Minnesota Health care News March 2013 by Minnesota Physician Publishing

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March 2013 â&#x20AC;˘ Volume 11 Number 3

Hayfever Nancy Ott, MD

Stretch your medication dollars Timothy Stratton, PhD

Melanoma Pierre George, MD

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MC4106-159

CONTENTS

4 7 8

MARCH 2013 • Volume 11 Number 3

NEWS

PERSPECTIVE Mark Meier, LISCW

10 QUESTIONS

PHARMACY Stretch your medication dollars By Timothy Stratton, PhD, BCPS, FAPhA

DERMATOLOGY Melanoma

ENVIRONMENTAL HEALTH Hayfever

Lindsey Thomas, MD Hennepin County Medical Examiner’s Office

CALENDAR World Autism Awareness Day

MINNESOTA HEALTH CARE ROUNDTABLE

By Janet Horvath

PEOPLE

Face It Foundation

PATIENT TO PATIENT Protect your hearing

GERIATRICS Mature drivers By Catherine N. Sullivan, PhD, OTR

T H I R T Y- N I N T H

SESSION

By Pierre George, MD, and Juan Jaimes, MD

By Nancy Ott, MD

PALLIATIVE CARE Easing the journey

PUBLIC HEALTH Newborn screening

By Michelle Silverman

By Amy Gaviglio, MS, CGC, Beth-Ann Bloom, MS, CGC, and Sondra Rosendahl, MS, CGC

POLICY Tobacco tax update By Molly Moilanen, MPP

Patient engagement Creating measures that work Thursday, April 25, 2013 1:00 – 4:00 PM • Duluth Room Downtown Mpls. Hilton and Towers

Background and focus: The next step in health care reform involves the patient becoming more actively engaged with staying healthy. New physician reimbursement models reward improved population health but bring new dynamics into the exam room. Incorporating patient attitude and lifestyle choices into health care delivery is necessary, but how should it be done? Creating conceptual and empirical clarity around this question may be best addressed by the term Patient Activation Measure (PAM).

Objectives: We will examine the development of PAM, what it means and how it works. We will explore patient engagement methods that have been successful and the role of health insurance companies and employers in this process. We will explore how PAM may be used across the continuum of care and whose job it will be to implement and track these measures. We will discuss the challenges that are inherent within the concept of PAM and how it may realize its best potential. Panelists include:

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

Vivi-Ann Fischer, DC, Chief Clinical Officer, Chiropractic Care of Minnesota, Inc. Peter Mills, MD, CEO, nGage Health William Nersesian, MD, MHA, Chief Medical Officer, Fairview Physician Associates Pam Van Zyl York, MPH, PhD, RD, LN, MDH Health Promotion and Chronic Disease Division Sponsors: ChiroCare • nGage Health

OFFICE ADMINISTRATOR MaryAnn Macedo mmacedo@mppub.com ACCOUNT EXECUTIVE Iain Kane ikane@mppub.com ACCOUNT EXECUTIVE Matt Nichols mnichols@mppub.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.

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MARCH 2013 MINNESOTA HEALTH CARE NEWS

NEWS

Skin Disorders Cause Most Clinic Visits, Mayo Study Finds A Mayo Clinic study finds that most common causes for primary care visits are skin issues, joint disorders, and back pain. Researchers used a comprehensive study of medical records from Olmsted County over a fiveyear period to determine the most common health issues for which people see providers. The study found that other top disease groups include cholesterol problems; upper respiratory conditions (not including asthma); anxiety, depression, or bipolar disorder; chronic neurologic disorders; headaches and migraines; and diabetes. “Surprisingly, the most prevalent nonacute conditions in our community were not chronic conditions related to aging, such as diabetes and heart disease, but rather, conditions that affect both genders and all age groups,” says Jennifer St. Sauver, PhD, primary

author of the study. St. Sauver found that almost half the study population had some type of skin disorder. She adds that the finding suggests there should be further study of why these conditions result in so many visits and whether changes in care delivery approaches might result in fewer clinic visits due to skin conditions.

New Dayton Budget Increases Spending On Health Gov. Mark Dayton would increase health and human services spending by $128 million over the next two years, according to the budget he submitted to the Legislature in late January. The plan would have several significant impacts on health care in the state, including expanding public health plans, increasing spending for medical education, and raising the cigarette tax. The budget overall would raise both taxes and spending in

the state, while redistributing the tax burden in a way that Dayton says is more fair to the middle class. Administration officials say Minnesota has been lurching from one deficit to the next and that the state needs to rework its tax system to stabilize its finances. “If the investments in my budget proposal are made, they will yield returns in new jobs, private investments, vibrant communities, and additional state and local tax revenues; and they will help keep our economy moving forward,” says Dayton. “They represent my best judgment about what Minnesota needs to grow our economy, expand our middle class, improve our quality of life, and take care of those most in need.” According to documents from the office of Minnesota Management and Budget, the budget calls for an 8 percent increase in spending on health and human services. The Dayton plan would expand eligibility and accessibility to state health plans

Health care for the whole person.

at a cost of $93 million, which would result in coverage of an additional 145,000 Minnesotans. The plan would give a $13 million boost to the state’s Medical Education Research Costs fund. It would spend $40 million on the Statewide Health Improvement Program and $48 million on early childhood education, child placement services, and mental health programs. It would also pay for $29 million in information technology updates to health care systems. Among the Minnesotans paying higher taxes would be smokers; Dayton is calling for increasing the cigarette tax by 94 cents per pack. Health care groups have been calling for higher cigarette taxes for several years, saying a tax increase would discourage smoking and thereby improve health for many Minnesotans.

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MINNESOTA HEALTH CARE NEWS MARCH 2013

Allina, Children’s Collaborate to Open Mother Baby Center Allina Health and Children’s Hospitals and Clinics of Minnesota unveiled their new collaborative effort, the Mother Baby Center, in January. Officials say the new facility is the only one of its kind in Minnesota and has capabilities matched by only a few hospitals nationwide. The four-story, 96,000square-foot building is located between Abbott Northwestern Hospital and Children’s Hospital in Minneapolis. The facility will have the capacity for 5,000 births a year and will feature a comprehensive approach to care, beginning with prenatal care and continuing through obstetrics, perinatology, labor and delivery, neonatology, and pediatrics. “Every delivery is unique, just as the wants and needs of expecting families are unique— some women desire a traditional birth, some want an alternative experience such as a water birth, and others require high-end specialty care for themselves or their baby,” says Penny Wheeler, MD, chief clinical officer of Allina Health and a practicing obstetrician. “Our goal at the Mother Baby Center is to support every mother, baby, and family in a state-of-the-art facility, surrounded by incredibly talented and compassionate doctors, nurses, and caregivers all committed to providing a positive and life-changing experience.” Officials say the new facility will address the growing incidence of high-risk pregnancies and preterm births, and will be an attractive option for older mothers, mothers with chronic health problems, and other women whose pregnancies may result in complications.

Serious Adverse Events up in 2012, Report Says The latest adverse events report from the Minnesota Department

of Health (MDH) showed that 2012 saw an increase in death and serious harm occurring in health care settings. Overall, the number of adverse events stayed about the same from 2011 to 2012. Most of the increase in deaths and serious harm was related to falls, state officials say. There were 14 deaths in 2012 compared with five in 2011, and 89 serious injuries compared with 84 in 2011. The report found hospitals and surgical centers improved during 2012 in a number of areas. These include the number of total pressure ulcers (bedsores), which declined by 8 percent. This is the first decline of this magnitude in the nine years of reporting, officials say. Medication errors dropped by 75 percent from the previous year and were at the lowest level in all nine years of reporting. “This year’s report shows that as a state we really need to redouble our efforts to reduce falls in hospitals,” says Minnesota Commissioner of Health Ed Ehlinger, MD. “While falls in health care settings can be very difficult to prevent, we also need to look at all opportunities to prevent injury when falls do occur, by focusing interventions on each patient's specific risk factors.” State health experts say the reporting system identifies problem areas and helps hospitals and providers know where to focus their patient safety efforts.

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Personalized Assisted Personalized Assisted Living L iving goes goes a long long way way ttoward oward optimizing optimizing the the daily d a i l y qquality u a l i t y of o f llife ife ffor or our our residents. residents. If If yyou ou have have a loved loved one one needs tthat hat n eeds a friendly friendly with eenvironment nvironment w ith a personalized p ersonalized care care plan plan designed d esigned jjust ust ffor or tthem, hem, ccall all o orr visit visit a B Brookdale rookdale Community C ommunity near near you. you. Because caring for our what wee rresidents esidents iiss w hat w do, d o , aand n d iit’s t’ s aalways lways personal to us.

New Website Aims To Educate Public on Insurance Exchanges As state lawmakers continue to develop legislation for creating a health insurance exchange, the Minnesota Management and Budget (MMB) agency has launched a website to educate the public on the concept. Officials say the site is designed to provide Minnesotans with up-to-date information about the exchange and how this new marketplace will affect their lives, and to detail progress being made

Call today to sch schedule hedule your personal visit.

1-888-694-3978 1-888-694-3 1 888 694 3 3978

It’s always personal to us. Your Y our o stor story r y continu continues ues here… herre… e www.brookdaleliving.com www w.br . ookdalelivving.com 5HJ 8 6 3DWHQW DQG 5HJ 8 6 3DWHQW DQG 70 2I¿FH G 70 2I¿FH MNM3-ROP19-0313 MNM3-ROP19-0313 LMM

News to page 6 MARCH 2013 MINNESOTA HEALTH CARE NEWS

News from page 5 in developing the exchange. “The new website is the next step in reaching out to the public and providing basic information for individuals and small businesses that could use the exchange to find affordable, highquality health care,” says MMB Commissioner Jim Schowalter. The website can be found at www.mn.gov/hix/ and features a video explaining the benefits of the health insurance exchange and how it will work; a benefits calculator that will determine if individuals are eligible for tax credits; background and public information about the exchange; information on analysis and grants; and targeted pages for individuals and families, small businesses, agents and brokers, health plans, and others. Health insurance exchanges are a key part of the Affordable Care Act’s effort to expand insurance coverage to more Americans. In Minnesota, MMB has established some basic com-

ponents of the exchange as lawmakers and regulators continue to work out the details of the program. As the exchange is developed, consumers will be able to stay informed via the website. “Along with public information, analysis, and quick facts, the improved website is the first in the nation to have an introductory video. We are excited to have this educational tool go live for the public’s use,” says April ToddMalmlov, who is executive director of the exchange.

No “July Effect,” Mayo Study Says There is no “July Effect,” a new study from Mayo Clinic in Rochester says. The notion that July is a dangerous time to have surgery because that’s the month new residents and fellows arrive at teaching hospitals seems to be a myth, researchers say. The report, published in the Journal of Neurosurgery: Spine, looked at seven years of data and found that surgeries in July did

not have a significantly higher rate of deaths and postoperative complications. In addition, no substantial July Effect was observed in higher-risk patents, those admitted for elective surgery, or those undergoing simple or complex spinal procedures. “We hope that our findings will reassure patients that they are not at higher risk of medical complications if they undergo spinal surgery during July as compared to other times of the year,” says study co-author Jennifer McDonald, PhD. “While we only looked at spinal surgeries, we think it’s likely we’d find similar outcomes among other surgeries and procedures.”

Delta Dental Funds Improvements to Bemidji Clinic Delta Dental has given $10,000 to help a dental clinic in Bemidji that serves low-income individuals and families. The Northern Dental Access

Center will use the funds to replace equipment, officials say. “It’s a huge relief,” says Jeanne Edevold Larson, Northern Dental executive director. “After serving more than 15,000 people, the wear and tear on our equipment has become an issue far sooner than we ever expected. And while it’s not very exciting, these funds will help purchase a new compressor system that is at the heart of all the dental tools used for every procedure. It’s become unreliable and is too small to handle our increased patient load, and without it, our services would stand still.” Northern Dental opened in 2009 as a community response to a shortage of dental care available for people enrolled in MinnesotaCare or Medical Assistance in northern Minnesota. Officials say some patients travel as many as 100 miles to the clinic. In 2011, 9,900 patients were served; officials estimate there was a 30 percent increase in patients served for 2012.

Supporting Our Patients. Supporting Our Partners. Supporting You. In 2008, Tanzanian missionaries brought little Zawadi Rajabu to the U.S. to seek treatment for her two severely clubbed feet. A physician referred Zawadi to Dr. Mark T. Dahl of St. Croix Orthopaedics. Using the Ilizarov Method, Dr. Dahl surgically changed the course of Zawadi’s feet and her life. Dr. David Palmer and Russ McGill, OPA-C, recently traveled to Tanzania on another of their frequent medical missionary trips. They dedicated an entire day to checking in on their partner’s patient. To their delight, they were greeted by 6-year-old Zawadi her face aglow, her healed feet dancing toward them.

David Palmer, M.D. & Zawadi’s brother Russ McGill, OPA-C & Zawadi

Appointments:

Online or Call 651-439-8807 Providing P roviding care care at at multiple mu ultiple moder modern n clinics in Minnesota Minne esota and Wisconsin Wisconsin

MINNESOTA HEALTH CARE NEWS MARCH 2013

PEOPLE Lakeview Hospital, Stillwater, recently presented Physician Recognition Awards to Lawrence Morrissey, MD, and Theodore Haland, MD. Morrissey, a board-certified pediatrician, practices at the Stillwater Medical Group main campus. He was recognized for his long commitment to Lakeview Hospital as well as his commitment to patient-centered care and to the St. Croix Valley Lawrence Morrissey, MD

community. Haland is a board-certified family

medicine physician who practices as a hospitalist at Lakeview Hospital and is the hospital’s medical director for both

Graduate School of Health & Human Services

Advance your career in

health & human services

hospice and for information systems. He was recognized for his commitment to Lakeview

SMU offers bachelor completion and master’s programs in the health & human services areas.

Hospital leadership and the community. Hennepin County Medical Center has recently hired several physicians. Jason Bydash, DO, graduated from Michigan State University College of Osteopathic Medicine. He completed his internal medicine residency training at Saint

Theodore Haland, MD

Vincent Mercy Medical Center in Toledo, Ohio, where he also served as

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www.smumn.edu/hhs

chief resident. He earned a nephrology fellowship at the University of Minnesota. Lisa Fish, MD, has joined the medical staff at Hennepin County Medical Center. She cares for patients with all types of endocrine problems and has a particular interest in endocrine and diabetes issues during pregnancy. Fish graduated from medical school at Brown University in Providence, R.I., and completed her residency in internal medicine at the University Lisa Fish, MD

of Minnesota, where she

also completed a fellowship in endocrinology. Uchemadu Nwaononiwu, MD, is now providing family medicine care at HCMC’s Downtown

If you have a 2 year history of a dust mite allergy, you may qualify for an allergy research study of an investigational drug.

Medicine Clinics and Whittier Clinic. Originally from Nigeria, Nwaononiwu completed his family and community medicine residency training at Hennepin County Medical Center. He worked in various capacities in both rural and urban settings

Uchemadu Nwaononiwu, MD

as a general practitioner before his residency training in the United States. Susy Rosenthal, MD, MPH, is now seeing patients at Whittier Clinic. She attended medical school at Sackler School of Medicine in Tel Aviv, Israel, and completed her residency in pediatrics at Maimonides Medical Center in Brooklyn, N.Y. She had been in private practice in the Twin Cities since 2003. Michael Guyette took over as president and CEO of Blue Cross and Blue Shield of Minnesota in January. Guyette most recently served as head

For adults and children ages 12 years and older The study will consist of 9 office visits Qualified volunteers receive study drug and study-related testing at no cost and compensation up to $780.00 for time and travel.

Clinical Research Institute

Since 1985 ± ³)RFXVLQJ RQ WRPRUURZ¶V WKHUDSLHV WRGD\´

of national accounts for Aetna in Hartford, Conn. Before that, he held leadership positions at Blue Cross and Blue Shield of Florida. Blue Cross and Blue Shield of Minnesota is the state’s largest commercial health insurer. Michael Guyette

Jakub Tolar, MD, PhD, has been named direc-

tor of the University of Minnesota’s Stem Cell Institute. He is an associate professor in the Department of Pediatrics, Blood and Marrow Transplantation, where he holds the Albert D. and Eva J. Corniea Chair

612-333-2200 x 5 www.CRIminnesota.com Offices in Downtown Minneapolis and at WestHealth in Plymouth

Harold Kaiser, M.D., Philip Halverson, M.D., Gary Berman, M.D. Allan Stillerman, M.D. Richard Bransford, M.D. Hemalini Mehta, M.D. Mary Anne Elder, FNP-C, Research Manager

and is director of Stem Cell/Gene Therapies. MARCH 2013 MINNESOTA HEALTH CARE NEWS

PERSPECTIVE

Male depression Unrecognized and untreated, it’s costly and dangerous

I Mark Meier, LICSW Face It Foundation

Mark Meier, LICSW, is the executive director of Face It Foundation, a Minneapolis-based nonprofit working with men to overcome depression. He is a community faculty member in the University of Minnesota’s Department of Family Medicine and Community Health and frequently speaks about his personal experience with depression, attempted suicide, and recovery. Face It offers peer support groups, individual outreach, and consultation on the management of depression.

magine for a moment that you suffer from a medical condition so serious it impacts nearly every aspect of your daily life. It leaves you fatigued, in pain, unable to concentrate, feeling hopeless, tearful, angry, and filled with anxiety. It disrupts your ability to eat, exercise, sleep, enjoy any activity, and in its severest forms makes getting out of bed almost impossible. Left untreated, this condition can become chronic. It’s associated with thousands of tragic deaths each year. And to top it off, this condition carries such stigma you can’t bring yourself to tell those closest to you how much pain you are in because you are too embarrassed by the fact you can’t get over it. This condition is male depression and it is very real.

costs approach $70 billion to $80 billion annually. In addition, men with depression often struggle in their personal relationships, are not as involved in raising their children as they would like to be, and are at greater risk for abusing drugs and alcohol.

answer is that depression is far different from the occasional bad day everyone experiences. Depression, unlike a bad day, doesn’t respond to a good pep talk, nor does it go away on its own. It affects a person physically, emotionally, and cognitively, and makes “looking at the bright side” impossible.

What Matt learned is that he needed to ask for help in order to overcome his depression. With support from his physician, family, and other men who have dealt with depression, and with effort on his part to learn new coping strategies, Matt has made great strides toward improving his depression. He now manages his depression instead of the depression managing him.

What can you do?

If you are a man wondering if you are suffering from depression or if you are concerned about a man who you think might be depressed, there is a Who is affected? great deal you can do. First, it is vitally important The National Institutes of to understand that depresMental Health estimates sion is a serious issue not to that more than 6 million Men are more likely to be taken lightly. You need to men are diagnosed with realize that often, while you minimize or under-report depression each year in the cannot see the outward U.S. and that 5 percent of signs of depression. impact of depression, on the men in this country live inside, depression is wreakwith it. However, in my exing havoc. perience as a clinical social worker and as a man who lived with untreated depression for 14 years Asking makes a difference before getting help, I believe those numbers are As Matt, a member of a Face It peer support low. This is due, in large part, to the unwillingness group, said, “On the outside, I appeared to have of many men to talk about their emotional needs the perfect life. I had a good job, a great wife and and the reluctance of our society to accept that kids, nice house, new cars … everything looked men can indeed suffer from serious depression. perfect. But on the inside, I pretty much hated Research shows that men are more likely to mini- myself and thought I was a loser.” This is the mize or under-report signs of depression and that dilemma for so many men. They think they have mental health professionals are less likely to rec- everything under control, yet they feel so miserable. This leaves them trying desperately to “get ognize depression in men than in women. Perhaps you’re thinking, “Don’t we all get over it” without any type of focused plan or interdepressed from time to time? Can’t people just ventions. This often doesn’t work and, in turn, look at the bright side of life and get over it?” The leaves them feeling even more depressed.

Consequences Unrecognized and untreated depression is costly and dangerous. Costs include lost work time, overuse of emergency services, and exacerbation of other chronic diseases such as diabetes. These

Untreated depression is also a significant risk factor for suicide. According to the federal Centers for Disease Control and Prevention, in 2010 there were 36,035 suicides in the U.S. Of these, 28,450 were men. That’s approximately 78 suicides each day.

MINNESOTA HEALTH CARE NEWS MARCH 2013

Face It is developing an online tool to help men learn about and deal with their depression, and to interact with other men who have dealt with depression. Visit www.FaceItFoundation.org for more information.

You call it â&#x20AC;&#x153;reminding mom to take her pills.â&#x20AC;?

We call it caregiving.

You or someone you know may be a caregiver. WhatIsACaregiver.org

10 QUESTIONS

Call the coroner Lindsey Thomas, MD Dr. Thomas is a board-certified forensic pathologist and an assistant medical examiner in the Hennepin County Medical Examiner’s Office, serving Hennepin, Dakota, and Scott counties. What is the difference between a medical examiner and a coroner? Historically, coroners originated in England as “crowners,” representatives of the Crown. Their job was to investigate sudden deaths in hopes of generating revenue for the Crown. This institution was brought to the New World but in the early twentieth century, some jurisdictions realized the value of having a medical person involved in death investigation, rather than a politician. This was the creation of the office of the medical examiner. Both medical examiners and coroners perform medicolegal death investigations. In Minnesota, a coroner must be a physician and may be either appointed or elected. A medical examiner must be a forensic pathologist who is appointed by the county board of commissioners. Forensic pathologists are doctors who are specially trained in medicolegal death investigation. However, these terms are used in different ways in other states. What kind of medical training is required to become a medical examiner and how does your training in forensic pathology help you? To become a medical examiner a person needs to earn a bachelor’s degree and a medical degree (MD or DO), and then obtain specialized training through a residency in pathology, plus additional specialized training obtained through a fellowship in forensic pathology. Pathology is the study of disease while forensic pathology is the specialty that concentrates on legal aspects of medicine, disease, and injury. Training in forensic pathology teaches us to keep an open mind, think critically about all aspects of a death investigation, and reach conclusions only after careful consideration. How did you become interested in this specialty? In medical school, I realized I had the wrong personality for clinical practice. So I chose pathology and found that what I enjoyed most were autopsies. I still find autopsies fascinating. Every person is different, and even after thousands of cases, every week or so I see something I have never seen before. The ways in which the human body can be diseased or injured are almost infinite. When I moved to Minnesota I already was trained in pathology and met Hennepin County Chief Medical Examiner Dr. Garry Peterson, who encouraged me to do a fellowship in forensic pathology. I feel incredibly lucky to have found a career that I love and that is so rewarding and meaningful.

Photo credit: Bruce Silcox

MINNESOTA HEALTH CARE NEWS MARCH 2013

You co-authored the book “Protecting the Right to be Free from Arbitrary Killing through an Adequate Autopsy and Investigation into Cause of Death.” Please tell us more. I first met Dr. Peterson through a Minnesota International Human Rights Committee (now known as The Advocates) project to write an autopsy protocol that could be used internationally where suspicious deaths occurred. This protocol was ultimately published by the United Nations and has been used around the world. There were many terrific, passionate advocates for human rights involved in this project.

Even after thousands Why are autopsies performed and During the past 10 years, what are there instances in which they have been the most dramatic of cases, every week or so should be performed but aren’t? advances in the technology you I see something I have Autopsies are performed to answer quesuse? DNA testing is one. The DNA in a never seen before. tions of identity, cause of death, public drop of sweat can prove someone’s pressafety or public health hazards, and what ence at a scene and the DNA in a small happened. There are many other issues that we address as well. We fragment of bone can confirm someone’s identification. But other believe that we are serving the living while caring for those who advances have also been important. Digital cameras make documenhave died, by providing information to families, the criminal and tation easier, and cell phones and computers increase the speed of civil justice systems, health agencies, and the community. obtaining and sharing information. Video surveillance cameras have Due to a real shortage of forensic pathologists in the U.S., there taught us a lot about what happens during various types of deaths. are instances where autopsies are not performed that should be. Has technology allowed you to reexamine a previous Tell us about the work you do in the field vs. in the lab. case to redefine the cause of death? Not so much to redeAs forensic pathologists, most of our work is done in the office and fine the cause of death as to identify possible perpetrators of homiautopsy room. We do go to scenes of suspicious deaths and homicides, and, likewise, to exonerate those incorrectly accused of cides, but, unlike TV, we are not involved in chasing the “bad crimes. DNA enables the legal system to determine whether or not guys.” We work with law enforcement personnel, but our job is to someone had contact with a deceased person. determine what happened, not who did it. At the scene, a medical examiner assists by estimating the approximate time of death and You undoubtedly examine a fair number of people who offering a preliminary idea about the cause and manner of death. died of easily preventable causes. What advice can you share? Don’t smoke. Don’t drink alcohol and drive, or ride in a What are some of the different ways information from car when the driver has been drinking. Always wear your seatbelt. a postmortem exam is used? Our data is used to prevent Don’t take any drug that has not been prescribed to you, and don’t deaths by identifying infectious diseases, genetic abnormalities, take any more of any drug than absolutely necessary. Get treated inherited conditions, and dangerous consumer products or drugs. for depression and other forms of mental illness. My final advice is We identify which deaths need further investigation. Exams can also to cherish every moment of your lives. One thing that medical help families get answers about what happened to a loved one. examiners learn is how fleeting and precious life is.

Chemical dependency in older adults is hard to recognize We help them live a healthier life Alcohol and drug abuse by seniors often goes unnoticed because of isolation and loneliness. As a result, the older adult continues to suffer in silence. Senior Helping Hands is a program of St. Cloud Hospital Recovery Plus and a recognized national leader providing support and services to stop the suffering. Senior Helping Hands serves individuals age 55 and older. Services • Outreach service and consultation with family or concerned persons • Evaluation and assessment for chemical dependency and/or mental health issues completed by qualified professionals • Volunteer support for older adults who are chemically dependent • Support from peer volunteer counselors for older adults with mental health issues Programs Older Adult Chemical Dependency Primary Treatment Program A comprehensive program that involves physical/psychosocial/chemical use assessments performed by professionals trained in chemical dependency and mental health, including a full time Medical Director who is an addictionist. The program provides a slow pace, holistic approach to recovery. Transportation and temporary housing are available if needed.

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MARCH 2013 MINNESOTA HEALTH CARE NEWS

PHARMACY

Stretch your medication dollars

There is very little that the average consumer can do to alter this cost equation. Nonetheless, there are ways you might be able to save money on prescription medication. Here are some strategies that you can use—and some you shouldn’t—to get the best value for the money you spend on medication. Do consider

Non-drug therapy. Ask your doctor if you can treat your re you one of the more medical condition by using than 875,000 Minnesotans non-drug approaches. Such age 45 or older who used approaches could include at least three prescription drugs changing diet, changing exerlast month? If so, you know that cise habits, changing sleeping medications are not cheap. habits, using ice to relieve Prescription drug prices are based pain, or quitting smoking. As on a complex equation of drug an added bonus, non-drug company research and development treatments likely cause fewer costs, drug company marketing side effects than medications. strategies, patent laws, public Older medication. Let policy, and purchasing arrangeyour doctor know if the cost ments between drug companies, of medication is a financial suppliers, and insurance companies. By Timothy Stratton, PhD, BCPS, FAPhA concern. Many community pharmacists have stories about patients who must decide between filling a prescription for a needed medication and having enough money to pay for rent, utilities, or even food. Your doctor might be able to prescribe an older, less expensive medication. Although not the “latest and greatest,” many older medications still will meet a patient’s treatment needs. Compare prices. Consult the Consumer Reports’ Best Buy Drugs Do you have trouble using the telephone due website to compare prices of prescription medication: to hearing loss, speech or physical disability? www.consumerreports.org/health/best-buy-drugs/index.htm Searches can be made by medical condition or by drug name. If so…the TED Program provides assistive telephone Store-sponsored generics. Utilize store-sponsored low-cost generic equipment at NO COST medication programs; some pharmacies offer generic drugs for only a to those who qualify. few dollars. Stop by your local pharmacy or check the pharmacy’s website to find out if it has a low-cost generic drug program. Then, Please contact us, ask the pharmacist if generic versions of the medications you use are or have your patients included in the pharmacy’s low-cost program. When price-checking, call directly, for more information. keep in mind that it is always best to get all medications from the same pharmacy since that allows the pharmacist to have a complete record of the medications someone takes. This is important because it 1-800-657-3663 helps the pharmacist check for potential adverse interactions between www.tedprogram.org the multiple medicines someone uses. Medication therapy management. Sit down with your pharmacist Duluth • Mankato • Metro for a comprehensive review of your medications. Patients with high Moorhead • St. Cloud blood pressure, high cholesterol, or diabetes, for example, have been found to be more likely to achieve their treatment goals if they have periodic comprehensive medication reviews with a pharmacist. The Telephone Equipment Distribution Program is funded through the Department of Commerce Telecommunications Access Minnesota (TAM) Increasingly, community pharmacies, chain store pharmacies, and and administered by the Minnesota Department of Human Services pharmacies located in clinics offer Medication Therapy Management, or MTM, services. These patient-pharmacist meetings typically last

Telephone Equipment Distribution (TED) Program

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MINNESOTA HEALTH CARE NEWS MARCH 2013

between 30 minutes and an hour, but may last longer either via mail order online or by picking up a predepending upon the number of medications you take scription in person. and the number of medical conditions you have. An Internet-only pharmacy that displays the Because of the length of a typical MTM meeting, “VIPPS” seal has met state licensure standards pharmacists usually ask patients to make an appointrequired of all pharmacies. (VIPPS stands for Verified Let your doctor ment for the visit. For people who use Medicare Part Internet Pharmacy Practice Sites.) The National know if the D to help pay for prescription drugs, Medicare will Association of Boards of Pharmacy maintains a webpay for several MTM visits each year. Many other site which lists legitimate pharmacies that carry this cost of health insurance policies that cover prescription drugs seal: www.vipps.info medication is also pay for these visits. Anyone can have a compreSamples. If your doctor offers you a sample of a financial hensive medication review with a pharmacist, but if brand-name medication in the office, be sure to ask your insurance does not cover MTM services, you these questions: concern. will need to pay for these visits on your own. • Will I need to take this medication for a long time? Before you go to your MTM visit, gather up all • Is the medication covered by my health insurance? of the prescription medications, nonprescription medications (also • How much will I need to pay for the medication, either as a copay known as over-the-counter medications, or OTCs), vitamins, and or in full? nutritional supplements you currently use. Take them, in their origi• Are there effective, but less expensive, options? nal containers, to your MTM meeting with the pharmacist. The pharMaximize benefit macist will discuss each medication, vitamin, or nutritional suppleMost people would rather not take medication. But for those us who ment with you to ensure you are getting the best possible benefit do need to take it on a regular basis, several steps can help reduce the from these products. The pharmacist will then work with you to create a medication treatment plan that meets your specific needs. You’ll amount we spend while getting the best possible benefit from the medications we do need to use. Talk to your doctor. Talk to your receive a copy of this treatment plan and an up-to-date list of your pharmacist. medications, vitamins, and nutritional supplements. With your permission, the pharmacist will share a summary of Timothy Stratton, PhD, BCPS, FAPhA, is a board-certified pharmacotherapy specialist and a professor of pharmacy practice at the University of your visit, and his or her recommendations, with your doctor or Minnesota College of Pharmacy, Duluth, where he teaches ethics and superother primary health care provider. This can alert different medical specialists who unknowingly are treating the same patient to a poten- vises medical and pharmacy students at the HOPE free clinic. tial adverse interaction between their respective prescriptions. Patient assistance programs. Many drug manufacturers are willing to provide assistance to people who use that company’s products. To learn if programs are available for the medication you need, look for a toll-free phone number for the manufacturer of your medication. The number may be on the Internet and should be available from your pharmacist. Use caution

It is best to get all medications from the same pharmacy.

Some people try to save money on medication by doing things that actually can put their health at risk. Online pharmacies. The Internet has given rise to a proliferation of online pharmacies. Many of these sites promise low prices on brand-name, expensive prescription medications. The U.S. Food and Drug Administration (FDA), the government agency charged with protecting the American public when it comes to the safety of medications, offers a free brochure outlining the risks of obtaining medication from online pharmacies: www.fda.gov/downloads/For Consumers/ConsumerUpdates/UCM204943.pdf Certainly, not all online pharmacies are suspect. Many U.S. national chain pharmacies and many local community pharmacies also have Internet sites through which a patient can get prescriptions filled and mailed to the patient’s home. These are known as “click and brick” pharmacies because the patient can obtain a prescription

t Eat more fruits, vegetables, whole grains and less fat t Be physically active every day t Do not smoke t Eat smaller portions and lose 10 pounds if you are overweight t Know your ABCs: A1C, Blood pressure and Cholesterol t Take your medicines as directed t Talk to your doctor

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MARCH 2013 MINNESOTA HEALTH CARE NEWS

G E R I AT R I C S

Mature drivers Increasing safety behind the wheel By Catherine N. Sullivan, PhD, OTR

â&#x20AC;&#x153;Driving allowed me to go wherever I wanted, whenever I wanted.â&#x20AC;? This was the consistent answer my graduate students heard when aging Minnesotans who had recently given up their car keys were asked what they valued most about driving. Because driving is linked to autonomy and the ability to participate fully in community, it can be tempting for an aging driver to ignore near misses and other warning signs of diminishing driving skill. However, promising findings from recent aging research indicate that many skills needed for safe driving can, with practice, be preserved and that failing driving skills can be remedied. Crashes The rate of fatal crashes per mile driven, the best measure of risk for a mature driver taking the wheel, increases sharply between the ages of 70 and 75, according to the Insurance Institute for Highway Safety (IIHS). The rate shows an even steeper increase above age 85, especially for men, where it becomes equal to that of teens. However, in contrast to teens,

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Resources older drivers’ risk of fatal injuries is much greater to themselves than to others, often because of seniors’ greater physical frailty. These IIHS statistics highlight the need for mature drivers to learn how to assess their risk level and how to remedy or compensate for specific problems. Self-assessment

1. AAA assessments: www.seniordriving.aaa.com/evalu ate-your-driving-ability 2. University of Michigan SAFER self-assessment: www.elderlydrivingassessments.com/ safer.php 3. AARP Older driver refresher course: www.aarp.org/home-garden/transporta tion/driver_safety/

7. NHTSA website with brochures about how various conditions affect driving: www.nhtsa.gov/people/injury/olddrive/ind ex.html 8. American Occupational Therapy Association: www.aota.org/Older-Driver/ 9. CarFit: www.Car-Fit.org 10. DriveSharp: www.drivesharp.com/ aaa-sne/index

Because age-related changes are so 4. Hartford Insurance: 11. MMAP (Minnesota Mobility for Aging gradual, they are difficult to recognize www.hartfordauto.thehartford.com/UI/Do Persons, a consortium promoting wnloads/FamConHtd.pdf without the help of assessments. lifelong safe community mobility): Driving requires many skills, including 5. Alzheimer’s Association Dementia www.minnesotatzd.org/topics/older/ & Driving Resource Center: good vision, sharp hearing, focused 12. “Love of Car: www.alz.org/care/alzheimers-demen attention, and quick reactions, all of Transportation as we age”: tia-and-driving.asp www.mngero.org/academics/loveof which tend to decline with normal 6. National Highway Traffic Safety car.html aging. Medical conditions such as Administration, “Safe Driving for Older arthritis, eye diseases, and neurological Adults”: www.nhtsa.gov/people/injury/old conditions can also affect the ability to drive/OlderAdultswebsite/index.html drive safely, as do many medications. Many helpful self-assessments are to eliminate the blind spot when making lane changes, a maneuver available (see Resources, above). The website of the Automobile that becomes more difficult with age. There are also new technoloAssociation of America (AAA) offers a paper-and-pencil self-rating gies available that can dramatically improve driving safety for older checklist, as well as an interactive tool called Roadwise Review. The drivers and that should be considered when purchasing a new car. University of Michigan Transportation Research Center has develYou’ll find them listed on the AARP website. oped an interactive online self-assessment tool called SAFER Mature drivers to page 34 Driving, available in downloadable paper-pencil format as the Driving Decision Workbook. Research has found SAFER facilitates decision-making and that it matches the results of on-road driving evaluation. All of these tools recommend what someone should do if problems are identified. After self-assessment, what next? Self-assessments are a good first step, but their drawback is that they rely largely on self-report. If several issues have been flagged, it is a good idea to request the opinions of trusted friends or family about an elder’s driving skills. Being open to family conversations allows potential problems to be addressed early enough that they can be handled before a preventable traffic accident occurs. Websites of Hartford Insurance and the Alzheimer’s Association provide online resources to help guide such conversations. If issues are identified, many sources offer solutions. Taking a mature driver refresher course from AARP is a sensible place to start. There is also a wealth of free online resources. The National Highway Traffic Safety Administration (NHTSA) website has a downloadable booklet titled “Safe Driving for Older Adults.” NHTSA also has a series of brochures on how to continue driving safely with certain medical conditions. The American Occupational Therapy Association (AOTA) website provides documents and recommendations aimed at helping older drivers and their families.

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PAT I E N T T O PAT I E N T

earing loss is grim, especially for people who love music. But few people realize that the worst-case scenario may not be hearing loss, but rather, devastating hearing injury.

Prelude

Protect your hearing Noise-induced damage and one musicianâ&#x20AC;&#x2122;s search for a remedy By Janet Horvath

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During a 31-year career as associate principal cello of the Minnesota Orchestra I saw many colleagues struggle with physical ailments caused by awkward posture and repetitive motion. It never dawned on me that one day my own career would be curtailed by injury. The injury While playing with the orchestra in 2006, I was seated with my left ear within two feet of huge audio speakers. Despite wearing hearing protection, I sustained an acoustic shock injury: Noise from the speakers caused intense pain in that ear and a vibrating/gyrating sensation inside it, with pain radiating into my neck, face, teeth, tongue, jaw, and head. After the concert, the least little sound caused painful spasms, even my own voice. For three months I was forced to isolate myself totally from soundâ&#x20AC;&#x201D;no music, no TV, no telephone. My family tiptoed around me. I wore headphones and earplugs if I had to leave the house, but any excursion had to be brief.

Eventually, symptoms improved enough for me to return to the orchestra, but from that day onward I wore an earplug in my left ear, onstage and off. The problem worsens However, over the course of several years my right ear started to hurt, despite the fact that I avoided loud sounds and never watched TV or listened to music except when I was at work. By 2010, my condition was deteriorating rapidly. The orchestra’s repertoire that year included enormously loud music. To make matters worse, my position onstage was in the center of that huge orchestral sound and immediately in front of the conductor, who often shouted instructions during rehearsal. By that point I couldn’t enter Orchestra Hall without an earplug in each ear. Most days, pain brought me to tears. I couldn’t talk with anyone because conversation hurt my ears. Normal sounds were painful; loud sounds, intolerable. It was as if the whole world had been turned on “high.” In August 2010, the orchestra toured Europe and performed in London before an audience of nearly 4,000 people. Their cheering and clapping was the end for me; I could no longer tolerate that much noise. My career as an orchestral musician was over. Emotional, physical fallout After the tour I was diagnosed with hyperacusis, an auditory disorder arising from a problem in the way the brain perceives noise. Simply put, it is extreme sensitivity to sounds, especially highfrequency ones. Few statistics exist on hyperacusis, although the American Academy of Otolaryngology estimates that approximately one in 50,000 people in this country suffer from this condition, which can affect people of all ages in one or both ears. In my case, it developed from continued exposure to noise after the acoustic shock injury in 2006. I was advised to resign my position with the orchestra immediately and to avoid all exposure to noise or else jeopardize my hearing and any chance of living a normal life. This condition made me become totally isolated because loud noise permeates our society—who knew when I might encounter a leaf blower, snow blower, or construction? I could not attend or play in a concert, nor participate in normal activities like going to a restaurant or small social gathering. All sounds were intolerable, including everyday ones like running water. High-frequency sounds were especially disturbing, even if they weren’t loud. I felt assaulted by the high-pitched beeps of grocery scanners, ATMs, gas pumps, and digital appliances. The situation seemed hopeless.

tion to hyperacusis, I also have low-grade tinnitus. People with one of these conditions often have the other one too. Both conditions are usually caused by acoustic shock injury and worsen from continued exposure to noise.) The OHSU team fitted me with attenuators, devices that provide five different levels of sound reduction and have given back my life to me. Another aspect Audiologists recommend of reclaiming particithe “60/60” guideline pation in our everyfor earbud use: Don’t day world involves listen for more than 60 dealing with the minutes/day, and keep hypervigilance and volume under 60 percent fear of sound I’d of maximum volume. developed as selfEditor’s note protective coping mechanisms. Like other people learning to live with hyperacusis, I am retraining my brain to tolerate sound by listening to recordings of pleasant sounds like rainfall and wind. Training starts by listening to the recordings at a very low volume and gradually increases the volume and the amount of time spent listening. Coda Today, more than six years after the acoustic shock Protect your hearing to page 19

Finding help Searching for help spanned five years and included consulting many specialists and getting every test in the book. It took two years to find an otolaryngologist who correctly diagnosed the acoustic shock injury and subsequent hyperacusis. Although I had stopped playing with the orchestra before any measurable hearing loss was detected, my acoustic shock injury and hyperacusis are permanent. In 2011, searching for solutions led me to Oregon Health and Science University (OHSU) in Portland, which has a clinic specializing in both hyperacusis and tinnitus, or ringing in the ears. (In addiMARCH 2013 MINNESOTA HEALTH CARE NEWS

March Calendar 9

Family and Caregiver Classes for Alzheimer’s Home Instead Senior Care presents a family Alzheimer’s training class and caregiver support group. Free. Call Erica at (763) 544-5988 for more information. Saturday, March 9, 9–11 a.m., Wayzata Library, 620 Rice St. E., Wayzata Pain Management Class Allina Health presents Tilok Ghose, MD, and Scott Anseth, MD, discussing hip/knee pain and how to get the correct diagnosis for it. Refreshments. Free. Call (651) 644-4108 for more information. Wednesday, March 13, 1–3 p.m., The Commons at Midtown Exchange, 2925 Chicago Ave., Minneapolis Alzheimer’s Education Alzheimer’s Association presents occupational therapist Susan Ryan, OTR/L, discussing practical suggestions for living with this disease. Light dinner provided by The Alton Memory Care. Free. Call Mike at (952) 857-0546 for more information. Tuesday, March 19, 6:30–8 p.m., Mount Zion Temple, 1300 Summit Ave., St. Paul Food Allergy Support Food Allergy Support Group of MN presents a support group for those with food allergies. Free. For more information, email info@FoodAllergySupportMN.org Wednesday, March 20, 7–8:30 p.m., Crystal Community Ctr., Game Rm., 4800 Douglas Dr., Crystal Mental Health Activism Discussion The University of St. Thomas presents David Wellstone addressing political activism and legislation in mental health and substance abuse treatment. Free. Call David Hamm at (612) 962-4441 for more information. Friday, March 22, 11:30 a.m.–1 p.m., Opus Hall, 1000 LaSalle Ave., Minneapolis

World Autism Awareness Day Did you know that one in 88 American children is identified as being on the autism spectrum? That is a tenfold increase in prevalence in 40 years, according to the Centers for Disease Control and Prevention. An estimated one in 54 boys and one in 252 girls are diagnosed with autism in the United States, with prevalence rates growing 10 percent to 17 percent annually in recent years. To raise awareness, April 2 has been designated World Autism Awareness Day. Autism cannot be definitively diagnosed until 18–24 months, but early signs can show in babies as young as 8–12 months of age. Look for no sharing of sounds, smiling, or other facial expressions by nine months, and no babbling or pointing by 12 months. There is no single cause of autism, but genetic and environmental factors are thought to be at work. Expectant mothers can lessen their chances of having a child with autism by taking prenatal vitamins, especially folic acid. Other risks to avoid include advanced parental age and maternal illness during pregnancy. For more information on autism: www.autismspeaks.org Apr. 3 ASD Treatments Skillshop Autism Society of Minnesota presents Amy Esler, PhD, LP, as she discusses commonly used treatments for Autism Spectrum Disorder (ASD) and evidence supporting these treatments. Cost is $10 for AuSM member with ASD. Call (651) 647-1083 for more information. Wednesday, Apr. 3, 7–9 p.m., 2380 Wycliff St., Ste. 102, St. Paul

Health Policy Lunch and Learn University of Minnesota Medical Industry Leadership Institute invites you to bring lunch and learn about health policy and regulatory affairs. Free. Call Monica at (612) 624-1532 for more information. Monday, March 25, 12–1 p.m., Carlson School of Management, Rm. 1-135, 321 19th Ave S., Minneapolis

Apr. 1–5

National Public Heath Film Festival University of Minnesota School of Public Health presents its National Public Health Week Film Festival. Films shown on various health-related topics; Q & A with experts after each night’s film. Free. Call Nichole at (612) 626-9303 for more information. Monday–Friday, April 1–5, 5–9 p.m., Mayo Memorial Auditorium, 4th Flr., 425 Delaware St. S.E., Minneapolis

Apr. 6

Cancer Survivor Series University of Minnesota presents the 8th Annual Survivorship Series. This conference addresses questions cancer and stem cell treatment survivors and their families may face after treatment. Free. Call (612) 624-2620 to register. Saturday, April 6, 8 a.m.–1:30 p.m., McNamara Alumni Ctr., 200 Oak St. S.E., Minneapolis

July 14-19

Gluten-Free Fun Camp R.O.C.K.-Twin Cities Chapter offers camp for kids 8–17 with celiac disease. Register now at: www.twincitiesrock.org/camp Sunday–Friday, July 14–19, Camp Courage, 8046 83rd St. NW, Maple Lake

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 mmacedo@ 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 18

MINNESOTA HEALTH CARE NEWS MARCH 2013

Protect your hearing from page 17

injury, my ability to manage hyperacusis has improved to the point that I can play cello in small groups of musicians. The injury to my ears is permanent and I will always need to avoid noisy situations, but at least I can tolerate being outside my home, thanks to the attenuators. Reinventing myself after losing my professional identity as an orchestral musician has not been easy. I feel fortunate to have had the support of medical personnel, friends, and family, and The problem with have worked hard noise-induced hearing not to let my loss is that you injury keep me from continuing a don’t feel it while meaningful life.

it’s happening.

Noise pollution Part of what makes my life meaningful is alerting people to noise pollution: traffic and construction noise, music blasting in retail establishments, and young people listening to loud music for hours. This results in a high proportion of people with hearing problems. According to research published in the Journal of the American Medical Association in 2010, 20 percent of U.S. adolescents aged 12 to 19 are losing their hear-

ing, a significant increase from the 15 percent of adolescents in 1988–1994 who had hearing loss. Currently, one in five teens cannot hear correctly. Even mild hearing impairment during youth can lead to decreased educational achievement and impaired socialemotional development. Another study revealed that the common denominator among students with hearing damage at a school in Ohio was that they listened to MP3-type portable music players. According to the Mayo Clinic, most personal listening devices can produce sounds up to 120 decibels, which is equivalent to an ambulance siren. Protect yourself The problem with noise-induced hearing loss is that you don’t feel it while it’s happening; it may take years before you realize that some of your hearing was permanently destroyed. How can you protect your hearing? Ask retail establishments to turn down the volume. Carefully consider the volume at which you play personal listening devices and the length of time earbuds are in your ears. Wear earplugs around lawn mowers, at rock concerts, and in other noisy settings. Get a hearing test to see if you have already sustained damage. Protect your ears before it’s too late. Janet Horvath is a cellist and a soloist, chamber musician, writer, and advocate for injury prevention. She writes about injury prevention for many publications, writes about music for www.interlude.hk, and has written an injury-prevention book for musicians (www.playinglesshurt.com).

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D E R M AT O L O G Y

Melanoma

Prevention and early detection are key to survival By Pierre George, MD, and Juan Jaimes, MD

Every hour, one American dies of melanoma, the most deadly form of skin cancer. There were 123,590 new cases of melanoma in 2011 and 8,790 deaths from it. Unfortunately, the incidence of melanoma continues to increase by 4 percent to 10 percent annually. One in 55 women and one in 36 men will develop melanoma during their lifetimes. If a melanoma is detected early in its development, it can be treated easily. However, if detected in later stages, survival rates are low. Thus, early diagnosis is paramount. Symptoms Typically, melanoma appears as a new mole or as one whose appearance is changing; 30 percent of these cancers arise in an existing mole. Melanoma can look like a multicolored mole, including one that’s brown and black, but it also can be a pink or red lesion. Often, this cancer appears on the back in men and on the legs in women, although it can develop anywhere on the body, including the eye or inside the mouth. Risk factors: Ban the tan

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Caucasian men over 50 are at highest risk for melanoma, but it is the most common cancer in people 25–29 years of age, and the second most common among those 15–29. Melanoma occurs less frequently in nonCaucasians, but having dark skin does not mean a person is risk-free. Bob Marley, of Jamaican reggae fame, died of a melanoma under his toenail. Risk factors include fair skin, blue or green eyes, red or blond hair, and the presence of multiple atypical moles and freckles. A personal or family history of melanoma increases susceptibility. All these factors are beyond a person’s control. The only preventable risk factor is exposure to ultraviolet (UV) radiation, which the U.S. If you are a man Department of Health and Human Services and the World Health aage 55 and older Organization have declared a cancer-causing substance. with a history of nocturia w UV radiation causes cancer because it damages genetic material in ((at a least 2 to 5 visits to the skin cells. This leads to aging of the skin, immune suppression, eye damage (including cataracts and ocular melanoma, or eye cancer), and bbathroom a night), skin cancer. Intense, intermittent sun exposure such as blistering sunyyou may qualify for a burns promotes the development of clinical research study of an cl melanoma. The risk for melanoma douCheck your investigational medication. in bles for people who have had more than birthday suit five sunburns at any age or one or more Qualified participants may Q on your blistering sunburns in childhood.

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birthday.

Increasing incidence The rising incidence of melanoma in the U.S. is due primarily to behaviors promoting recreational UV exposure. Sunburn before age 21, outdoor summer jobs as a teen, and the use of tanning beds are recognized risk factors. Indoor tanning increases the risk of melanoma by 75 percent overall and by 87 percent for those who start before age 35. Just one indoor tanning session increases the user’s chance of developing melanoma by 20 percent. Despite this risk, 28 million Americans visit tanning salons annually, nearly 70 percent of whom are Caucasian women ages 16 to 29. Despite compelling evidence that tanning beds cause skin cancer, including melanoma, the use of indoor tanning continues to rise. Legislation banning indoor tanning and prohibiting its advertising is urgently needed. Although the majority of states have laws limiting use of tanning beds by minors, these laws usually are not enforced.

Prevention: Slip, slap, slop Melanoma is largely a preventable lifestyle disease. The cornerstone of prevention involves minimizing UV exposure. Rules of smart sun exposure are simple and well known, but often ignored. Only one-third of adults and even fewer teens routinely practice these sun-protective behaviors:

MDH reminds winter vacationers about sun protection The Minnesota Department of Health (MDH) reports that melanoma is one of the most rapidly increasing cancers in Minnesota. The number of Minnesotans diagnosed with invasive melanoma of the skin nearly tripled between 1988 and 2009. “If not found early, melanomas can spread to other parts of the body and can be deadly,” says Commissioner of Health Ed Ehlinger, MD. “… we also want to remind people taking winter vacations that they risk serious health consequences if they don’t protect their skin from ultraviolet light,” he adds. “The idea that it is a good health move to get a ‘base tan’ before going on vacation is a myth.”

• Ban the tan. Tanning promotes skin cancer, regardless of whether the tan comes from a tanning salon or outdoors. • Wear a broad-brimmed hat.

• Wear long-sleeved shirts and long pants. These are available in lightweight, SPF-impregnated fabric. • Apply broad-spectrum sunscreen that blocks both UVA and UVB rays and has an SPF of 30+. • Use sunscreen daily, even on cloudy days. (Ultraviolet rays penetrate clouds.) • UVA rays penetrate most window glass; use sunscreen when driving or sitting next to a window. • Seek shade, especially between 10 a.m. and 4 p.m. If your shadow is shorter than you are, stay in the shade. In Australia, these guidelines are called Slip, Slap, Slop (slip on a shirt, slap on a hat, slop on sunscreen). Sunscreen’s effectiveness in preventing melanoma is well documented: A recent Australian study showed that the risk of developing melanoma was reduced by 50 percent for daily users of sunscreen, compared with people who didn’t use sunscreen regularly.

D) Diameter. Melanomas are usually larger than a pencil eraser although smaller melanomas are not rare. E) Evolution. Any change in color, size, shape, height, or other characteristic, or any new symptom such as bleeding, itching, or crusting, indicates danger and should be evaluated by a doctor. Periodically taking photos of your moles is a good way to detect changes over time. Treatment

The treatment for melanoma is surgery. When a lesion is detected early, removing it and a margin of normal skin around it is usually a cure and can be done in the doctor’s office. In more advanced cases, when melanoma cells may have spread beyond the borders of the tumor, removing nearby lymph nodes and adding chemotherapy may be helpful. Early detection Melanoma is one of the fastest-growing cancers. However, it’s also one of the most preventable and curable, if caught early. Recommendations for prevention are simple: Seek shade, cover up, wear sunscreen, and wear sunglasses, especially wraparounds, which protect the sides of the eyes. Early detection is critical. Examine your skin routinely, and see a dermatologist if you find anything changing, growing, or new. Pierre George, MD, and Juan Jaimes, MD, are board-certified dermatologists who practice with Dermatology Consultants in St. Paul and Woodbury.

Spot it, stop it If you can spot melanoma, you can stop it. There is no effective cure for this disease once it’s in the advanced stage, so early detection is the best method to save lives. If a melanoma is found early in its development and before it spreads to the lymph nodes, it can easily be treated with a surgical procedure that results in a 98 percent survival rate over a five-year period. (This means that 98 percent of the people who were treated had not died from melanoma five years after treatment.) Survival falls to 62 percent if the disease reaches the lymph nodes, and 15 percent once it metastasizes (spreads) to distant organs. Early diagnosis is critical. For more information Check your skin every one www.aad.org to two months using two mirwww.skincancer.org rors or the help of a partner; 80 percent of melanomas are detected by the patient or a spouse. If you can’t do it that, at the very least check your birthday suit on your birthday and report any suspicious lesions to your dermatologist. Look for any mole that has changed color, size, or shape, using “ABCDE” to remember what to look for. A) Asymmetry. Most melanomas are asymmetrical; a line through the middle of the mole or lesion does not create matching halves.

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B) Border irregularity. Borders of a melanoma are uneven. Edges may be scalloped or notched. C) Color variability. A melanoma may have varied shades of brown, tan, black, red, white, or blue.

MARCH 2013 MINNESOTA HEALTH CARE NEWS

E N V I R O N M E N TA L H E A LT H Spring: Trees are budding, crocuses are blooming, windows are open. Who wouldn’t want to go outside? Twenty percent of the population, that’s who. For these hayfever sufferers, itchy, swollen eyes and sneezing signal the onset of spring allergies triggered by pollen. Pollen is a fine powder produced by certain plants when they reproduce, which occurs from spring through fall in Minnesota. Trees pollinate in spring, grass in summer, and weeds, from August to frost. Symptoms of pollen allergies can begin in early childhood or as late as middle age, but usually show up between childhood and a person’s 20s. Symptoms

Hayfever How to cope By Nancy Ott, MD

Symptoms include a stuffy and/or runny nose, postnasal drip (drainage down the back of the throat), sneezing, and itching. Dark circles around the eyes may indicate congestion, as can breathing exclusively by mouth, which can produce bad breath. Poor sleep caused by severe stuffiness may indicate hayfever; sinus and ear infections and allergic asthma may be associated. Skin may feel itchy, particularly around the eyes. It’s important to address itching because repetitive skin scratching can trigger eczema. Eczema is characterized by redness, bumps, and patches of scaly, thickened skin.

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MINNESOTA HEALTH CARE NEWS MARCH 2013

In addition, certain fresh fruits Claims that one and vegetables can cause mild itching antihistamine is better than in the mouth and throat because they another for “outside” or contain proteins similar to pollen. “inside” use are unfounded. Cooking the produce prevents this reaction. This phenomenon, known as oral allergy syndrome, suggests the can be used safely for three to five days. Using OTC nasal decongespresence of hayfever. It can precede eye and nose symptoms. tant sprays longer than one or two weeks can cause worsening conDiagnosis gestion as the spray wears off. If the spray is then used repeatedly in Diagnosis often is made initially by a primary care provider, based an attempt to keep nasal passages open, it creates a “rebound” cycle on patient symptoms. Determining what, exactly, is causing the that is hard to break. hayfever is done by testing sensitivity to pollen from trees, grasses, Oral decongestants such as pseudoephedrine or phenylephrine and weeds. Tree pollen in the Upper Midwest involves six pollens: can be used daily with less chance of rebound, but may lead to oak, elm, maple, birch, cottonwood, and ash. These tree pollens sleeplessness and high blood pressure. Antihistamines available in cross-react with other tree pollens, so testing for them will detect combination with decongestants are sold as Claritin-D, Allegra-D, allergies to all regional trees. Minnesota’s Junegrass and timothy and Zyrtec-D. The decongestants in these products often last 12 to grass cross-react with all grasses in this region; testing for those two 24 hours. Generic medications are less expensive than brand-name grasses will detect allergies to regional grasses. Since ragweed is the drugs and work just as well. dominant weed in Minnesota and other weeds are less likely to be a Eye drops. Just as nasal decongestants can lead to rebound, so major allergy trigger, testing for ragweed is all that is necessary to can eye drops such as Visine. Eye drops claiming to “get the red out” detect weed allergies. are vasoconstrictors, meaning they constrict blood vessels. They Hayfever sufferers who spend a lot of time in different areas of should be used short term, similar to decongestant nasal sprays. the country, such as those who winter in Texas, should be tested for Nonvasoconstrictor eye drops, such as ketotifen eye drops, can be pollen found in those areas too. Texas, for instance, has mountain used safely every day. Ketotifen is an anti-inflammatory OTC noncedar tree pollen and grasses that do not grow in Minnesota. steroidal eye drop available as Zatidor, Alaway, and other names. Mold spore allergy or hayfever? Mold spore allergy can cause Hayfever to page 27 congestion but is unlikely to cause the itching and sneezing caused by pollen. The highest level of mold spores outdoors occurs during late fall, when leaves are being raked after the frost. Reaction to the spores isn’t considered classic hayfever. However, because it can occur in the late summer and early fall at the same time as weed allergies, mold spore allergy can complicate the process of determining the cause of congestion. Self-treatment Avoidance strategies. Shower immediately after being outside and place in the laundry any clothing worn outside. Leave shoes at the door. Nasal rinses with neti pots or squeeze bottles of sterile salt water can flush allergens and mucus. Eye rinses help relieve eye symptoms. Keep windows closed to keep pollen outside the home. Go outdoors later in the day, when pollen counts are typically lower, or immediately after it has rained. Over-the-counter (OTC) medicine such as nonsedating antihistamines can help control itchy, runny eyes and/or noses. DeterShots may mine what works for you via trial and error; decrease loratadine (Claritin), cetirizine (Zyrtec), and allergy fexofenadine (Allegra) are options. Advertising claims that one antihistamine is better symptoms than another for “outside” or “inside” use over time. are unfounded. Each person responds differently to each antihistamine regardless of whether an allergen is outside or inside the house. OTC decongestants can alleviate congestion but may cause side effects. Nasal spray decongestants such as Afrin or Neo-synephrine MARCH 2013 MINNESOTA HEALTH CARE NEWS

PA L L I AT I V E C A R E

Easing the

journey Addressing cancer’s psychosocial impact By Michelle Silverman

ore than half of adult cancer patients and survivors report experiencing significant distress during treatment, recovery, or survivorship, according to the 2007 Institute of Medicine (IOM) groundbreaking report, “Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs.” In fact, cancer patients and parents of young children with cancer sometimes meet the criteria for post-traumatic stress disorder (PTSD), reports the IOM. Such stress puts cancer patients and their families at increased risk for anxiety, depression, and other mental health problems. Depression alone costs an estimated $8,400 annually for the cancer patient who experiences it, reports Cancer Support Community, an international nonprofit organization that provides support and education to people affected by cancer.

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In addition to economic cost, patients suffering from depression, anxiety, or excessive stress can have difficulty remembering, concentrating, and making decisions. These problems can compound the challenges of cancer treatment and decrease a patient’s motivation to complete treatment, resulting in a debilitating, downward spiral. Support eases stress But it doesn’t have to be that way. A Stanford University clinical trial found that women who participated in support groups while undergoing cancer treatment demonstrated significant improvement in making necessary life changes, a positive attitude toward their illness, better interpersonal communication, and a significant decrease in PTSD symptoms: • 87 percent of the women experienced reduced stress • 86 percent of the women felt less fearful

Gilda’s Club Twin Cities Gilda’s Club Twin Cities (GCTC), an affiliate of the Cancer Support Community, is scheduled to open in 2013 as a place where men, women, teens, and children living with cancer, along with their families and friends, can join with others to receive social, emotional, and psychological support. GCTC expects as many as 17,000 annual visits based on the experience of Gilda’s Clubs located nationwide in similar metropolitan communities. Named for comedienne Gilda Radner, who died of cancer in 1989, this organization’s nationally acclaimed program includes support groups, education, healthy lifestyle programs, social opportunities, and information and referral services. All services are facilitated by licensed professionals and are free.

• 85 percent of the women felt they could face the future more positively • 83 percent of the women felt more in control of their lives Increasingly, cancer treatment experts advocate collaboration between a patient’s medical team and community resources that address the psychosocial impact of cancer. Although managing stress is recognized by the medical community as an important factor in the cancer journey, only 14 percent of the oncologists surveyed by the IOM in 2007 screened patients for stress. However, that will change in 2015 when the American College of Surgeons Commission on Cancer, which accredits cancer treatment centers, begins requiring centers to screen patients for stress as a prerequisite for accreditation. Those screenings and any needed services provided in response will benefit both the patient and the health care system as a whole. According to an article Many caregivers in Progressive Brain Research entireported that they tled The Cost-Effectiveness of Mind-Body Medicine Interventions needed help (2000), evidence supports the effecdealing with tiveness of services aimed at relievtheir loved one’s ing the emotional distress that emotional distress. accompanies cancer. This occurs even if patients are experiencing debilitating depression, anxiety, or both. Early identification and treatment of psychosocial distress through counseling and support services pays off: Patients experience decreases in average length of hospital stays, hospitalization frequency, physician office visits, emergency room visits, and the number of prescriptions received.

In addition, many individuals do not want to receive support services at the same place where they are treated for cancer. That’s why offering psychosocial support services outside a hospital or clinic setting is necessary to attract the very people who need them. Caregiver support A need for support includes not only a person living with cancer but his or her family members and friends. For example, when parents Easing the journey to page 26

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wherever you are!

Patient support Health care systems provide some help, such as support groups for people with certain cancer diagnoses. However, they cannot provide all the services needed by cancer patients and their families due to confidentiality laws and constrained resources, says Brenda Weigel, MD, division director of pediatric hematology/oncology at the University of Minnesota and medical director of the clinical trials office at the university’s Masonic Cancer Center.

www.mppub.com MARCH 2013 MINNESOTA HEALTH CARE NEWS

place, they were able to adjust better.” According to research published in learn their child has cancer, it is not an article in the Journal of Clinical unusual for them to want to reach out Geropsychology (Impact of psychoto other parents going through the educational interventions on distressed same trauma and associated stress. Additional Resources caregivers, 2000), fatigue can exhaust a However, points out Dr. Weigel, • www.cancersupportcommunity.org caregiver’s physical and mental reserves “Because of confidentiality, we can’t • www.gildasclubtwincities.org and make caregiving a difficult, if not introduce families to each other. impossible, task. Providing early and • www.cancer.org Instead, they meet in hospital hallways frequent support for the caregiver helps and cafeterias. These aren’t the ideal to mitigate these effects and ensures a healthier environment for all settings. Other organizations can facilitate those connections in those involved. ways we cannot.” An American Cancer Society survey of caregivers found that Reducing cancer’s burden a significant percentage of people caring for someone with breast The American Cancer Society estimates that more than 13 million cancer experienced the same level of distress as the patient. Many cancer survivors live in the U.S. Given the size of this population caregivers reported that they needed help dealing with their loved and the fact that survivors now live longer one’s emotional distress, especially at the after diagnosis than in the past, treating the Early identification and two- and five-year anniversaries of the diagemotional and psychological distress that nosis. Caregivers also reported needing help treatment of psychosocial often accompanies cancer is a necessity. dealing with their own emotional distress at Early intervention and consistently availdistress through counseling those times. able support services have been proven to and support services pays off. promote healthier, less stressed patients Not surprisingly, the survey found that “[o]ne of the most stressful events in the and caregivers, thus reducing cancer’s course of the cancer experience is being told that the cancer has burden on both the individual and the community. come back. Some of them were faced with that awful news, and Michelle Silverman is executive director of Gilda’s Club Twin Cities, others had to prepare for the loss of their loved one. During those Minnetonka. times, especially, if the caregivers had a strong support system in Easing the journey from page 25

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Keep windows closed to keep pollen outside the home. Hayfever from page 23

Medical treatment Prescription nonsteroidal eye drops or antihistamine eye drops similar to ketotifen can help prevent itching, tearing, and swelling. It is best to use these eye drops before allergen exposure, if possible, as this gives the best chance of preventing symptoms. If you use the drops after symptoms begin, it may seem as though it takes the drops longer to be effective. This is because the previous inflammation that caused symptoms needs to diminish before improvement can be detected. Prescription nasal sprays can contain antihistamine, corticosteroid (alone or combined), and anticholinergics. Antihistamine sprays can relieve itching and drainage and need to be used daily because their effects last only 12 hours. Inhaled nasal corticosteroids (INS) are miniscule amounts of cortisone-like sprays that coat nasal passages and decrease swelling of the nasal tissue, mucus production, and response to pollen. INS is the most effective type of medicated nasal spray for controlling symptoms. Because the dose is so small, INS needs to be used daily to control symptoms and may take up to four to six weeks to alleviate symptoms. The OTC anti-inflammatory nasal spray Nasalcrom can be used as a mild symptom preventer/ controller similar to INS. Anticholinergic sprays such as ipratropium

decrease thin, watery nasal discharge but do not significantly decrease congestion or itching. Oral corticosteroids. For people with unbearable symptoms that make it impossible to go to work or school, sleep, or perform normal activities, a short course of oral corticosteroids lasting five to seven days can bring acute symptoms under control enough to allow topical (applied to the surface of the body) prescription or other treatments to be implemented to control symptoms. Allergy shots. If medication and avoidance strategies do not control symptoms, consider consulting an allergy specialist for skin tests to pinpoint allergens (substances causing an allergic reaction). Once allergens are confirmed, an allergist may prescribe allergy shots. Shots may decrease allergy symptoms over time because injecting small amounts of an allergen can teach a person’s body to tolerate it. It’s manageable Don’t let hayfever sidetrack you. For more information, visit: www.aaaai.org and www.acaai.org Nancy Ott, MD, is a board-certified allergy/immunology specialist with Southdale Pediatrics, where she treats adults and children.

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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

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PUBLIC HEALTH

ince 1965, newborn screening has identified nearly 5,000 Minnesota infants who, because screening detected rare medical disorders, were able to receive early treatment that prevented serious complications. The Centers for Disease Control and Prevention calls newborn screening one of the great public health accomplishments of the 21st century.

How it began In 1965, when newborn screening became available statewide in Minnesota, infants were screened for only one disorder, phenylketonuria (PKU). Without early treatment, children with this disorder suffer significant, permanent developmental delay. In those days, most children with PKU lived in institutions. Thanks to the development of newborn screening tests, PKU-affected children are now identified at birth, which allows them to immediately start a special diet. This diet protects children with PKU from developmental MS, CGC, delay and gives them the chance to live healthy lives and to grow up with their families. To give all children an equal chance of a healthy life, legislation was passed that requires newborn screening be offered to parents of all newborns and makes it a public health program administered by the Minnesota Department of Health (MDH). Screening is covered by insurance. Today, newborns in Minnesota are screened for 54 medical disorders. This includes severe combined immune deficiency (SCID), added to the screening panel in January 2013.

Newborn screening Simple tests produce lifetime benefits By Amy Gaviglio, MS, CGC, Beth-Ann Bloom, and Sondra Rosendahl, MS, CGC

The process Shortly after birth, a small amount of Legislation a newbornâ&#x20AC;&#x2122;s blood from his or her was passed heel is collected on special paper. that requires This blood spot is dried and sent to the MDH public health laboratory, newborn where rapid testing for 54 diseases is screening be completed on 200-plus infants each offered to day. If test results are abnormal, genetic counselors contact the infantâ&#x20AC;&#x2122;s parents of all doctor to arrange for additional diagnewborns. nostic testing. MDH staff follows up with the doctor and family to ensure recommendations are followed and that the infant sees a specialist for treatment, if needed.

Leftover dried blood spots In addition to screening newborns, MDH staff constantly check screening accuracy and look for ways to improve tests. To do this, leftover dried blood spots are needed. Current Minnesota law allows MDH to keep any leftover blood for 71 days after normal

MINNESOTA HEALTH CARE NEWS MARCH 2013

Everett’s story screening results and for two years after abnormal results in order to provide ongoing assessment and improvement of the screening process. Leftover dried blood spots can be used for: • Quality assurance • Test improvement and development • Further testing for the child or family • Public health studies

Everett Olson’s mom, Korissa, remembers looking at Everett when he was born and seeing an apparently healthy baby. Because he seemed healthy, Korissa declined newborn screening. Only after hospital nurses discussed the importance of testing did she agree to have Everett tested. Four days later, the Olsons were told by their pediatrician that Everett’s newborn screening had detected galactosemia. Children with galactosemia are unable to break down naturally occurring sugar in milk, so dangerous levels of this sugar accumulate in their blood. Without prompt treatment they develop brain damage, mental retardation, cataracts, liver failure, and infections, and can die young. Although Everett seemed fine during his first few days of life, he soon showed symptoms of galactosemia. Because of newborn screening, his disease was diagnosed quickly, appropriate treatment was started right away, and today Everett is a happy, healthy fouryear-old. View his story at www.youtube.com/watch?v=Q7oEz6pmhPA&feature=youtube

Quality assurance activities that monitor testing accuracy could not be done without using leftover dried blood spots. This is not considered research, and is mandated by federal regulations covering all clinical laboratories. Improving existing tests and developing tests for disorders not currently on the screening panel are integral to the program. An individual’s blood during the newborn period is very different from blood in adults and older children. Newborn blood contains constituents that disappear as a child ages, and therefore cannot be detected during childhood or adulthood. As a result, developing tests for newborn screening can only be done using blood from newborns. If dried blood spots had not been previously available to newborn screening programs, Minnesota infants would be screened today for only PKU rather than for 53 additional treatable diseases. Families occasionally contact MDH in an effort to understand why their child developed a medical disorder. For example, the family of a child with hearing loss might ask for their child’s blood spot so that doctors can determine if the hearing loss was caused by an infection at birth. In cases like this, the dried blood spot is the only sample available that can answer this question. Dried blood spots may also be used to help identify a missing or deceased child. Public health researchers sometimes contact MDH in an effort to learn more about public health. Some study environmental exposures; others, congenital infections not obvious at birth. While leftover blood spots are kept for a short time and are available for quality assurance and process improvement during that Newborns in time, they are not made available for Minnesota are development of new testing, further health testing for the child, or screened for research to benefit the public health 54 medical without informed consent from the disorders. parents. Parents who want to have their child’s dried blood spots and screening results saved at the MDH beyond the standard 71 days (for normal spots) or two years (abnormal spots) can sign the consent form at: www.health.state.mn.us/newbornscreening/docs/storage_use.pdf Signing this form allows storage and use of the dried blood spots until the child is 18; parents can revoke consent at any time. Dried blood spots are used anonymously and MDH never uses all of a child’s dried blood spot; some sample remains available should the family need it. While newborn screening has expanded beyond the days of PKU testing, its mission remains the same: to find newborns with treatable diseases as early as possible in order to give them the best chance at a healthy life. Minnesota’s health care professionals and

the Newborn Screening Program cannot accomplish this mission without support. Parents now have an opportunity, by completing and submitting the consent form, to help improve and expand newborn screening. This will benefit not only their own children, but future generations of Minnesotans. Amy Gaviglio, MS, CGC, certified genetic counselor, supervises the Shortterm Follow-up unit of the MDH Newborn Screening Program. Beth-Ann Bloom MS, CGC, and Sondra Rosendahl MS, CGC, are certified genetic counselors with the MDH Newborn Screening Program.

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MARCH 2013 MINNESOTA HEALTH CARE NEWS

POLICY

TOBACCO TAX UPDATE A high-stakes legislative issue By Molly Moilanen, MPP

Research shows there is one clear way to motivate smokers to quit and prevent young people from starting: Raise the price of cigarettes. Increasing prices on cigarettes is the top driver of smoking declines in our state and around the country. But Minnesota has fallen behind the pace in our cigarette taxation.

Tobacco in Minnesota: Still a problem Today, Minnesota’s adult smoking rate is 16 percent. That number may sound low compared to 20 years ago, and it is. But 16 percent still translates into 625,000 addicted Minnesota adults, and our kids are still using tobacco at alarming rates. The results are frightening. Each year 5,100 people die in our state from smoking and exposure to secondhand smoke. That’s more deaths than those resulting from alcohol, murders, car crashes, AIDS, drugs, and suicide— combined. And it isn’t happening by accident. Far from having been neutralized by regulations and lawsuits, tobacco companies are still spending millions targeting our kids. In Minnesota, 77,000 middle school and high school students are current tobacco users; they will buy or smoke 13.4 million packs of cigarettes this year. Further, the simple dollars and cents are a stark reminder of tobacco’s effects on our health care system and economy. Smoking costs Minnesota $3 billion per year in excess health care costs: This equals $554 for every man, woman, and child in the state, regardless of whether they smoke. Employers are adversely affected by smoking too. They end up paying the price through higher health insurance premiums and lost productivity of smoking employees, who are more likely than nonsmokers to miss work.

WHO’S GOT BETTER MOVES ON THE DANCE FLOOR, YOU OR ME? Every day is a reason for a person with Down syndrome to smile. And find joy in things the rest of us often overlook. To learn more about the richness of knowing or raising someone with such an enthusiasm for life, call your local Down syndrome organization. Or visit ndsccenter.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 30

MINNESOTA HEALTH CARE NEWS MARCH 2013

A clear solution

Facts about tobacco use in Minnesota

smoke, saving 47,700 of them from a life of addiction. It could save 25,700 Minnesotans from a premature death. The health-care cost savings are also enormous. In the next five years, fewer lung cancer cases would save the state more than $5 million, fewer smoking-affected pregnancies and births could save nearly $13 million, and fewer heart attacks and strokes could save more than $12 million. Minority populations and lowerincome Minnesotans are disproportionately affected by smoking and smokingrelated diseases. Native Americans have the highest lung cancer rates in Minnesota, and African American men and women are 30 percent to 40 percent more likely to die of lung cancer than their Caucasian counterparts. Meanwhile, for nearly 50 years the tobacco industry has directly marketed its products to minorities, with campaigns in recent decades targeting African Americans, Latinos, the LGBT community, and other communities. Tobacco tax increases drive quitting among all smokers, but especially among lower-income individuals, who are the most likely to benefit, both economically and in terms of health improvement, from any increase in the price of tobacco. Bringing down the smok-

• 5,100 Minnesotans die each year from smoking and exposure to secondhand smoke. • Minnesota’s 77,000 kids who are current tobacco users will buy or smoke 13.4 million packs of cigarettes this year. • Smoking costs Minnesota $3 billion per year in excess health care costs: $554 for every man, woman, and child in the state. • The price of tobacco has been found to be the single most effective tool for influencing smoking behaviors in the state. • In 2005, when the cost of a pack of cigarettes in Minnesota rose by 75 cents, one-fourth of thensmokers attempted to quit.

That’s the bad news. But there is good news, too. A new research study has taken the deepest-ever look into what tactics have successfully reduced smoking here in Minnesota. Funded by tobacco control nonprofit ClearWay Minnesota, the Minnesota SimSmokeModel examined data to learn what fueled the 27 percent decrease in smoking prevalence Minnesota experienced between 1999 and today. The results were clear. The price of tobacco was found to be the single most effective tool for influencing smoking behaviors in the state, responsible for 43 percent of smoking declines during the period studied. (Other helpful efforts included smoke-free policies, media campaigns, youth access laws, and cessation programs.) For example, in 2005 a health impact fee increased the cost of a pack of cigarettes in Minnesota by 75 cents, and motivated onefourth of then-smokers to attempt to quit. In 2009, a 62-cent federal tax increase on cigarettes flooded cessation programs with requests for help. QUITPLAN Services, the free cessation program provided by ClearWay Minnesota, saw a 150 percent increase in helpline volumes during the first week the tax took effect. Nationwide, the 2009 increase prevented 220,000 American youth from using tobacco in just the first two months after implementation. The Minnesota SimSmoke findings reinforced previous research from across the country showing that cigarette tax increases were among the most effective strategies for reducing smoking.

State cigarette taxes: Behind the times? Minnesota is a leader in health care in many regards. In 2012, the state celebrated the five-year anniversary of the monumental Freedom to Breathe Act, our strong smoke-free law. Minnesota is healthier because of this law, and support for it has grown, with an overThe price of whelming number of Minnesotans— nearly 80 percent—now supporting tobacco was the law. found to be Considering the strong public supthe single most port for health and policies that reduce youth tobacco use, it is surprising and effective very disappointing that our state has not tool for increased its own tax on cigarettes since influencing 2005. In fact, Minnesota’s tobacco tax smoking now ranks in the bottom half of states nationally. States that have increased behaviors tobacco taxes have seen steep declines in the state. in their smoking prevalence as a result. Minnesota should follow suit, but political dynamics and shifts at the Capitol have presented challenges.

Tobacco tax to page 32

In the next issue.. • Fish consumption • Blood banks • Bladder cancer

Benefits: Thousands of lives, millions of dollars Research has projected many public health benefits for Minnesota if we succeed in increasing the cost of tobacco products. A $1.50-perpack increase would result in 16 percent fewer kids starting to MARCH 2013 MINNESOTA HEALTH CARE NEWS

Tobacco tax from page 31

ing prevalence rate will have a particularly positive effect on these populations and give them a better chance at health. It is undeniable that quitting improves individuals’ quality of life and happiness. At ClearWay Minnesota, we have heard many stories from those who used our QUITPLAN programs and promotions to quit. One woman wrote of the joy of running her first-ever 5K race after quitting. Another happy quitter saved the money he would have spent on cigarettes and eventually was able to buy a camper with those savings. And by extending life and improving its quality, quitting smoking also gives individuals more and better time with their families and loved ones.

77,000 middle school and high school students will buy or smoke 13.4 million packs of cigarettes this year.

How can you help? Raising the price of cigarettes seems like common sense, but in the realm of public policy there are always challenges. You can help. I ask you to join the growing effort to make a new, significant tobacco tax increase in Minnesota a reality rather than a dream. There are many ways to do that. Consider communicating with your representatives at the Minnesota Legislature (to find contact information for your legislators, go to www.leg.state.mn.us/). At ClearWay Minnesota’s website, www.clearwaymn.org,

our Action Center provides suggestions and data for you to use in writing letters to lawmakers and the op-ed pages of newspapers. Raise it for Health (www.raiseitforhealth.org) is a coalition of leading health and nonprofit organizations that includes ClearWay Minnesota, Blue Cross and Blue Shield of Minnesota, the Minnesota Hospital Association, the Minnesota Medical Association, the Twin Cities Medical Society, the American Lung Association, the American Heart Association, the American Cancer Society Cancer Action Network and many others, who have banded together to reduce tobacco use in Minnesota and advocate for a tobacco tax increase of $1.50 per pack. The stronger these organizations are, the more effective they can be in this fight, so your active membership will increase their clout on this issue. The cost of doing nothing is too great—to our economy and to the health of our citizens. Please join us in asking our state leaders to support raising the tobacco tax. Molly Moilanen, MPP (Master of Public Policy), is the director of public affairs at ClearWay Minnesota and cochairs the Raise it for Health Coalition.

Minnesota

Health Care Consumer February survey results ... Association

1. I believe that state and federal government

23.53%

25 20 14.71%

11.76%

Agree

No opinion

Disagree

40 30

11.76%

11.76% 10 0

Strongly disagree

17.65%

20 5.88% Strongly agree

Agree

No opinion

Disagree

will encourage healthier behaviors.

20.59%

15 8.82%

29.41%

20 14.71% 8.82%

2.94% Agree

No opinion

Percentage of total responses

40 30 20

20.59%

17.65% 11.76%

8.82%

2.94% Disagree

Strongly disagree

MINNESOTA HEALTH CARE NEWS MARCH 2013

Strongly agree

Agree

No opinion

Disagree

Strongly disagree

5. I believe raising taxes on soda pop and energy drinks

41.18%

Strongly agree

44.12% Percentage of total responses

Percentage of total responses

Strongly agree

50 32.35%

14.71%

35.29%

Percentage of total responses

health care costs related to smoking.

40 35

52.94%

35.29%

4. I believe raising taxes on cigarettes will reduce

health care costs associated with gun violence.

health issue.

3. I believe limiting access to guns will reduce

2. I believe gun control is a serious public

can reduce health care costs through tax and regulatory initiatives.

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.

Strongly agree

Agree

No opinion

Disagree

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 2013 MINNESOTA HEALTH CARE NEWS

Mature drivers from page 15

Practice visual attention. Efficient visual scanning is essential for anticipating the need to stop quickly as a child approaches a crosswalk. With age, all of us tend to have a more difficult time dividing our visual attention between various parts of the visual field. New research has found that attention training can result in lowered crash risk and may delay the need for older adults to stop driving.

If self-assessment identifies only minor issues and the driver has no medical conditions, it can be beneficial to take several refresher lessons from a driving instructor. Research shows that driver education classes for older drivers result in reduced risk when combined with on-the-road refresher lessons. However, if self-assessment reveals more serious issues, consider a profesDriver education classes sional driving evaluation. Older drivers with a medical condition should choose a for older drivers certified driving rehabilitation specialist result in reduced risk. (CDRS) instead of a driving instructor. That’s because CDRSs—typically, specWhile this research used DriveSharp attention-training software, ially trained occupational therapists—can show drivers how to any regular activity that requires fast reaction to visual input, like address underlying losses of body function that may be linked to racquet sports or playing ball with grandkids, can help improve driving problems, such as loss of muscular control. Older drivers visual attention. should consult a physician about how any medical conditions they Decision-making. Driving safely also requires making approprihave could affect driving. ate decisions about when to drive and when to use other modes of Prevention maintains safety transportation. Since women typically outlive their driving era by 10 years and men by seven years, being comfortable walking or Stay healthy. Vision-friendly nutrition and regular eye checks help forestall chronic eye diseases. Regular physical activity is linked to a using buses and other transportation alternatives allows seniors to lower crash risk for older drivers. Since research has found that peo- continue participating in community life regardless of driving status. This facilitates independence and continued social engagement, both ple who have sustained falls are at increased risk for crashes, so important to mental and physical health. enrolling in an exercise program and/or a fall-prevention program can improve physical conditioning that, in turn, can help decrease both falls and crash risk. Engaging in physical activity that requires fast reactions, like racquet sports, has also been found to prevent the normal, age-related decline in reaction time.

Catherine N. Sullivan, PhD, OTR (Occupational Therapist), an associate professor at St. Catherine University, St. Paul, teaches occupational therapy and conducts research with older drivers.

When Alzheimer’s disease touches your life, turn to us. The Alzheimer's Association can help. The Alzheimer’s Association Minnesota-North Dakota Chapter is the premier source of information, support and hope for those with Alzheimer’s disease, their families and caregivers; and offers a broad range of programs and services state-wide, including: • 24/7 Information Helpline – 1.800.272.3900 • Family and Community Education • Support groups • Care Consultation • Professional Education • Advocacy • Research ® ® • Medic Alert + Safe Return

Make the first call for help 24/7 Information Helpline—1.800.272.3900 Visit us online - www.alz.org/mnnd

MINNESOTA HEALTH CARE NEWS MARCH 2013

• 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