to become cancerous.

Center for Disease Control/Prevention www.cdc.gov/cancer/colorectal/basic_info/screening/

Prevention

Obesity raises the risk of colon cancer in both men and women, although the link seems to be stronger in men. The American Find a screening site: www.mnhealthscores.org Cancer Society recommends that Find a genetic counselor: www.mygenepool.org/ people maintain a healthy weight throughout life by balancing what they eat with physical activity. If you for a known mutation within a are overweight, ask your doctor about a weight loss plan that will family, those members who are work for you. found not to have the mutated Diets high in vegetables, fruits, and whole grains have been gene may be able to begin screen- linked to a lower risk of colon cancer. Diets high in processed meat, ing at age 50 with follow-up red meat, or both have been linked to a higher risk. The American screening tests every decade, just Cancer Society recommends that you eat a healthy diet that emphalike people in the general popula- sizes foods from plants. tion who have an average risk. The American Cancer Society also recommends that adults get at least 30 minutes of moderate or vigorous physical activity on five What if I don’t have insurance? or more days of the week. Moderate or vigorous activity for at least Sage Scopes is a free colorectal cancer screening program that pro45 minutes on five or more days of the week may lower your risk vides testing for Minnesotans between the ages of 50 and 64 who for colorectal cancer even more. meet specific income guidelines. For more information, call (651) Matthew Flory is the Minnesota director of Healthcare Partnerships for the 556-0680 or visit www.MNSage.com. To learn more about Sage Scopes, Minnesota’s free colorectal cancer screening program, visit www.mnsage.com or call (651) 556-0680.

Are there signs that I might have colorectal cancer? Symptoms of colorectal cancer usually appear only after the disease is advanced. This is why getting a screening test before symptoms appear is so important. Colorectal cancer may cause one or more of the following Questions to ask symptoms. If you have any, see your doctor if you your doctor right away. are 50 or older • I’ve read that there’s more than one test for colorectal cancer. Which one is right for me?

• A change in bowel habits, such as diarrhea, constipation, or narrowing of the stool, that lasts for more than a few days

• How is a colorectal cancer test done? How do I prepare for it? What will happen to me during the test, and what will it feel like?

• A feeling that you need to have a bowel movement that does not go away after you have one

• Should I get tested before I’m 50 if I have relatives who have been diagnosed with colorectal cancer?

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• Rectal bleeding, dark stools, or blood in the stool • Cramping or pain in your abdomen • Weakness and fatigue • Unintended weight loss

Most of these symptoms are more often caused by conditions other than colorectal cancer, such as infection, hemorrhoids, or inflammatory bowel disease. Still, if you have any of these problems, it’s important to see your doctor right away so the cause can be found and treated, if needed. Regular screening can often detect colorectal cancer early, when it is most likely to be curable. In many cases, screening can prevent colorectal cancer altogether. That’s because your doctor can remove polyps as soon as they are detected during the screening

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MARCH 2012 MINNESOTA HEALTH CARE NEWS

CARDIOLOGY Symptoms and diagnosis ne in every 120 children is born with a heart defect The cause of most congenital heart due to congenital heart defects is not known, although disease (CHD), which is a strucdefects can sometimes be due to tural, functional, or positional genetic factors, environmental facdefect of the heart that is present tors, or both. Parents who have at birth. The surgical specialty that had heart defects may have a fixes these defects, pediatric cardiac slightly increased chance of having surgery, is a technically demanding a child with a heart defect. Envirspecialty, in part because a child’s onmental factors such as smoking heart can be as small as a strawor drinking during pregnancy, and berry. Yet, most heart defects today the use of certain medications durcan be fixed safely with low risk ing pregnancy can also play a role and high probability of a good in the development of heart defects. long-term outcome. Proper prenatal care based on medDiagnosing and Medicine has made remarkable ical guidance can help reduce the advances over the last 30 years possibility of CHD. treating congenital heart disease with respect to treating children. There are approximately 20 By Joseph A. Dearani, MD Pediatric cardiac surgery, and espedistinct types of congenital heart cially infant heart surgery as it is defects that may show up in a varitypically performed today, was introduced in the 1980s and perfected ety of ways. The most common symptoms of heart defects in babies in the 1990s. Doctors continue to advance operative techniques and include a bluish coloring of the skin caused by lack of oxygen in the perioperative care, and the quality of life for patients has vastly blood, a condition called cyanosis; low blood pressure; a heart murimproved. Now, the majority of children who receive cardiac surgery mur; breathing difficulties; feeding problems; and poor weight gain. live normal or near-normal lives well into their adult years. They may Children with CHD may experience shortness of breath; fatigue; or go on to receive an education and have careers, and many of the girls malnutrition due to decreased energy intake, increased energy requirewho require cardiac surgery grow up to be women who can safely ments, or both. withstand the physical demands of pregnancy. Minor defects may not cause symptoms and may not be diagnosed until a routine medical checkup prior to starting school; occasionally, some may not be identified until adulthood. A heart defect may be identified in an adult due to discovery of a heart murmur, high or low blood pressure, or decreased exercise capacity. At times, the defect may be picked up incidentally on a screening X-ray or Have you subscribed to Minnesota’s best source of other imaging study. health care information? To receive your personal Pediatric patients who are suspected of copy of Minnesota Health Care News each month, Most heart complete and return the form below. having CHD are typically referred to a pedidefects today atric cardiologist for a physical exam and a review of their medical history. At that time, can be it may be decided that additional tests are fixed safely. needed. These may include a chest X-ray, an electrocardiogram to record heart rate patterns, and an echocardiogram to record images of the heart. All of these tests are noninvasive and do not involve surgery. Sometimes, these initial tests do not provide enough information for a complete diagnosis. In such cases, more tests may be needed and may include cardiac catheterization and angiography, magnetic resoName/Title ____________________________________________________________________ nance imaging (MRI) and computerized tomography scanning (CT Company ______________________________________________________________________ scanning), Holter monitoring, and stress testing. Address ______________________________________________________________________

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MINNESOTA HEALTH CARE NEWS MARCH 2012

Surgery Prior to surgery, it is helpful for patients to stay as healthy as possible. This may include taking extra precautions during the two weeks before surgery to keep the patient away from people who have a cold or fever, or avoiding situations where germs are easily spread, such as preschool or daycare. It is also typical for parents and patients to receive a tour of the hospital prior to surgery to meet the nurses and hospital staff that will care for their child during and after surgery.

One in every 120 children is born with a heart defect and nearly 90 percent of newborns with congenital heart disease (CHD) live in an area of the world where medical care is inadequate or unavailable. There are not enough trained medical professionals for children with heart disease in developing countries. Children’s HeartLink is creating sustainable cardiac care for children around the world. Volunteer medical teams from leading hospitals teach local medical teams in developing countries to diagnose and treat heart disease among children. As a result of this transfer of knowledge, more children with heart disease are successfully treated. But there are many children who still need help. To find out more, visit www.childrensheartlink.org

Left: Dr. Joseph A. Dearani (right) operates alongside Dr. Ulisses A. Croti (left), chief of pediatric cardiac surgery at Children’s HeartLink partner Hospital de Base in São José do Rio Preto, Brazil. Children’s HeartLink sponsors cardiac training visits to Hospital de Base to help advance the latter’s pediatric cardiac program. Above: A mother comforts her daughter, who is undergoing treatment at Hospital de Base in São José do Rio Preto, Brazil, which partners with Children’s HeartLink to provide pediatric cardiac surgery. Right: Italo, a 9-year-old boy, receives treatment during a Children’s HeartLink training visit to Hospital de Base in São José do Rio Preto, Brazil. He and his father traveled many miles from their small town in the Amazon region to receive the treatment Italo needed. Photos courtesy Eloisa Mattos

Open-heart surgery is the procedure most frequently used to repair or fix a congenital heart defect. During typical open-heart surgery, the patient is under anesthesia. A heart-lung machine, also called a cardiopulmonary bypass machine, is used to allow the blood to bypass the heart and lungs. Once the heart-lung machine is activated, the patient is given medication that temporarily stops the heart from pumping. At this point, the cardiac surgeon can safely open the heart and repair the defect in a bloodless field to optimize visualization. Once the defect has been repaired, the surgeon closes the heart, allows the blood to fill the heart, and restarts the heart’s pumping action. After the heart has resumed normal pumping function, the heart-lung machine is turned off and the connections from the machine to the patient are removed. Echocardiography is typically performed in the operating room (before and after the procedure) to ensure that the defect is properly repaired. The incision is closed and the child is transferred to the intensive care unit. In some circumstances, when the There are procedure is higher risk, the chest incision approximately may be temporarily left open for 24 to 48 20 distinct hours to allow stabilization; the incision is then closed. types of Another procedure, interventional carcongenital diac catheterization, is being used in a heart defects. growing number of instances. In this procedure, the heart defect can be repaired without surgically opening the chest. A catheter is inserted through blood vessels in the legs or neck for access to the heart to facilitate repairs. This procedure is less invasive and allows faster recovery time than does open heart surgery, but is currently used for only a small percentage of defects.

Rarely does a congenital heart defect require a heart transplant, which is seen as a last option and carries the greatest risk of complication.

Recovery The majority of open-heart operations in children can be done safely and with high probability of a good long-term outcome. As with most surgery, maintaining safety during the procedure is the biggest factor in preventing complications. Risks related to surgery are rare, but can include infections, neurologic injuries, and lung or kidney damage. Depending on the outcome of an individual’s surgery, patients recovering from open-heart surgery may be in the hospital for a few days or a week. High-risk patients may require longer hospitalization. While the patient recuperates in the hospital after surgery, his or her heart function will be monitored with a variety of tests, which may include blood tests, electrocardiograms, echocardiograms, and chest Pediatric cardiac surgery to page 34

MARCH 2012 MINNESOTA HEALTH CARE NEWS

Smoking or drinking during pregnancy can also play a role in the development of heart defects.

Pediatric cardiac surgery from page 33

X-rays. Patients may also be given medication to increase or decrease blood pressure or heart rate, or to eliminate extra fluid that can accumulate around the lungs or in the legs as a result of the extra fluid that is given with the use of the heart-lung machine. Pain following surgery is managed with medication, but often goes away within a few days or within a week or two after the operation and within a month or two, most children are back to their normal activities. Many are able to play sports again at this time, although others may have short- or long-term restrictions. The need for repeat operation(s) later on in life can vary. Some patients may need only one operation as a permanent solution to their CHD. Others may need an additional operation later in life or repeated procedures over their lifetime, most commonly for a valve related problem. Importantly, for most patients who require more than one procedure, their quality of life between procedures is generally very good. The importance of a team approach in the care of patients with CHD cannot be overemphasized. This includes a knowledgeable team of professionals that are involved with the care before, during, and after the operation.

Advances Pediatric medicine has improved during the last few decades, leading to earlier detection of CHD and ensuring that children born with CHD have a greater chance to lead healthy, normal lives. Improvement of diagnostic techniques over the years, including chest X-rays, electrocardiograms, echocardiography, and cardiac catheterization, allows doctors to diagnose congenital heart defects earlier and more accurately. Improvements in surgical techniques and emphasis on

quality and safety in the operating room have reduced the risk of death and serious complications in children undergoing open-heart surgery to exceedingly low levels. New approaches to surgery are being explored, including the use of minimally invasive and robotic approaches to fix selected (usually simple) defects. In children and young adults, very small incisions can be utilized with the aid of a videoscope, which further reduces recovery time. Alternatively, in robotic-assisted heart surgery, a console controlled by one heart surgeon aids a second surgeon who navigates instruments held by a robot that facilitates perfect surgical technique and suture placement. Multiple members of the surgical team facilitate the entire process, resulting in very small incisions, minimal postoperative pain, and short (one- to two-week) recovery times. Roboticassisted heart surgery is currently used for only a small number of patients with congenital heart defects. Over the years, the results of heart surgery in children and infants have dramatically improved to the point that almost all of these children survive into their adult years with an excellent quality of life, and only some need additional procedures as adults. The importance of lifelong medical follow-up care cannot be overemphasized. Joseph A. Dearani, MD, is a congenital heart surgeon, professor of surgery, and chair of the Division of Cardiovascular Surgery at Mayo Clinic, and is the volunteer medical director of Children’s HeartLink.

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MINNESOTA HEALTH CARE NEWS MARCH 2012

• Serious low blood sugar (hypoglycemia) may occur when Victoza® is used with other diabetes medications called sulfonylureas. This risk can be reduced by lowering the dose of the sulfonylurea.

Important Patient Information This is a BRIEF SUMMARY of important information about Victoza®. This information does not take the place of talking with your doctor about your medical condition or your treatment. If you have any questions about Victoza®, ask your doctor. Only your doctor can determine if Victoza® is right for you. WARNING During the drug testing process, the medicine in Victoza® caused rats and mice to develop tumors of the thyroid gland. Some of these tumors were cancers. It is not known if Victoza® will cause thyroid tumors or a type of thyroid cancer called medullary thyroid cancer (MTC) in people. If MTC occurs, it may lead to death if not detected and treated early. Do not take Victoza® if you or any of your family members have MTC, or if you have Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). This is a disease where people have tumors in more than one gland in the body. What is Victoza® used for? • Victoza® is a glucagon-like-peptide-1 (GLP-1) receptor agonist used to improve blood sugar (glucose) control in adults with type 2 diabetes mellitus, when used with a diet and exercise program. • Victoza® should not be used as the first choice of medicine for treating diabetes. • Victoza® has not been studied in enough people with a history of pancreatitis (inflammation of the pancreas). Therefore, it should be used with care in these patients. • Victoza is not for use in people with type 1 diabetes mellitus or people with diabetic ketoacidosis. ®

• It is not known if Victoza® is safe and effective when used with insulin. Who should not use Victoza®? • Victoza should not be used in people with a personal or family history of MTC or in patients with MEN 2. ®

• Victoza® may cause nausea, vomiting, or diarrhea leading to the loss of fluids (dehydration). Dehydration may cause kidney failure. This can happen in people who may have never had kidney problems before. Drinking plenty of fluids may reduce your chance of dehydration. • Like all other diabetes medications, Victoza® has not been shown to decrease the risk of large blood vessel disease (i.e. heart attacks and strokes). What are the side effects of Victoza®? • Tell your healthcare provider if you get a lump or swelling in your neck, hoarseness, trouble swallowing, or shortness of breath while taking Victoza®. These may be symptoms of thyroid cancer. • The most common side effects, reported in at least 5% of people treated with Victoza® and occurring more commonly than people treated with a placebo (a non-active injection used to study drugs in clinical trials) are headache, nausea, and diarrhea. • Immune system related reactions, including hives, were more common in people treated with Victoza® (0.8%) compared to people treated with other diabetes drugs (0.4%) in clinical trials. • This listing of side effects is not complete. Your health care professional can discuss with you a more complete list of side effects that may occur when using Victoza®. What should I know about taking Victoza® with other medications? • Victoza® slows emptying of your stomach. This may impact how your body absorbs other drugs that are taken by mouth at the same time. Can Victoza® be used in children? • Victoza® has not been studied in people below 18 years of age. Can Victoza® be used in people with kidney or liver problems? • Victoza® should be used with caution in these types of people. Still have questions?

What is the most important information I should know about Victoza®? • In animal studies, Victoza® caused thyroid tumors. The effects in humans are unknown. People who use Victoza® should be counseled on the risk of MTC and symptoms of thyroid cancer. • In clinical trials, there were more cases of pancreatitis in people treated with Victoza® compared to people treated with other diabetes drugs. If pancreatitis is suspected, Victoza® and other potentially suspect drugs should be discontinued. Victoza® should not be restarted if pancreatitis is confirmed. Victoza® should be used with caution in people with a history of pancreatitis.

This is only a summary of important information. Ask your doctor for more complete product information, or • call 1-877-4VICTOZA (1-877-484-2869) • visit victoza.com Victoza® is a registered trademark of Novo Nordisk A/S. Date of Issue: May 2011 Version 3 ©2011 Novo Nordisk 140517-R3 June 2011

FOR TYPE 2 DIABETES

Victoza® helped me take my blood sugar down…

and changed how I manage my type 2 diabetes. Victoza® helps lower blood sugar when it is high by targeting important cells in your pancreas—called beta cells. While not a weight-loss product, Victoza® may help you lose some weight. And Victoza® is used once a day anytime, with or without food, along with eating right and staying active.

Model is used for illustrative purposes only.

Indications and Usage: Victoza® is an injectable prescription medicine that may improve blood sugar (glucose) in adults with type 2 diabetes when used along with diet and exercise. Victoza® is not recommended as the first medication to treat diabetes. Victoza® is not insulin and has not been studied in combination with insulin. Victoza® is not for people with type 1 diabetes or people with diabetic ketoacidosis. It is not known if Victoza® is safe and effective in children. Victoza® is not recommended for use in children. Important Safety Information: In animal studies, Victoza® caused thyroid tumors—including thyroid cancer—in some rats and mice. It is not known whether Victoza® causes thyroid tumors or a type of thyroid cancer called medullary thyroid cancer (MTC) in people which may be fatal if not detected and treated early. Do not use Victoza® if you or any of your family members have a history of MTC or if you have Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). While taking Victoza®, tell your doctor if you get a lump or swelling in your neck, hoarseness, trouble swallowing, or shortness of breath. These may be symptoms of thyroid cancer. Inflammation of the pancreas (pancreatitis) may be severe and lead to death. Before taking Victoza®, tell your doctor if you have had pancreatitis, gallstones, a history of alcoholism,

If you’re ready for a change, talk to your doctor about Victoza® today.

or high blood triglyceride levels since these medical conditions make you more likely to get pancreatitis. Stop taking Victoza® and call your doctor right away if you have pain in your stomach area that is severe and will not go away, occurs with or without vomiting, or is felt going from your stomach area through to your back. These may be symptoms of pancreatitis. Before using Victoza ®, tell your doctor about all the medicines you take, especially sulfonylurea medicines or insulin, as taking them with Victoza® may affect how each medicine works. Also tell your doctor if you are allergic to any of the ingredients in Victoza®; have severe stomach problems such as slowed emptying of your stomach (gastroparesis) or problems with digesting food; have or have had kidney or liver problems; have any other medical conditions; are pregnant or plan to become pregnant. Tell your doctor if you are breastfeeding or plan to breastfeed. It is unknown if Victoza® will harm your unborn baby or if Victoza® passes into your breast milk. Your risk for getting hypoglycemia, or low blood sugar, is higher if you take Victoza® with another medicine that can cause low blood sugar, such as a sulfonylurea. The dose of your sulfonylurea medicine may need to be lowered while taking Victoza®.

Victoza® may cause nausea, vomiting, or diarrhea leading to dehydration, which may cause kidney failure. This can happen in people who have never had kidney problems before. Drinking plenty of fluids may reduce your chance of dehydration. The most common side effects with Victoza® include headache, nausea, and diarrhea. Nausea is most common when first starting Victoza®, but decreases over time in most people. Immune system-related reactions, including hives, were more common in people treated with Victoza® compared to people treated with other diabetes drugs in medical studies. Please see Brief Summary of Important Patient Information on next page. If you need assistance with prescription drug costs, help may be available. Visit pparx.org or call 1-888-4PPA-NOW. You are encouraged to report negative side effects of prescription drugs to the FDA. Visit fda.gov/medwatch or call 1-800-FDA-1088. Victoza® is a registered trademark of Novo Nordisk A/S. © 2011 Novo Nordisk 0611-00003312-1 August 2011

To learn more, visit victoza.com or call 1-877-4-VICTOZA (1-877-484-2869).

Non-insulin • Once-daily