Minnesota Health care News May 2011 by Minnesota Physician Publishing

Your Guide to Consumer Information

FREE May 2011 • Volume 9 Number 5

Asthma action plans Susan Ross, RN

Bicycling safety Michael Bluejay

Crohn’s disease Ronald Schwartz, MD

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CONTENTS

4 7 8

MAY 2011 • Volume 9 Number 5

16 18

NEWS

PEOPLE

PERSPECTIVE

MINNESOTA HEALTH CARE ROUNDTABLE

By Ronald M. Schwartz, MD

CALENDAR Huntington’s Disease Awareness T H I R T Y- S I X T H

SESSION

Gary Christenson, MD Midwest Arts in Healthcare Network

GASTROENTEROLOGY Crohn’s disease

10 QUESTIONS

By Paul E. Johnson, MD

Mark T. Zeigler Northwestern Health Sciences University

TAKE CARE 10 ways not to get hit by cars

22 24 28

Shared decision-making By Russel Kuzel, MD, MMM

What’s in a word? By Loree K. Kalliainen, MD

PULMONOLOGY Have asthma? Get an action plan By Susan K. Ross, RN, AE–C

By Michael Bluejay

SPECIAL FOCUS: PATIENT-PROVIDER RELATIONSHIPS Cooling the hot spots

WOMEN’S HEALTH When you’re certain your family is complete ... By Christine Sarkinen, MD

HOSPITALS Reducing hospital readmissions By William Nersesian, MD, MHA, Barry Baines, MD, and Becky Schmidt, RN–BC

www.mppub.com PUBLISHER Mike Starnes mstarnes@mppub.com EDITOR Donna Ahrens dahrens@mppub.com

Accountable Care Organizations Accountable to Whom? Thursday, October 13, 2011 1:00 – 4:00 PM • Duluth Room Downtown Mpls. Hilton and Towers

Background and focus: Created as part of national health care reform, accountable care organizations (ACOs) are now part of every health care policy discussion. As defined by the 111th Congress, ACOs are organizations that include physicians, hospitals, and other health care organizations with the legal structure to receive and distribute payments to participating physicians and hospitals to provide care coordination, invest in infrastructure and redesign care processes, and reward high-quality and efficient services.

Exactly what this means is unclear, and a confusing array of levels and qualifications for ACOs has been proposed. With 2012 as a start date for Medicare reimbursement through ACOs, Congress is developing firm definitions at this time. Some say ACOs turn physicians into insurance companies; others say they are a way for physicians to take a leadership role in fixing a broken system. As health care organizations race to join, create, or redefine themselves as ACOs, they all face more questions than answers. Objectives: We will review the history, goals, and rationale behind the ACO model. We will review the latest federal guidelines defining what an ACO can be. We will discuss how the ACO will affect health insurance companies, employers, and the pharmaceutical industry. We will illustrate what must not be allowed to happen if the model is expected to succeed. We will examine who decides if ACOs are successful and how those decisions will be made. We will explore why so many people, representing very different perspectives on health care, are opposed to the idea and what can be done for it to achieve its best potential.

ASSOCIATE EDITOR Martha Malan mmalan@mppub.com ASSISTANT EDITOR Scott Wooldridge swooldridge@mppub.com ART DIRECTOR Elaine Sarkela esarkela@mppub.com OFFICE ADMINISTRATOR Juline Birgersson jbirgersson@mppub.com ACCOUNT EXECUTIVE John Berg jberg@mppub.com ACCOUNT EXECUTIVE Sharon Brauer sbrauer@mppub.com

Please send me tickets at $95.00 per ticket. Mail orders to Minnesota Physician Publishing, 2812 East 26th Street, Minneapolis, MN 55406. Tickets may also be ordered by phone (612) 728-8600 or fax (612) 728-8601. Name Company Address

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Minnesota Health Care News is published once a month by Minnesota Physician Publishing, Inc. Our address is 2812 East 26th Street, Minneapolis, MN 55406; phone (612) 728-8600; fax (612) 728-8601; e-mail mpp@mppub.com. We welcome the submission of manuscripts and letters for possible publication. All views and opinions expressed by authors of published articles are solely those of the authors and do not necessarily represent or express the views of Minnesota Physician Publishing, Inc., or this publication. The contents herein are believed accurate but are not intended to replace medical, legal, tax, business, or other professional advice and counsel. No part of this publication may be reprinted or reproduced without written permission of the publisher. Annual subscriptions (12 copies) are $36.00. Individual copies are $4.00.

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MAY 2011 MINNESOTA HEALTH CARE NEWS

NEWS

Health Groups Join To Promote ACA A new group has been formed to advocate for preserving the health care reforms enacted by the Affordable Care Act (ACA). The Minnesota Patient Advocacy Coalition is a coalition of health care groups that support specific reforms that the ACA put into law, such as prohibiting insurance companies from dropping people because of pre-existing conditions, ending annual limits or lifetime restrictions on coverage, and guaranteeing coverage for preventive care. The coalition consists of 16 groups, including AARP, the American Cancer Society Cancer Action Network, the American Heart Association, and the National MS Society Minnesota Chapter. Matt Schafer, spokesman for the coalition, says the group seeks to be a voice for patients at a time when health care reform remains controversial. “There are coalitions for providers and for health insur-

ance companies, but I don’t know that there is an advocacy coalition that focuses exclusively on the patient,” Schafer says. The member groups share a belief that the ACA is good for the patients and families they represent, and they felt they needed to stand up and say so, he adds. “We have gone far too long in not telling our side of the story and we collectively made a decision amongst our organizations that it was time to do that,” Schafer says. “The media portrays the reforms as too complicated. To us, we looked through the health insurance reforms and said, ‘No, these are pretty simple, and we want them to remain in law.’”

MDH Urges Parents To Keep Children’s Vaccinations Current Minnesota health officials are urging parents to make sure their children are up to date on basic vaccinations after several cases

MINNESOTA HEALTH CARE NEWS MAY 2011

of measles were found among children in the metro area. The news comes on the heels of a report that found a significant drop in rates of vaccination for children in Minnesota. The report, released on March 8 by Children’s Hospitals and Clinics of Minnesota, found the state had dropped sharply in some areas of vaccinations, due in some cases to myths and misinformation that led parents to decide against vaccinating children. The latest cases include several Somali children who had not been vaccinated because of parental concerns about the vaccination for measles, mumps, and rubella (MMR). Officials with the Minnesota Department of Health (MDH) say in recent years the Somali community has seen a drop in MMR vaccinations because of concerns about safety. “Contrary to misinformation that may still be circulating, the measles vaccine is safe and effective. Without it, the risk of disease is real. Children can die from

measles,” says Edward Ehlinger, MD, Minnesota commissioner of health.

Senate Votes to Cut Health Care Spending The Minnesota Senate passed a health and human services omnibus bill last week that would reduce spending by $1.6 billion, remove more than 100,000 Minnesotans from public health coverage, and cut a wide range of health-related programs. The budget passed on March 30 on a party-line vote, with Republicans hailing it as an approach to health care reform that emphasizes individual choice and DFL members blasting it as unrealistic and harmful to the state’s most vulnerable populations. “The state’s budget deficit is a strong signal in itself that the Legislature needs to place its focus on reform from government regulation of the health care industry to a more incentivebased approach by implementing

consumer-friendly policies like tax deductions or health savings accounts,” says Sen. David Hann (R-Eden Prairie), chair of the Senate Health and Human Services Committee. “I certainly do not believe that any meaningful reform or change will be achieved by implementing more intrusive government policies into the health care industry.” Health groups such as the Minnesota Medical Association and the Minnesota Hospital Association (MHA) were quick to criticize the Senate’s approach to health care reform. MHA President and CEO Lawrence Massa said the Republican plan would seriously diminish access to care in the state, while further straining the health care infrastructure. “Cutting health care coverage is the worst thing you can do in an economy that is still teetering on the edge,” he says. “People will still get sick and will be forced to access care in the ER, which is the most expensive place to get care.”

Hospital Rankings Focus on Specialties U.S. News & World Report, known for its annual ranking of best hospitals in the country, has introduced a new ranking system for hospitals serving metro areas. The new report uses the magazine’s annual rankings of specialties at hospitals to determine rankings for metro area hospitals. Metro hospitals are ranked first by a hospital’s number of nationally ranked specialties and then by the number of other specialties in which it was among the top 25 percent nationally. U.S. News & World Report notes that this methodology is most helpful in directing a patient toward the best care for his or her particular condition. “The No. 1 hospital in a metro area is not necessarily the best in town for all patients,” says Avery Comarow, senior writer for the magazine. “Other hospitals may outshine it in various spe-

cialties. We expect that savvy consumers will consider not merely a hospital’s overall rank in the metro area, but its expertise in the specialty relevant to their care.” In the Twin Cities area, the magazine’s top-rated hospital is University of Minnesota Medical Center, Fairview. The rest of the top 10 are, in order: Abbott Northwestern Hospital, Hennepin County Medical Center, United Hospital of St. Paul, Fairview Southdale Hospital, North Memorial Hospital, Regions Hospital, Unity Hospital, St. Joseph’s Hospital, and Fairview Ridges Hospital. The top-ranked children’s hospitals in the metro area are University of Minnesota Amplatz Children’s Hospital, Children’s Hospitals and Clinics of Minnesota, and Gillette Children’s Specialty Healthcare.

Health Plans, Dayton Agree on Plan to Cap Profits in 2011

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In an unprecedented move to respond to pressure from lawmakers, the state’s private health plans have agreed to cap their profits on the public health insurance programs they administer. The plans have been under a spotlight for making profits on public plans at a time of large state budget deficits, and both the Legislature and Gov. Mark Dayton have moved forward with measures to increase scrutiny on health plan finances. Dayton, with the use of executive orders and the regulatory power of the state’s Department of Human Services (DHS), has taken the lead, negotiating directly with plans about returning some of the $3 billion they annually receive from the state to provide health insurance to low-income Minnesotans. After UCare’s announcement that it would return $30 million to the state, Dayton called on other plans to follow suit. Following an April 1 report on health plan News to page 6 MAY 2011 MINNESOTA HEALTH CARE NEWS

News from page 5 financials, which showed insurance companies making a 3.8 percent profit on public plans in 2010, the health plans quickly announced an agreement with Dayton on capping profits in 2011. On April 5, Dayton announced an agreement with Blue Cross and Blue Shield of Minnesota, HealthPartners, Medica, and UCare to place a 1 percent cap on profits for state plan managed-care contracts in 2011. Any amount over 1 percent that the plans earn will be returned to the state, officials say. Dayton and DHS Commissioner Lucinda Jesson say that after 2011, other new measures will help ensure better oversight of public plan finances. In March, Dayton put in place a new competitive bidding process for health plans, along with other new regulations. “Our managed care reforms will result in purchasing better care at better prices in the future,” says Jesson. “In the short

term, we have a budget challenge and I appreciate our state health plans helping to address that shortfall.”

Health Reform Law Still Controversial One Year Later A year after the Affordable Care Act (ACA) was signed into law, statements from Minnesota’s congressional delegation show the health reform law remains deeply controversial. In Minnesota, the biggest impact of ACA has probably been the Medicaid expansion that Gov. Mark Dayton set in place, providing expanded coverage for low-income Minnesotans. The program will cover approximately 95,000 Minnesotans, create 20,000 health care jobs, and reduce costs because of federal matching funds, according to state estimates. Private health plans in Minnesota have had to adjust to new regulations about pre-

existing conditions and other coverage requirements, and Minnesota’s medical device manufacturers are bracing for new taxes on medical technology. As the law is phased in over the next three years, other parts of the reform, such as health insurance exchanges, will also have an impact. Beyond the nuts and bolts of implementing new regulations, politicians continue to argue about nearly every aspect of the sweeping law. The new Republican majority in the state Legislature has jumped into that debate as well, proposing laws that would cancel the Medicaid expansion or require Minnesota to join lawsuits against ACA. But the biggest critics of ACA remain the state’s two most visible Republican congressional representatives. Rep. Michele Bachmann regularly assails the law as a government takeover of health care, and Rep. John Kline, chair of the House Education and Workforce Committee, has called for a full repeal of the law.

“Health care ‘reform’ shouldn’t take away coverage from Minnesotans who like what they have,” Kline says. “It shouldn’t force private-sector job creators to lay off workers because they can’t afford to provide health care coverage. And it shouldn’t put federal bureaucrats in charge of what procedure is covered and what medication is not.” Sen. Al Franken, a Democrat, offers the pro-ACA perspective. “In its first year, the ACA has made it easier and cheaper for people all over the country to get quality health care,” he says. “It prevents insurers from cutting off coverage because of lifetime caps and from denying coverage to children who have pre-existing conditions. In Minnesota alone, 16,000 young adults are now eligible for their parents’ health insurance and nearly 100,000 small businesses are eligible for tax credits to help them cover their employees.”

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MINNESOTA HEALTH CARE NEWS MAY 2011

PEOPLE John Chang, DO, recently joined St. Luke’s (Duluth) Internal Medicine Associates. Chang is

Cataract Specialists

a nocturnist, ensuring that patients continue to receive quality care throughout the night while at St. Luke’s Hospital. Chang received his medical degree from the University of North Texas Health Science Center in Fort Worth. He completed his residency in internal medicine and served as John Chang, DO

chief resident at United Health Services Wilson

Medical Center in Johnson City, N.Y. Prior to joining St. Luke’s, Chang was clinical assistant professor of medicine at the University of New England College of Osteopathic Medicine and director of the Samaritan Medical Center Hospitalist Program. Chang is board-certified in

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

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Arlington Blaine Bloomington Maplewood

James Donovan, MD, family practice physician at Miller Creek Medical Clinic, a St. Luke’s clinic in Hermantown, has been named a diplo-

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mate of the American Board of Bariatric Medicine (ABBM). The ABBM is an independent

James Donovan, MD

medical specialty board responsible for certifying physicians in the field of bariatric medicine, a medical specialty involved in treating obesity and its related comorbidities. Jeffrey Mackner, OD, has been elected president of the Minnesota Optometric Association (MOA). Mackner is a partner in Minnesota Eyecare Network, Inc., which has offices in Pelican Rapids, Perham, Wadena, Long Prairie, and Barnesville, Minn. Mackner has practiced optometry for 21 years and has been active on the MOA board of trustees since 2006. The MOA board also elected the following officers for 2011: president-elect, Teresa Theobald, OD, Theobald Family Eye Care, LLP, Duluth; vice president, Jonathan Schorn, OD, Focused Eye Care, Lakeville; and treasurer, Larry Morrison, OD, Morrison Eye Care, Detroit Lakes. Two new trustees were also elected: Mary Gregory, OD, Uptown Eye Care, Monticello, and Viktoria Davis, OD, Madelia Optometric, Madelia. Sally Buck, associate director at the Duluthbased National Rural Health Resource Center, has been selected as one of 12 rural health fellows by the National Rural Health Association (NRHA). The fellows participate in a year-long, intensive program aimed at developing leaders who can Sally Buck

articulate a clear and compelling vision for rural

America. Fellows receive training and skill-building in the areas of personal, team, and organizational leadership; health policy analysis and advocacy; and NRHA governance and structure. Buck has been with the center since 1993 and is responsible for new program development, internal operations, and preparing grant and contract pro-

Cataracts A cataract is a clouding of the eye’s natural lens that inhibits or diminishes the passage of light to the retina. Cataracts progress at different rates and can affect one or both eyes at the same time. When a cataract develops, a patient may wish to have it surgically removed. The surgery is performed as an outpatient procedure under local anesthesia and takes approximately 10-20 minutes. Once the cataract has been removed, a new clear lens, called an intraocular lens implant (IOL) is put in place of the natural lens. Most patients return to their normal work or lifestyle in a day or two. Cataract surgery is one of the most common and successful surgical procedures performed today. Many patients report vision that is even better than before they developed cataracts, especially with the optional newer implant that often eliminates the need for close vision glasses after surgery. New alternatives for treatment In choosing an intraocular lens for cataract surgery, you have several options. Speak with your family eye doctor and your surgeon to determine which is best for your eye and your lifestyle.

posals. She facilitates state and national health-care work force forums, including health information technology; consults with other state offices of rural health in designing rural recruitment programs; and conducts health professional demand analyses. Shyanne McGregor, DPT, has joined Orthopaedic Associates of Duluth as a physical therapist. McGregor specializes in orthopedic, sports medicine, and manual techniques, as well as treatments for back and cervical injuries. McGregor earned a doctorate in physical therapy from the College of St. Scholastica and is pursuing an addi-

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PERSPECTIVE

Medicine and art, a healing blend Creative expression benefits mind, body, spirit

Gary Christenson, MD Midwest Arts in Healthcare Network

Gary Christenson, MD, is director of mental health at Boynton Health Service on the Twin Cities campus of the University of Minnesota. He is an adjunct associate professor of psychiatry in the University of Minnesota Medical School and a Distinguished Fellow of the American Psychiatric Association. Christenson is co-chair of the Midwest Arts in Healthcare Network as well as a board member and president-elect of the Society for the Arts in Healthcare. He is also a selftaught painter with an emphasis on portraying the landscapes of northernmost Norway.

t the dawn of medicine, healers possessed few effective remedies for disease. Treatment relied on a heavy dose of ritual, and outcomes depended more on the natural course of illness (which often resolved on its own or resulted in the patient’s death), the patient’s belief, and the influence of techniques that we are now more likely to call art than medicine. These included elements of story, dance, music, and drama.

often lost in the hospital environment. Music has also been found to be a useful adjunct to patient care. For example, a recent study demonstrated a marked reduction in the requirement for both sedation and nurse attention if children were allowed to choose and listen to music during diagnostic procedures. Not only does this improve the child’s comfort, but the potential cost savings over time are substantial.

Continued advances in effective treatments such as vaccinations, antibiotics and other pharmaceuticals, and surgical procedures define modern medicine. But such progress may have come with a cost. The house call has become nearly extinct, the ceremony of healing has been replaced by procedures and protocols, and our medical centers are prone to be easily viewed as sterile treatment machines. As we advanced the “art of medicine,” we almost lost the “art in medicine,” an important clinical tool that can benefit our patients.

Artists can be found more and more often at the bedside. Art-making is an incredibly strong tool that allows patients to express their feelings, gain a sense of control, and distract them from or, alternatively, help them face their fears about illness. Bedside musicians can reduce patient stress and anxiety. Music has also proved to be a powerful tool for specific medical conditions. For example, patients with strokes at times can communicate through song even when their normal speech is impaired. Dance and movement likewise have been utilized to increase range of motion, strength, and coordination in a variety of neurological and musculoskeletal disorders, including Parkinson’s disease and fibromyalgia.

Artists at the bedside

As we advanced the “art of medicine,” we almost lost the “art in medicine.”

Fortunately, we are witnessing a resurgence of interest in a more holistic approach to healing that includes the reintroduction of the arts as an adjunct to medical treatment. A growing body of research supports such efforts, and several organizations, such as the internationally based Society for the Arts in Healthcare (www.thesah.org) and the local Midwest Arts in Healthcare (www.maihn.org), have established themselves as networks to bring artists, creative arts therapists, physicians, nurses, administrators, and others together to discuss, research, and promote the use of art in health care. A healing environment

The environment in which health care is provided has been one of the major focuses of the arts in health care movement. Appropriate design is essential not only for effective and efficient treatment but can also be healing in itself. For example, it has been demonstrated that a room with a view to nature results in decreased use of pain medication by patients as well as shorter hospital stays. Furthermore, research has demonstrated that even the artistic representation of nature can reduce patients’ discomfort. Hospitals are taking such research to heart and selecting healing imagery for patient rooms. Many hospitals have adopted art carts that bring art directly to patients to make their own selections. Through this process, patients not only benefit from the healing effects of the art, but also regain a sense of control that is

MINNESOTA HEALTH CARE NEWS MAY 2011

Creative art therapies combine the power of the arts with talk therapy. The creative art therapies include music therapy, art therapy, dance and movement therapy, as well as therapies that use poetry, writing, or drama as their central creative medium. They are increasingly being used as another approach to explore patients’ emotions and thoughts. Art in medical education Art is also finding its way into medical education. Literature has been used for years to introduce medical students to topics such as the patient experience and medical ethics. More recently, drama and the visual arts have been used. One fascinating study found that medical students trained in fine art concepts and art observation also demonstrated improvement in their visual diagnostic skills. The arts, be they visual, musical, literary, dance, or drama, tap into the highest creative, mental, and physical capabilities of the human body. It makes sense that they can also be employed to promote healing. Patients can only benefit from the continued recognition of the arts as an important tool in health care.

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10 QUESTIONS

& Mark T. Zeigler, DC Dr. Zeigler is president of Northwestern Health Sciences University in Bloomington. What is chiropractic? It’s a health care profession that focuses on disorders of the neuromusculoskeletal system and the nervous system and the effects these disorders have on general health. Doctors of chiropractic practice a drug-free, hands-on approach to health care that includes patient examination, diagnosis, and treatment. Chiropractors have broad diagnostic skills and they’re also trained to recommend therapeutic and rehabilitative exercises as well as to provide nutritional, dietary, and lifestyle counseling and coaching. Please tell us about the education, ongoing training, and licensure for chiropractors. To enroll in our program, a student must have 90 credit hours of undergraduate coursework heavily weighted to the sciences. We divide our program into 10 trimesters over three-and-a-half years. The first half focuses on the basic sciences, the latter on clinical experiences. Students must pass four national board tests and competency exams before they can be licensed to practice by a specific state. Each state also requires chiropractors to complete continuing education hours for relicensure. In Minnesota, the requirement is 20 hours of continuing education per year. What conditions do chiropractors treat? Primarily low-back pain, neck pain, headache, radicular pain in the arms or legs, chronic disorders such as arthritis, and degenerative diseases. But our emphasis is on wellness and prevention. We take a very proactive approach in educating patients on how to make lifestyle changes in order to stay healthy. Please tell us about chiropractic subspecialties. We have master’s degrees in radiology. The profession also has master’s degrees in clinical nutrition, orthopedic and sports rehabilitation, public health. Right now at our institution we have seven candidates for PhDs in education and research. Why does chiropractic care often require multiple treatments? Sometimes it does and sometimes it doesn’t. In general, the average treatment may require anywhere from four to eight visits. When you have an acute low-back pain problem, you’re generally dealing with the pain and inflammation. Once that subsides over two or three days, then you can start working on addressing the problem and correcting the underlying issue, along with health coaching so that the patient can take care of himself so he doesn’t have an injury or aggravate the problem. It’s really about taking care of the whole person.

Photo credit: Bruce Silcox

MINNESOTA HEALTH CARE NEWS MAY 2011

How is chiropractic care becoming more integrated into traditional medical practice? The shift in today’s health care environment is toward integration. It requires all providers to look at how to practice smarter in a care delivery system that is different from the past. We need to have shared decision-making and look at patient preferences and the best evidence. That requires an integrated approach to addressing patient problems. I think traditional medicine is taking a step back. Medicine today is a broken system. That’s why at the federal level they’re taking an entire new look at the system. I think medicine is shifting more to our point of view: How can we encourage patients to make better choices in their health care and lifestyles? How do we address cardiovascular disease, obesity, diabetes, musculoskeletal problems? They’re an incredible economic drain on our society, and it requires us to take a different look at how we approach health care, collectively.

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I think medicine is shifting more to our point of view: How can we encourage patients to make better choices in their health care and lifestyles?

What are the barriers to access to chiropractic care? In today’s marketplace, the insurance industry creates a major barrier. In most cases, you’ll see all major insurers cover chiropractic care. But it’s how they cover it—with higher copays. Another barrier is lack of good information. I think it’s important for us in the health care environment to be clear about what is efficient and effective in providing the best care possible for different conditions—good information consumers can draw on to make decisions about their health. And, to a certain extent, public policy. We’re starting to make inroads into the Department of Defense, into the Veterans Administration, expanding Medicare coverage, but it’s been a long journey. What factors should patients consider when selecting a chiropractor? When you look at any health care provider, it’s about personal relationships. Credentials, training, experience, ethics play a role. In some cases, location, convenience. What kind of resources do they have to provide the best care possible? Do they have the relationships to support the care I might need? You want somebody who can evaluate a condition and say, “These are your best options. You need to be part of this decision-making. Let’s do a shared discussion about what’s the best treatment for you.”

What are some common misperceptions about chiropractic care? That once you go, you always have to go. That’s not true at all. What people find is that it’s a profession aligned with making healthy choices and healthy decisions, so it almost becomes a part of your lifestyle, rather than me as a chiropractor saying you need to come back. Sometimes I think we have an identification problem. When should I go to a chiropractor? In particular, when you’re dealing with low-back pain, neck pain, and sometimes chronic pain, you should see a chiropractor first. For those patients, outcomes are better, patient satisfaction is higher, and they’re saving money in the long run. Clearly, the body of research today supports that. What message do you have for our readers about chiropractic care? Chiropractic isn’t alternative anymore—it’s a first choice when it comes to dealing with some very important physical and economic problems of our society. Consumers are now spending more money on alternative and complementary health care than they are on traditional medicine. Given those numbers, spend your money where you can spend it wisely. Seek out the best care possible. In instances such as back pain and other neuromusculoskeletal problems, chiropractic care is the best choice. It can provide you with solid information not only for taking care of those problems, but for making good, solid, smart choices for a healthy lifestyle.

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TA K E C A R E

10 ways NOT to get hit by cars For bicyclists, prevention is paramount By Michael Bluejay

inneapolis (officially, and St. Paul by proximity) proudly bears Bicycling magazine’s designation as the nation’s Best Bike City. No other city can hold a candle to our hard-core bikers who pedal relentlessly through the snow and ice of winter and the potholes of spring. For thousands of summer cyclists, though, now is the start of the season. For these casual cyclists, we present a refresher course to help you avoid unpleasant encounters with the cars, trucks, and motorcycles that are sharing your streets and highways. A requisite starting point is the helmet. Wear one. If you are in an accident, it may save your life. Beyond preparing for the worst, though, is preventing the worst. Here are 10 of the most common scenarios for car-bike collisions, along with advice on how to avoid them.

1 The Right Cross A car is pulling out of a side street, parking lot, or driveway on the right. Either you’re in front of the car and the car hits you, or the car pulls out in front of you and you slam into it.

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MINNESOTA HEALTH CARE NEWS MAY 2011

How to avoid this collision: If you’re riding at night, you should absolutely use a headlight. It’s required by law. Even during the day, a bright white light in flashing mode can make you more visible to motorists. Helmet-mounted lights are the best, because you can look directly at drivers to make sure they see your light. Honk. Get a loud horn and use it whenever you see a car approaching (or waiting) ahead of you and to the right. If you don’t have a horn, then yell “Hey!” Some states require bells on bicycles; Minnesota is not among them. Slow down. If you can’t make eye contact with the driver, slow down so much that you’re able to stop completely if you have to. Where possible, ride further left. You’re probably used to riding very close to the curb, because you’re worried about being hit from behind. But that driver on the right isn’t looking in the bike lane or the area closest to the curb; he’s looking in the middle of the lane, for other cars. The farther left you are, the more likely the driver will see you. If the motorist doesn’t see you and starts pulling out, you may be able to go even farther left, or to speed up and get out of the way before impact, or to roll onto their hood as they slam on their brakes. In short, it gives you some options. But if you stay all the way to the right and they pull out, you may have no choice but to run right into the driver’s side door. Riding to the left does make you a little more vulnerable to the cars behind you. But you’re far more likely to get hit by a car at an

intersection ahead of you that can’t see you than by a car behind you that can see you clearly.

The Door Prize A driver opens his door right in front of you. You run right into it if you can’t stop in time. How to avoid this collision: Ride far enough to the left that you won’t run into any door that’s opened unexpectedly. You’re more likely to get doored by a parked car if you ride too close to it than you are to get hit from behind by a car that can clearly see you.

In 2009, the most recent year for which figures are available, 630 bicyclists were killed in traffic accidents on U.S. roads. Ten of those fatalities occurred in Minnesota. —National Highway Traffic Safety Administration

3 The Crosswalk Slam Riding on the sidewalk, you cross the street at a crosswalk. A car makes a right turn, right into you. Drivers aren’t expecting bikes in the crosswalk, so it’s very easy for you to get hit this way. Studies have found sidewalk-riding to be significantly more dangerous than road riding. How to avoid this collision: Don’t ride on the sidewalk. In addition to the possibility of being hit by turning cars, you are also vulnerable to cars pulling out of parking lots or driveways. And you pose a danger to pedestrians.

The Wrong-Way Wreck You’re riding against traffic, on the left-hand side of the street. A car turns right from a side street, driveway, or parking lot, right into you. They didn’t see you because they were looking for traffic only on their left, not on their right. Even worse, you could be hit by a car coming at you from straight ahead. They have less time to see you and take evasive action because you’re going towards them rather than away from them. And if they hit you, it’s going to be a much more forceful impact, for the same reason.

The Right Hook, Part 1 A car passes you and then tries to turn right directly in front of you, or right into you. They think you’re not going very fast just because you’re on a bicycle. This kind of collision is hard to avoid because you typically don’t see it until the last second, and because there’s nowhere for you to go when it happens. How to avoid this collision: Don’t ride on the sidewalk. When you come off the sidewalk to cross the street, you’re invisible to motorists. Ride to the left, making it harder for drivers to pass you to cut you off or turn into you. Glance in your mirror—a necessary piece of equipment, mounted on your handlebar or helmet—well before you get to an intersection.

The Right Hook, Part 2 You’re passing a slow-moving car (or another bike) on the right, when it unexpectedly makes a right turn right into you. How to avoid this collision: Don’t pass on the right. Look behind you before turning right to make sure a bike isn’t trying to pass you. This is an opportunity to avoid hitting cyclists who violate tip No. 1 above and try to pass you on the right. (Also remember that they could be coming up from behind you on the sidewalk while you’re on the street.) 10 ways NOT to get hit by a car to page 34

How to avoid this collision: Don’t ride against traffic. It’s illegal and it’s dangerous.

5 Red Light of Death You stop to the right of a car that’s already waiting at a red light or stop sign. They can’t see you. When the light turns green, you move forward, and then they turn right—into you. How to avoid this collision: Don’t stop in the blind spot. Stop BEHIND a car, instead of to its right. This makes you very visible to traffic on all sides. If you are in front of a car or line of cars at a stoplight, then ride quickly to cross the street as soon as the light turns green. If you are behind one car and in front of another, DON’T pass the car in front of you when the light turns green—stay behind it. If it doesn’t make a right turn right away, it may unexpectedly turn right into a driveway or parking lot. Don’t count on drivers to signal. Assume that a car can turn right at any time and NEVER pass a car on the right. Stay ahead of the car behind you until you’re through the intersection; otherwise, they might cut you off as they turn right.

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WOMEN’S HEALTH

When you’re certain your family is complete …

Micro-inserts deliver permanent birth control By Christine Sarkinen, MD

Leg Pain Study Do your legs hurt when you walk? Does it go away when you rest? Or, have you been diagnosed with PAD? You may have claudication, caused by lack of blood supply to the leg muscles The University of Minnesota is seeking volunteers to take part in an exercise-training program, funded by the National Institutes of Health

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

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

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MINNESOTA HEALTH CARE NEWS MAY 2011

ne of the most common reasons a woman visits her gynecologist today is to discuss her choices for birth control. As a gynecologist and advocate for women’s health, I feel that offering safe and effective birth control is just as important as performing screening procedures such as Pap tests and mammograms. Fortunately, there are several options for putting a woman in charge of her fertility and, ultimately, her life. An overview of alternatives Barrier methods such as condoms, spermicides, and diaphragms are still used but not reliably effective in preventing pregnancy. In addition, they can be messy, cumbersome to use, and often forgotten. Hormonal options include injections, implants, pills, patches, and rings. Hormones can be a very effective way to prevent pregnancy, but some people are unable to use certain hormones due to various medical conditions. Also, the potential for significant variation in the way a patient uses hormones can result in unintended pregnancy. IUDs (intrauterine devices) are small, T-shaped objects that, when placed in a woman’s uterus, effectively prevent pregnancy for five to 10 years. Finally, permanent options include tubal ligation, vasectomy for men, and micro-inserts that go into a woman’s Fallopian tubes to block the fertilization of her eggs. Tubal ligation, in which the Fallopian tubes are surgically tied, was first performed in the United States in 1880. It became popular during the sexual revolution of the 1960s and today about 700,000 are performed annually in the U.S. However, tubal ligation is not without risk. It is a surgical procedure done in the operating room. It requires general anesthesia and insertion of a tube into the patient’s airway, and there is risk of injury to vital structures including bowels, bladder, and large blood vessels. In addition, there is risk of wound infection. Recovery usually takes three to five days, sometimes longer. As for vasectomy, the male birth control procedure, I see dozens of women who have been waiting literally for years for their partner to go in for vasectomy. Unfortunately, many unplanned pregnancies occur in this time. Again, as with any surgical procedure, there is risk involved— namely, bruising, pain, swelling, and infection. Vasectomy requires a few days’ recovery time. Permanent birth control with micro-inserts The Food and Drug Administration (FDA) has approved two microinsert devices, Essure and Adiana, for permanent birth control. In my practice, I work with Essure, which in 2002 became the first microinsert to be approved for use in the United States. The most effective form of birth control available, it is a safe, simple, in-office procedure that can be performed quickly and gently, usually in less then 10 minutes. Because it is done in the office setting, women will avoid anesthesia, incisions, and time spent in the hospital. Mild cramping that often accompanies the procedure dissipates for most women in no more than two or three hours. Before micro-inserts, the only permanent choice for women was tubal ligation, which has a higher failure rate. Most women, given the choice, would prefer to avoid a trip to the operating room and the associated risk and cost it brings. Cost comparison of procedures can be difficult, but broadly speaking, tubal ligation is the most expensive permanent birth control. The cost, which ranges from $3,000 to $6,000, is high because it

is performed in the operating room. Both vasectomy and micro-inserts are performed in the office, so the price is less—anywhere from $800 to $1,500 for vasectomy, $1,500 for inserts.

With a pregnancy-preventing effectiveness rate of almost 100 percent, micro-inserts are the most effective option available for permanent birth control.

Insertion procedure

Risks with micro-inserts

Inserts are placed just after a woman’s period. This will optimize the physician’s view of the opening to the Fallopian tubes and reduce the risk of undiagnosed pregnancy. During this simple procedure we gently place a tiny camera through the patient’s vagina and cervix into her uterus, so that we can visualize the openings to the Fallopian tubes. We then place soft, flexible inserts into the tubes. These inserts are made from polyester fibers and metals that have been used successfully for more than 20 years in heart stents and other medical devices. Most women report the cramping associated with the procedure is no worse than menstrual cramps. Over about three months, the patient’s body heals around the inserts. The resulting scar tissue forms a natural barrier that will prevent sperm from reaching an egg. During the three months following the procedure, a patient must continue to use another form of birth control. At the end of three months, a simple x-ray test verifies that the inserts are in place and that the tubes are successfully blocked, giving a woman peace of mind that her birth control is effective and reliable. With a pregnancy-preventing effectiveness rate of almost 100 percent, inserts are the most effective option available and the only female option that confirms it is in fact working. Over 500,000 procedures have been performed with outstanding patient satisfaction. Because micro-inserts are also hormone-free, they are safe for almost everyone and do not disrupt the body’s natural menstrual cycle.

Micro-inserts are a low-risk, highly effective option. As with any procedure, patients should be aware of potential risk. People who have a nickel allergy or an allergy to x-ray contrast mediums are not candidates for the procedure. Not all women are able to have two inserts successfully placed, and not all tubes will be blocked at three months. As with any tubal procedure, if pregnancy does occur there is increased risk for ectopic (tubal) pregnancy. In addition, it is possible that the inserts could be expelled or perforate through the Fallopian tube. Long-term problems are minimal, but reports show back and abdominal pain as potential risks. A thorough discussion with one’s health care provider can clarify the risks and benefits of each option, so that the patient will be able to make an informed decision. A simple option for permanent protection A safe, permanent procedure that can be done in the office setting gives women the ability to take charge of their fertility. Another very practical consideration for the modern woman is the financial aspect. Paid for by most insurance providers, not only are micro-inserts generally safe and effective, they are also cost-effective. Depending on insurance coverage, for most women the procedure costs no more than an office copay and a few hours away from work or home. Christine Sarkinen, MD, is an obstetrician/gynecologist at Oakdale Obstetrics & Gynecology in Maple Grove and Plymouth.

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MAY 2011 MINNESOTA HEALTH CARE NEWS

GASTROENTEROLOGY

Causes of Crohn’s disease

Crohn’s

disease For these patients, “routine” preventive care is anything but By Ronald M. Schwartz, MD

rohn’s disease is a chronic inflammatory condition of the digestive tract that can affect the mouth, stomach, small intestine, colon, and anus. Sometimes, other organs can be involved, resulting in inflammation of the skin, joints, eyes, or respiratory system. Crohn’s disease afflicts more than 700,000 Americans. Up to 20 percent of those with the disease are diagnosed before the age of 18. While the disease is lifelong and there is no known cure, a number of medical treatment options exist. Many of the most effective treatments have become available in the last decade, revolutionizing the treatment of this condition.

The exact cause of Crohn’s disease is unknown, but the best explanation to date is that an individual has to have a specific genetic makeup predisposing him or her to the disease. That, coupled with an environmental trigger (perhaps an infection), causes a chronic and persistent inflammation, most typically in the lining of the intestines. Interestingly, some individuals may have the genetic makeup to develop Crohn’s disease, but never get the disease because they are never exposed to a trigger. An example of this is when an identical twin develops Crohn’s and the other twin does not. Until we can better define the specific genes and the exact triggers, we will not find a cure. Currently, we treat the inflammation and prevent flareups, typically using medications that suppress the immune system. These medications include steroids, immunomodulating agents (e.g., azathioprine, 6-mercaptopurine, and methotrexate) and biologic agents. Biologic agents are typically administered by

When Surgery is Necessary Medical management is key to the care of patients with Crohn's disease, but surgery is needed at times. When surgery is necessary, it is important to have a surgeon with experience and interest in surgical care of patients with inflammatory bowel disease, particularly Crohn's disease. Colon and Rectal Surgery Associates has specially trained surgeons with that expertise and experience. We provide comprehensive care you can trust! www.crsal.org

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MINNESOTA HEALTH CARE NEWS MAY 2011

intravenous infusion or injection and include infliximab (Remicade), adalimumab (Humira), and certolizumab (Cimzia).

Health care maintenance Health care maintenance refers to the routine preventive health care that children and adults should receive on a scheduled basis. However, patients with chronic medical conditions are often so focused on treating their illness that routine health care maintenance falls by the wayside. While health care maintenance is important for every adult, there are some unique concerns specific to patients with Crohn’s disease, especially those who require chronic medical therapy.

Crohn’s disease afflicts more than 700,000 Americans. The disease is lifelong and there is no known cure.

Vaccinations. All adults should receive routine vaccines according to national guidelines. These include a tetanus/diphtheria booster every 10 years and pneumovax. Routinely, pneumovax is recommended for patients over the age of 65. However, because of the potential need for immune-suppressing medications, all patients with Crohn’s are advised to receive pneumovax at the time of diagnosis, regardless of age, with a one-time booster shot five years later. In addition, influenza vaccine is recommended annually. It should be given as a shot rather than the nasal Flumist vaccine, which contains live virus. Other vaccines such as hepatitis A, hepatitis B, and menningococcus are recommended for Crohn’s patients, regardless of their medical therapy. Vaccines containing live viruses cannot be given to patients with Crohn’s who are on immunosuppressing medications. Live vaccines, including zoster (shingles) and varicella (chickenpox), can only be given if the patient is not taking steroids, immunomodulators, or biologic agents. Other live vaccines that must be avoided include yellow fever, measles/mumps/rubella, and smallpox vaccines. Bone health. An individual’s bone mass peaks between the ages of 20 and 25. After that, bones slowly weaken and become less dense year after year. Decreased bone mineral density is known as osteopenia or, in its more severe form, osteoporosis. There are several risk factors for osteoporosis, including tobacco use, alcohol use, a sedentary lifestyle, and family history of osteoporosis. There are additional bone health concerns for patients with Crohn’s. Intestinal inflammation interferes with the absorption of bonestrengthening nutrients, including calcium and vitamin D. In addition, medications used to treat a flare-up, such as prednisone, cause calcium loss through the urine. This is a major contributing factor to the development of osteoporosis in patients with Crohn’s disease. Blood tests can identify patients deficient in vitamin D, who may require prescription-strength vitamin D supplements. Bone mineral density testing, or DEXA scans, are indicated for patients over the age of 18 with a history of steroid use to determine if bonestrengthening medications (bisphosphonates) are indicated. Colon cancer screening. While the average risk population does not need to begin colon cancer screening until the age of 50, patients whose Crohn’s disease affects more than one-third of their colon or large intestine are considered at high risk for developing colon cancer. These individuals should undergo screening colon-

oscopy to identify precancerous changes eight to 10 years after diagnosis, regardless of age. Follow-up exams are typically every two to three years, but scheduling depends on the findings at the time of the initial colonoscopy.

Women’s health issues. Human papilloma virus (HPV) is sexually transmitted and a major risk factor for the development of cervical dysplasia (precancerous change) and cervical cancer. Immunosuppressive therapy increases the risk of infection with HPV as well as the risk of developing cervical dysplasia and cervical cancer. Women on chronic immunosuppressive therapy for Crohn’s disease require more frequent Pap smears to screen for these conditions than the healthy population. Current cervical dysplasia screening recommendations for women on immunosuppressive drugs include two screenings in the first year after drug initiation and then annually thereafter. Women with Crohn’s who are not on immunosuppressing medications should have annual Pap smears until age 30 and then every two to three years if there have been no Pap smear abnormalities. Also, the Gardisil vaccine for prevention of HPV is recommended for all women ages 9 to 26, including women with Crohn’s disease, regardless of immunosuppressive drug therapy.

Tobacco cessation. In addition to being a major factor in the development of lung cancer and heart disease, cigarette smoking is associated with more aggressive Crohn’s disease and a poorer Crohn’s disease to page 19

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

Thank you for choosing independent medical care. www.midwestipa.org • 952-883-3133 MAY 2011 MINNESOTA HEALTH CARE NEWS

May Calendar 12

Senior Wellness Expo This free event will offer door prizes, health and wellness screenings, demonstrations and seminars, and refreshments. Learn about the latest products, local resources, housing developments, programs, and equipment to help you live a healthier and happier life. For more information call 651-249-2230 or visit www.maplewoodcommunitycenter.com. Thursday, May 12, 10 a.m.–2 p.m., Maplewood Community Center, 2100 White Bear Ave., Maplewood I Survived My Stroke … Now What? Come and learn about an exciting new study for people with aphasia. Hear presentations about the mechanics and prevention of stroke, stroke recovery, living with stroke, dealing with changes, and accessing resources. Lunch is provided. $30 fee. Registration deadline is Monday, May 9. Call 952-993-6789 for more information. Saturday, May 14, 8:30 a.m.–2 p.m., Methodist Hospital, Park Nicollet Heart & Vascular Ctr., 6500 Excelsior Blvd., St. Louis Park Breastfeeding Preparation Research has confirmed the benefits of breastfeeding for both mothers and babies. Receive an introduction to the basics of breastfeeding and resources for ongoing support. Your partner and others who will support you after your baby is born are encouraged to attend. This class is best taken during the second half of your pregnancy. Fee: $30 per attendee and one guest. To register, call 866-904-9962. Tuesday, May 17, 6:30–9 p.m., United Hospital, John Nasseff Medical Ctr., 255 Smith Ave. N., Miller Rm., St. Paul Making Tough Health Care Decisions This free session is intended to educate you and your family about making tough health care decisions. You will learn tools to help clarify your preferences and values about treatment options. Patients and caregivers are welcome to attend. For

questions, please call the Coborn Cancer Center at 320-229-4907. Wednesday, May 18, 1–2 p.m., CentraCare Health Plaza, Coborn Cancer Ctr., 1900 CentraCare Circle, Carlson Classroom, St. Cloud

Huntington’s Disease Awareness Huntington’s Disease (HD) is an inherited disorder resulting in slow and irreversible loss of both mental and physical capacity. There are 30,000 people in the U.S. currently diagnosed with HD and each of their siblings and children has a 50 percent chance of developing it. HD is a family disease, not just because it is inherited from a parent, but also because it profoundly affects the entire family unit emotionally, socially, and financially. HD, like Alzheimer’s and Parkinson’s, takes people away from their loved ones and the rest of the world long before they die. HD typically begins in mid-life, between the ages of 30 and 45, though onset may occur as early as age 2. Children who develop the juvenile form of the disease rarely live to adulthood. It is characterized by a loss of neurons in certain regions of the brain and progressively affects cognition, personality, and motor skills. In the later stages of HD, people almost certainly require continual nursing care. Secondary diseases such as pneumonia are the actual cause of death, rather than the disease itself. The good news is that researchers are working hard to find a cure and there are many resources for support in our community. The Minnesota Chapter of Huntington’s Disease Society of America offers more information at www.hdsa. org/mn or call 763-502-1407. The 26th Annual Huntington’s Society of America annual convention will be held June 24–26 at the Sheraton Bloomington Hotel. Visit the Minnesota chapter website or call for more details.

HD Support Group Patients, families, and caregivers are welcome to attend this free gathering every third Saturday of the month. Another meeting is held monthly in Rochester. For more information, call Jessica Hancock at 612-371-0904 or email Jhancoc1@ good-sam.com. Saturday, May 21, 10:30 a.m.–12:30 p.m., Oak Grove Lutheran Church, 7045 Lyndale Ave., Richfield

Hearing Loss Support Group The Hearing Loss Chapter of America is devoted to the welfare and interests of those who cannot hear well, but are committed to participating in the hearing world. This support group meets the third Saturday of the month, Sept.–May. Contact Merrilee Knoll at 763-537-7558 TTY, or rKnoll5200@aol.com. Saturday, May 21, 9:30 a.m.–noon, Courage Center, 3915 Golden Valley Rd., Education Ctr. 3 & 4, Golden Valley

Ovarian Cancer Support Group The Minnesota Ovarian Cancer Alliance (MOCA) provides an ongoing ovarian cancer survivor support group on the second and fourth Wednesday of the month. You may join at any time. For more information, contact Lindsay at lkohn@mnovarian.org or call 612-822-0500. Wednesday, May 25, 6–7:30 p.m., MOCA office, 4604 Chicago Ave. S., Minneapolis

Sporty Saturdays Fun play for everyone! Come join the Hennepin County Medical Center’s “Taking Steps Together Staff” for an hour of supervised games and activities for kids and parents. Sporty Saturdays are open to everyone of all ages. No need to register—just show up to play. Saturday, May 28, noon–1 p.m. (rain or shine), Elliot Park Recreation Ctr., 1000 14th St. E., Minneapolis

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 e-mail them to jbirgersson@ mppub.com. Please note: We cannot guarantee that all submissions will be used. CME, CE, and symposium listings will not be published.

America's leading source of health information online 18

MINNESOTA HEALTH CARE NEWS MAY 2011

Crohn’s disease from page 17

response to biologic medications such as infliximab. Smoking cessation is an important part of health care maintenance for every patient with Crohn’s disease. It improves Crohn’s patients’ quality of life and disease severity while decreasing their risk of developing heart and lung disease. Eye health. Annual eye exams are recommended for all patients with Crohn’s, regardless of age. Steroid use contributes to the development of glaucoma and cataracts. Other health maintenance considerations. Immunosuppression appears to increase the risk of non-melanoma skin cancers, including basal cell and squamous cell carcinomas. Crohn’s disease patients on chronic immunosuppression should have complete skin exams annually to evaluate the presence of precancerous or cancerous skin lesions. Depression is commonly associated with chronic medical conditions. Up to one-third of patients with Crohn’s disease suffer from depression. Symptoms of depression include anxiety, excessive fatigue, and difficulty sleeping. All need to be addressed and discussed with the treating physician. Treating co-existing depression can greatly improve the quality of life and overall well-being of patients with Crohn’s disease. High blood pressure affects up to one-sixth of the U.S. population. Patients with Crohn’s disease are at increased risk for hypertension, which is likely related to medication use, including steroids.

There are some unique concerns specific to patients with Crohn’s disease, especially those who require chronic medical therapy.

Frequent blood pressure monitoring is indicated and appropriate treatment is needed when high blood pressure is present. Breast and prostate cancer screening for Crohn’s patients should follow current national guidelines.

Keeping on track for good health A major challenge of living with chronic disease is finding the right medical treatment plan to keep the disease controlled and in remission. It is just as important for patients’ overall well-being to follow recommended guidelines for routine health care screening and maintenance. People with Crohn’s disease are no exception. However, these patients have some unique health care maintenance issues that need to be addressed on a regular basis to keep them on track to live long and healthy lives. Ronald M. Schwartz, MD, is a gastroenterologist with Minnesota Gastroenterology, PA, where he focuses his practice on inflammatory bowel disease. He volunteers for the Crohn’s and Colitis Foundation of America (CCFA). He currently serves on the CCFA Professional Education Committee and is past president of CCFA Minnesota/Dakotas Chapter.

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MAY 2011 MINNESOTA HEALTH CARE NEWS

S P E C I A L F O C U S : PAT I E N T- P R O V I D E R R E L AT I O N S H I P S

Cooling I the hot spots

n a New Yorker article earlier this year (“The Hot Spotters,” Jan. 24), Atul Gawande, MD, describes innovations in care delivery targeted at complex, high-cost populations. Health care delivery systems, Gawande points out, are not designed to care for the high-cost populations, the sickest of the sick. New approaches are required to address the complex issues present in these health care hot spots. Beginning last summer, Hennepin County Medical Center (HCMC) initiated its own effort to redesign care for the most complex populations. Early results show that one Minneapolis hot spot is, in fact, starting to cool down. To begin to understand this, you need to know Tony’s story. Coordinated Care Delivery Systems

Tony (not his real name) was one of the first patients targeted by care redesign efforts at HCMC. Now he is often found in his wheelchair manning the clinic lobby. Comfortable and truly at home, he greets staff and patients as they filter in. He is cheery and positive. This is truly remarkable when you consider his station in life. At 50, he is unemployed, impoverished—repeatedly denied benefits by Social Security—and homeless. He just lost a leg to amputation. He is losing his vision. It is unclear if and when he will ever walk, much less work. But he has the right attitude and, for once, is actively engaged in his own health care. This scenario would never have played out if not for the Minnesota experiment known as CCDS, for Coordinated Care Delivery Systems. Last spring, former Gov. Tim Pawlenty electBy Paul E. Johnson, MD ed to stop funding for the Minnesota GAMC program, which had provided health insurance for 40,000 poor, single adults. In place of the GAMC program came CCDS. HCMC was one of four care systems that stepped forward to provide essential medical services in this new program. CCDS was created to provide care for the GAMC population with one big change: In place of a fee-forservice insurance payments, the hospital received a block grant to It raises many questions few cover services. of us are prepared to answer, The funding change was dramatic. HCMC was expected to such as: provide care that historically had generated more than $90 million • How can I take time off from work? in billing for just $30 million. The GAMC program, always a poor • Can I get help paying bills? payer, had been transformed into a loss leader of eye-catching proportions. In addition, the financial incentives in care delivery were • What is the difference between a health care directive turned on their head. Fee-for-service was gone. No longer were care and a power of attorney? systems paid more to do more. Now they were paid a global fee. • Can I keep my health insurThis change led HCMC to look at its hot spots and proactively ance even if I lose my job? manage high-cost patients. • And many others. Tony, a typical hot-spotter If you or a loved one is facing One look at the hot spot roster brought Tony to HCMC’s attention. cancer, we are here to help. Years removed from drug addiction, he had long suffered from diaWe provide free cancer related betes and hypertension. However, he had largely steered clear of legal information on a wide health care until 2009. Then, his chronic illnesses finally caught up range of topics. We are a nonprofit organization funded entirely with his circulation. Foot ulcers, a dreaded complication of diathrough grants and donations. Please visit our web site to betes, developed. Hospitalizations ensued. An endless stream of Your tax-deductible find out more: donations are welcome. antibiotics and wound care proved ineffective. Swelling, drainage, www.cancerlegalline.org and pain returned after each stay. Unable to engage in clinic-based care, Tony repeatedly bounced in and out of the hospital. From fall 2009 through summer 2010, he rang up 16 admissions, 85 hospital days, and nearly $400,000 in charges. Every care system has patients like Tony. In the HCMC CCDS educate.inform.empower population, probably about 3 percent of patients are in the hot

Care redesign improves outcomes for complex patients while reducing costs

A diagnosis of

Cancer

is overwhelming news.

MINNESOTA HEALTH CARE NEWS MAY 2011

spot. These patients generate about 50 percent of the total program cost. They often suffer from chronic medical illnesses that, in good circumstances, are manageable. However, when complicated by homelessness, chemical use, severe mental health problems, cogni-

With Coordinated Care Delivery Systems, fee-forservice was gone. No longer were care systems paid more to do more.

tive impairment, or chronic pain, these manageable conditions spiral out of control. Neither patients nor providers can cope. Traditional clinic models of care are inadequate. Inpatient care often seems the only solution. Re-engineering outpatient care

In an effort to better care for these high-cost users, HCMC reengineered outpatient care. The redesign hinged on the realization that these hot-spotters needed intensive, multifaceted, team-based attention. An ambulatory intensive care unit was called for. This unit would have intensive staffing ratios. A multidisciplinary care team was assembled. Specialized functions (social work, chemical health, RN care coordinators, pharmacists, mental health specialists), typically hard to find in a clinic setting, were present in ample supply. Visit volume, a traditional marker of clinic financial health, was largely ignored. A new clinic space, the Coordinated Care Center (CCC), opened in late summer. Tonyâ&#x20AC;&#x2122;s CCC experience Tony first entered the CCC late last summer. Like many hotspotters, he was suspicious about the new endeavor. His problems had never been managed out of the hospital. What would be different now? Initially, things were not much different. He had uncontrolled pain, severe high blood pressure, high sugars, and an ulcerated limb that was not healing. After his first visit to the clinic, he was rapidly rehospitalized. This time, however, there was a change. Within 48 hours of discharge, he was seen in follow-up. Two days later, clinic staff called to check on him. More contacts followed. Concerned about his homelessness, Tony saw the social worker. Worried about transportation, he called the care guide. Confused about medications, he talked to the pharmacist. He connected with the clinic many times, at least twice a week for the next month. The whole team got to know Tony. He began to trust the team. Lurking in the background was the issue of his hopelessly diseased leg. Tony had not agreed to previous recommendations for an amputation. He wanted to keep the limb at all costs. How could he be a homeless amputee? Where could he rehabilitate after surgery?

Was surgery the only course? Previously, he lacked faith that he was getting the right advice. However, after many meetings with his new care team, he began to trust them. In October, he made the difficult choice to proceed with amputation. Now seven months removed from surgery, Tony has stabilized. Not only have his diabetes and blood pressure come under control, he has not been hospitalized. He is not the exception in this regard. Almost all CCC enrollees have experienced reduction in inpatient care. There has been almost a 40 percent reduction in hospital admissions and ER visits. Though these are results on just 70 patients, on an annual basis this represents $1.5 million in medical savings. This degree of savings is possible only in a hot spot and can happen only with upfront investment and effort. Clinic members have had a ninefold increase in clinic contacts. Their outpatient costs average around $500 per patient per month. This intensive and expensive outpatient care leads not only to higher quality but to lower costs as well. What a value! Equally important, patients love the new system. Contact is frequent. Caregivers are familiar. Patient satisfaction scores are off the scale. Tony, like many patients, is for the first time connected to a care system and empowered about his health. For many, there is finally a team that can address their complex needs. For once they can take charge and cool down. After all, it is no fun to be a hot spot. Paul E. Johnson, MD, is medical director of the Coordinated Care Center at Hennepin County Medical Center and an assistant professor of medicine at the University of Minnesota.

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S P E C I A L F O C U S : PAT I E N T- P R O V I D E R R E L AT I O N S H I P S

or several months, Sara had been suffering from sharp shooting pains radiating down her right leg. The pain was most severe when she bent over—for example, to tie her shoelaces or get into the car. She tried applying heat and ice to the painful area, resting, and taking over-the-counter pain medications. But the pain persisted. So she scheduled an appointment with her doctor, who diagnosed the pain as sciatica, most likely brought on by compression of the sciatic nerve from a herniated (or bulging) disc. Knowing Explaining that Sara had several options to help relieve her pain and restore her range of motion, her doctor gave her information about them—from the least invasive alternatives such as physical therapy or an injection to the more aggressive alternative of surgery. Sara and her doctor discussed the risks and benefits of each option, as well as the longterm outcomes or possible complications. They also talked about Sara’s preferences and which choices fit best with her values, her culture, and her family and work situation.

more directly in their care, and is most effective when used for health care decisions that are not always clear and easy to make. During their conversation, Sara and her doctor walked through several decision points to decide on the next steps. They balanced the benefits of one decision against possible complications of another.

Shared decision-making

A new dialogue

The conversation that took place between Sara and her doctor is called shared decision-making. This process involves patients

MINNESOTA HEALTH CARE NEWS MAY 2011

your options to improve your health By Russel Kuzel, MD, MMM

For a patient like Sara, suffering from a herniThey talked about how Sara’s health care deciated disc, these decision-support tools helped sions must also take into account her personal guide the conversation as she and her doctor values and priorities, her cultural beliefs, and her weighed the most aggressive option—back surdoctor’s advice. Communicating with gery—against other, less invasive choices. These Shared decision-making represents a subtle discussions focused on Sara’s desired outcome, shift in the traditional doctor-patient relationship. patients through the time that it would take to recover from the Clinicians are engaging in more open conversashared decision-making condition, and the time required to recover from tions with patients about treatment decisions is most effective the surgery. The tools also helped inform and when no clear “best” path is indicated. In these when there is more facilitate conversations about medication for cases, the clinician probes his or her patient’s the condition and high-tech digital imaging test preferences, values, quality of life, and cultural than one treatment considerations. biases. The clinician also offers information to option and outcomes help the patient better understand the outCultural perspectives are uncertain. comes—and risks and benefits—of different Cultural beliefs and attitudes play an important options. Together, doctor and patient collaborate role in shared decision-making. A 2004 study on the best course of action for a particular of shared decision-making in a culturally diverse community, conhealth condition or screening test. ducted at the University of Amsterdam, recommended training Cathy Charles, PhD, and her colleagues at McMaster physicians to better recognize the communication limitations during University in Hamilton, Ontario, Canada, introduced the concept of shared decision-making in the 1990s. Since then, shared decision-making and better deal with the barriers in an intercultural setting. it has gained ground across the United States. The princiUCare, for example, serves a large Hmong population. Because ples of shared decision-making state that at least two parHmong culture places a high value on the family and clan, health ticipants, the clinician and patient, are involved; that both care providers need to broaden their approach to shared decisionparties share information; that both parties take steps to build a consensus about the preferred treatment; and that making with Hmong patients to include other family and clan members. an agreement is reached on the treatment to implement. Shared decision-making to page 27 The approach empowers patients to make informed choices according to their own treatment preferences, and supports the understanding that: • Patients have the right to accurate information about their health conditions and treatment options. • Medical decisions made with a patient’s informed input are most likely to yield the best results for the patient and his or her family.

In the next issue..

• Every person, with the benefit of good information, can improve the quality and the results of his or her health care. Asking the “right” questions

UCare, an independent health plan that provides coverage to 200,000 members in Minnesota and western Wisconsin, views shared decisionmaking as an extension of its commitment to the Institute for Healthcare Improvement’s Triple Aim objectives: to improve the population’s health; to enhance the patient’s experience of care; and to reduce, or at least control, the per capita cost of health care. In support of shared decision-making, UCare is actively providing better decision-making tools for its members and network providers. Our approach is to facilitate sharing of health care information to ensure that members get the most appropriate and effective care that meets their needs. The health plan wants its members to feel comfortable that they have made a health care decision that seems best for them. In order to do that effectively, the plan provides its members with the information they need to understand upfront their treatment options and the associated risks, side effects, and benefits. UCare offers print and online decision support tools from Healthwise (www.healthwise.com) to both members and providers. Members who have access to the latest knowledge about treatment options are in a better position to “ask the right questions” as they consider important health care decisions.

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S P E C I A L F O C U S : PAT I E N T- P R O V I D E R R E L AT I O N S H I P S Over the past decade, it has become an increasingly common practice in health care to call patients “customers,” in keeping with the evolving view of medicine as a business and of patients as purchasers receiving services from a vendor. How the medical system views people, whether as patients or as customers, may affect the nature of the relationship between doctors and the people under their care. Interestingly, surveys have shown that people prefer the word “patient” to “client” or “customer.” If patients begin to see themselves as customers, might they adopt perspectives that, while appropriate in a buyer-seller relationship, may impair the doctor-patient relationship? This article explores the potential consequences of adopting a “patient as customer” mindset.

and patients is widely recognized. However, the establishment of trust between doctor and patient is one of several actions that can take the edge off the effects of asymmetry. Ideally, the doctor-patient relationship is based on trust and effective communication. Physicians can promote trust by avoiding paternalistic, father- (or mother-) knows-best behaviors and treating patients as partners in health decisions. For their part, patients can become as well educated about their condition as possible by continuing to ask questions of the physician until they understand both their health problem and the risks and benefits of treatment options. It may be helpful to ask for other sources of information such as brochures, books tailored to nonmedical people, and appropriate Internet sites. Bringing a family member or friend to the visit is helpful, as is taking notes either before or during the visit. Patient aids such as “Ask Me 3” (www. npsf.org/askme3/) can help patients focus on their most important concerns. Extensive research has shown that peoAn argument against ple remember only about onethird of the information from a patient as “customer” visit to the doctor. The techniques By Loree K. Kalliainen, MD above may improve that.

What’s in a

word?

Imbalance in the doctorpatient relationship The notion of asymmetry is a good place to start in looking at both patient-physician and buyer-seller transactions. The existence of a power imbalance (asymmetry) between doctors

MINNESOTA HEALTH CARE NEWS MAY 2011

A trusting relationship in turn promotes effective communication, putting the patient in a position to make informed decisions. In this way, the development of mutual trust can counter the potential negative effects of information asymmetry: That the physician knows more medicine than the patient is less important than the way in which she or he communicates that knowledge. If the physician expresses that she is willing and interested in educating the patient, it helps build trust. Trust also may lead to increased patient satisfaction; and patients who are satisfied may participate more fully in the care plan, stick with one physician, and be less likely to sue. Studies have shown that if patients actively participate in health maintenance plans, if they are well educated, and if they have a more equitable partnership with the physician, the cost of medical care may decrease. In contrast, the cost of care may increase if the patient does not trust the physician, seeks multiple opinions because of inadequate communication, or views the doctor-patient relationship as adversarial. Ackerlof’s “Lemon Law” Now consider the economic sphere, where asymmetry of information between buyers and sellers of goods frequently leads to mistrust because of the presumption that the seller is trying to best the buyer. The buyer tries to minimize the risk of being cheated or to minimize losses if he or she is cheated. The concept of information asymmetry is intrinsic to the doctorpatient relationship as well. If the doctor-patient relationship is viewed in largely economic terms, and if patients see themselves as “customers” (buyers), patients may develop concerns, whether recognized or unrecognized, that they are being “cheated”—much as they could be in other economic transactions. In addition, patients who are encouraged to view themselves as customers may have expectations that, while appropriate to economic transactions, do not translate to the medical arena. In 1970, George A. Akerlof, one of the winners of the 2001 Nobel Prize in economics, published a paper called “The Market for ‘Lemons.’” It turned on its head the prevailing view in economic theory that information between buyer and seller was symmetrical— i.e., that the same information was available to both the buyer and the seller. To challenge this view, Akerlof used the example of the used-car business. When someone buys a new car, assumptions can be made about the quality of the vehicle. There is always a chance the car will be defective, but the probability is fairly low. With used cars, however, faults apparent to the seller may not be apparent to the buyer; therefore, the exchange is defined by its asymmetry of information. Information asymmetry can lead to a lack of trust between buyer and seller, because the car could truly be in good condition—or it could be a “lemon.” In such a transaction, the buyer must try to determine how much of a lemon the car may be, but it is not easy to determine this without considerable experience with or knowledge of cars. Even in routine trading situations (such as buying a new car), the buyer of a good or service has certain expectations of quality and refunds. For example, the buyer expects that the purchased item can be replaced or repaired if it is faulty, and that an alternative will be available if the item fails to live up to expectations. Customers may take measures to reduce the chance of being cheated or to minimize their losses if they are taken advantage of—for example, by deferring pur-

chases, avoiding purchases, or bargaining to pay less for the product. Taking a consumer approach to the doctor-patient relationship— which is, by definition, asymmetrical—could impair the patient’s trust in the physician and damage communication. If either patients or physicians view the interaction as primarily an economic transaction, the relationship will be harmed. The complexity of our health care system is staggering. And, although the practice of medicine is more effective than it was hundreds of years ago, our therapies are still imperfect. There are still many problems for which medicine has no effective treatment, all treatments have risks, and the number of people with multiple health problems is increasing. The intrinsic nature of the doctor-patient relationship is special because of the training physicians receive, the Hippocratic Oath, the What’s in a word? to page 26

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Akerlof proposed that one way to reduce the risk of a consumer being lied to was to increase the buyer’s knowledge. Even without potential to do harm, the difficulty of predicting outcomes, and the adopting the perspective of patients as customers, we can extrapohistorical element of not always being able to offer effective treatlate lessons in building trust to the doctor-patient relationship. It is ments. Physicians have always been expected to have patients’ best important for patients (or their proxies) to be educated about their interests at heart. This is the crux of the challenge of physician as health and to verify that they have an acceptable degree of underhumanitarian versus physician as someone in a business. standing. Knowledgeable patients ask more and better questions and Balancing the doctor-patient relationship are more aware of the risks and benefits of the options available to them. The physician’s willingThe professed goal of the patient-as-customer menness to provide information should increase the tality is to encourage patients to take a greater role patient’s confidence in the physician and decrease in their health maintenance and health care and to the patient’s anxiety. move away from paternalism. When people purThough it is obvious that certain elements of chase goods such as health insurance, medications, Trust may health care are commercial, those should not be or bandages, it is not inappropriate to call them lead to allowed to overweigh the humanistic spirit of medcustomers; but the same terminology may well be increased icine. Viewing the doctor-patient relationship in an impediment when applied to the relationship purely economic terms promotes expectations between doctor and patient. patient more suited to commercial rather than medical It is not necessary to be called a customer—or satisfaction. ventures and implies a business transaction rather thought of as one—to be an active partner with a than the development of a helping, trusting relaphysician in the decision-making process. The printionship. Calling patients customers devalues the highly complex ciples of respect, doing good, doing no harm, and seeking justice are nature of the doctor-patient relationship and fails to recognize the not business principles but ethical ones. Information asymmetry is care, compassion, and trust that are unique to that relationship. inherent in the doctor-patient relationship: While patients are not What’s in a word? from page 25

qualified to dictate every element of their medical care, it is crucial that decisions be made in a shared and informed fashion. However, the potentially negative effects of information asymmetry may be tempered with the establishment of communication, engagement, respect, and trust.

MINNESOTA HEALTH CARE NEWS MAY 2011

Loree K. Kalliainen, MD, is chief of staff at Regions Hospital, where she practices in the Department of Plastic and Hand Surgery, and is an assistant professor of surgery at the University of Minnesota Medical School. A version of this essay was part of the author’s work toward a master’s of philosophy degree at the University of Minnesota.

Shared decision-making from page 23

From the Hmong perspective, important decisions are likely to affect all family members. Medical decision-making is hierarchical, with the oldest male family member making the decisions in consultation with other family and clan members. Women generally do not make important health care decisions for themselves; instead, their husbands or oldest sons are consulted. Ultimately, the family or clan leader has the final decision-making power. Working with Hmong patients, it is important for care managers and health care professionals to take time and exercise patience in allowing them to consult with family and clan members. When there are no easy answers

seeks to relieve pain, anxiety, shortness of breath, fatigue, nausea, loss of appetite, and other symptoms, and to provide emotional and spiritual support. Practitioners of palliative care involve patients and their families in shared decision-making to help them understand treatment options, and they facilitate effective communication among health care professionals, patients, and family members. It improves patient care by helping patients and their families plan for the best quality of life—however they choose to define quality for themselves. The approach offers individuals and families compassion, comfort, and peace of mind during difficult times. An evolution in the doctor-patient relationship

Empowering health care consumers to be “smarter” about their Communicating with patients through shared decision-making is health care decisions through shared decision-making is a positive most effective when there is more than one treatment option and outevolution of the doctor-patient relationcomes are uncertain. Shared decisionship. Most people feel more comfortable Empowering health care consumers making also can be applied to decisions with a life decision when they have to be “smarter” about their health care about imaging tests and preventive researched it thoroughly; consulted with screenings such as mammography. decisions through shared experts, family, and friends; and spent Palliative care is another area that decision-making is a positive evolution time thoughtfully weighing the pros and fits well with shared decision-making. cons. Furthering the conversation between of the doctor-patient relationship. It is care that manages serious and patients and providers enables them to advanced illness by focusing on relievreach a decision that best fits each indiing symptoms, alleviating suffering, vidual’s health care goals and core and improving quality of life for values. patients and their families. Russel Kuzel, MD, MMM, is chief Treatment, customized to meet medical officer at UCare. the needs of each individual,

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PULMONOLOGY

Have asthma? Get an action plan. Self-management strategy could save your life By Susan K. Ross, RN, AE–C

sthma is one of the most common chronic conditions of the lungs, with recurring symptoms that vary greatly in each person. In Minnesota, an estimated 434,000 adults (11 percent) and 116,000 children (9.5 percent) have been diagnosed with asthma at some point in their lives. Approximately 304,000 adults (almost 8 percent) and 85,000 children (7 percent) currently have asthma, with approximately half of adults and 41 percent of children with asthma having had an asthma attack in the past year. Physiology People with asthma have an underlying swelling or inflammation of the lining of their bronchioles (the lower branches of the airways), resulting in a narrowing or obstruction. Inflammation of the airway lining causes an overproduction of mucus (normally a protective fluid in the lungs), which can become thick and sticky. This overabundance

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of mucus can lead to further airway narrowing and potentially clog the tiny airway openings. People with asthma who have both the inflammation and overproduction of mucus, with airways that are easily irritated and prone to spasms, are very likely to need help controlling and managing their disease. Learning how to self-manage asthma successfully requires that patients and clinicians work together to develop an individualized treatment plan. Along with the plan, patients and caregivers need to receive individualized, culturally appropriate asthma self-management education to give them the confidence to make decisions and take action quickly. These actions need to be written in an easy-to-understand, yet highly detailed fashion. An asthma action plan (AAP), sometimes called a self-management plan, fits that description to a tee. Why have an AAP? The Centers for Disease Control and Prevention (CDC) recommends that everyone who has asthma should have a written asthma action plan. An AAP helps people who have asthma manage and prevent symptoms, and it provides important information for those who care for them. It is especially important to have an AAP if a person has moderate to severe asthma or he or she has had a serious asthma attack in the past. An AAP is a patient-specific written plan developed in collaboration with a doctor or other health care provider. A well-written AAP can help people control asthma by clearly defining what medications to take and when, what symptoms they are most likely to experience if their asthma flares up, and what specifically triggers their asthma symptoms. Most importantly, an AAP helps a patient or caregiver understand how to control asthma long-term and how to handle worsening asthma symptoms or a full-blown asthma episode. An effective AAP will list patient-specific control and rescue medications, dosing instructions, and steps to help the patient regain or maintain control over asthma and respond to emerging symptoms. Symptoms and peak flow zones

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Action plans are based on zones of asthma care defined by an individual’s personal best peak expiratory flow (PEF) rate and/or by the individual’s specific symptoms. A PEF measures how much air a person can exhale from his or her lungs. A personal best peak flow is the greatest peak flow achieved over a two-week period when asthma is well controlled. A personal best can change as a person ages and as the underlying asthma condition improves or declines. A PEF meter is not a diagnostic tool; it is a useful, objective way to help people track the intensity of their symptoms. Some people with asthma have difficulty perceiving how serious their asthma symptoms are. Measuring PEF on a daily basis may help them more easily associate symptoms (or lack thereof) with their action zones, thus helping them track how well their asthma is being managed. Patients and health care providers decide collaboratively whether to base an AAP on symptoms, PEF, or both. Action plans are divided into three zones that reflect escalating symptoms and a dropping peak flow rate. The provider should review with the patient or caregiver the medication and action steps in each

Asthma resources

are difficulty breathing or shortness of breath, coughing, wheezing, and tightness in the chest. It can be increasingly difficult to work or play easily and you might wake up at night coughing. The yellow zone means you may be having an asthma attack or that your medicines might need to be adjusted. Actions for symptoms in the yellow zone usually instruct you to start taking your rescue inhaler or nebulizer. Depending on how well you respond to your rescue inhaler, you may need to take additional puffs of your rescue inhaler or possibly a dose of an oral corticosteroid and call your provider. If symptoms subside and your PEF moves back into the green zone, you should continue to monitor how you feel and act accordingly.

Centers for Disease Control and Prevention: www.cdc.gov/asthma/ Minnesota Asthma Program, Minnesota Department of Health: www.health.state.mn.us/asthma/ Interactive Asthma Action Plan: www.Asthma-iAAP.com Air Quality Index, Minnesota Pollution Control Agency: http://aqi.pca.state.mn.us/ Coach’s Asthma Clipboard Program: www.WinningWithAsthma.org Guidelines for the Diagnosis and Management of Asthma, National Heart, Lung, and Blood Institute: http://www.nhlbi.nih.gov/guidelines/asthma/

zone so that he or she understands the most effective way to treat or prevent asthma symptoms. The steps listed below are generalized, and each patient’s symptoms and action steps may be different.

• Green means “GO”—Your PEF is 80 percent to 100 percent of your personal best. Your green zone may list controller medications you should take every day. If your asthma is exacerbated by exercise, another medication called a “rescue” or “pre-exercise” medication may be listed to take before you exercise. You should be free of asthma symptoms when you are in the green zone. This is where you want to be every day. • Yellow means “CAUTION”—Your PEF is 50 percent to 79 percent of your personal best. Symptoms may be mild to moderate or, for some people, difficult to perceive. Common yellow zone symptoms

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• Red means “STOP”—Your PEF is less than 50 percent of your personal best. This is an urgent situation. Symptoms are usually severe but can vary by individual. Common red zone symptoms include: great difficulty breathing, nostrils flaring open wide, and, in children, ribs showing as the lungs struggle to pull in air. Rescue inhaler or nebulized medication may not seem to help; you may have trouble walking or talking and your lips or fingernails may be grey or bluish in color from insufficient oxygen. Have asthma? Get an action plan. to page 30

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An AAP should clearly explain when to call your health care provider.

Have asthma? Get an action plan. from page 29

You should seek medical help immediately and follow your action plan. Take your rescue inhaler medications as listed in the red zone. You may need emergency treatment, so call 911 or go to the emergency room and, if possible, call your provider or have someone call for you. If symptoms subside and your PEF moves back into the yellow zone, you should continue to monitor how you feel and should still contact your provider.

An AAP should clearly explain when to call your health care provider, and when to go to the emergency room or call 911. Your goal should be to return to and remain in the green zone. Keep it handy An AAP can help only if it’s kept in an easily accessible location and shared with others who may provide assistance in a crisis. At home, some people keep a copy on their refrigerator door. When children have asthma, a copy of their AAP should be shared with the school health office, day care providers, grandparents, teachers, coaches, or any person who may be caring for the child. Adults should share their plan with spouses and significant others and always keep a copy with them. Since your AAP should reflect current triggers, medications, and personal best PEF rates, review your plan with your health care provider at least once yearly. Twice is better.

is to tell your provider whether your AAP communicates the most crucial information in an easy-tounderstand manner. There are a number of tools available to help providers develop an AAP. The Minnesota Department of Health (MDH) offers an online tool to aid clinicians in writing a patient-specific AAP. The interactive Asthma Action Plan (iAAP) is a computerized clinical decision support tool for licensed prescribing providers who treat patients with asthma. The iAAP helps the provider follow the National Institutes of Health 2007 Asthma Guidelines in assessing asthma patients’ severity and/or control levels. The iAAP enables the provider to select guideline-specific treatment plans and lists those choices on an easy-to-read, patient-specific printed AAP. The AAP can be printed in English or Spanish. Physicians or other health care providers can download or access the iAAP for free by going to www.Asthma-iAAP.com. Patients or parents can access additional asthma information by going to the MDH Asthma Program website at www.health.state.mn.us/asthma. Susan K. Ross, RN, AE–C, is a certified asthma educator, member of the Guidelines Implementation Panel of the National Asthma Education and Prevention Program, and the senior clinical adviser on the staff of the Minnesota Department of Health Asthma Program.

Where to get an asthma action plan? There is no absolute right or wrong AAP format and there are hundreds of examples available for download from the Internet. The key

Minnesota

Health Care Consumer April survey results... Association

1. I am confident I understand what advance directives are.

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 April survey.

35.3%

39.2%

40 30 20

9.8%

37.3%

13.7% 9.8%

3.9%

Strongly agree

Agree

Not sure

Disagree

0.0%

20 9.8%

10 0

Strongly disagree

0.0% Strongly agree

Agree

Not sure

40 33.3% 30 20

15.7%

10 2.0%

Strongly agree

Agree

Not sure

Disagree

Strongly disagree

MINNESOTA HEALTH CARE NEWS MAY 2011

Strongly agree

Agree

Not sure

Disagree

60.8%

60 50 40

39.2%

30 20 10

0.0% Strongly disagree

Disagree

5. I have created a formal advance directive.

49.0%

Percentage of total responses

25 20

3.9%

4. I believe it is important that people should talk with their physician about advance directives.

Percentage of total responses

41.2%

0.0%

45.1%

51.0% Percentage of total responses

Percentage of total responses

3. I am confident that having an advance directive will ensure compliance with what a patient wants.

2. I feel it is important that everyone should have an advance directive.

Yes

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;? MAY 2011 MINNESOTA HEALTH CARE NEWS

H O S P I TA L S

Reducing hospital readmissions Pilot program shows promising early results At 68, “Fred Lowell”considered himself to be in good health, except for one thing: a heart condition called paroxysmal atrial fibrillation. Whenever he had an episode, his blood pressure would go sky-high, his heart would race at more than 200 beats per minute, and he would feel weak and lightheaded. Sometimes it stopped on its own, but not always. On those occasions, Fred went to the emergency department (ED), where doctors administered medication intravenously to convert his heart back to normal. In April Fred had an episode that sent him to the hospital. Released the next day with instructions to start a new medication and make an appointment with his primary care physician, he didn’t get around to making the appointment. Three days later, he was back in the ED after having a bad reaction to the new drug. Fred (the “patient” in this hypothetical example) wondered how he could have avoided going back to the hospital. Our pilot program at Fairview Southdale Hospital also seeks the answer. Reducing hospital admissions, readmissions, and ED visits is best for patients and represents a key part of any serious effort to contain health care costs. Nationwide, 20 percent of hospitalized Medicare patients are readmitted within 30 days.

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MINNESOTA HEALTH CARE NEWS MAY 2011

In February 2010, Fairview Physician Associates (FPA), UCare, and primary care physicians in the FPA network piloted a program to reduce Medicare readmissions at Fairview Southdale Hospital. FPA is a network of approximately 1,200 physicians affiliated with Fairview Health Services. UCare, a health plan, serves more than 200,000 Medicaid and Medicare enrollees in Minnesota and Wisconsin. FPA contracts with UCare for case management services to some 14,000 UCare Medicare Advantage enrollees.

By William Nersesian, MD, MHA, Barry Baines, MD, and Becky Schmidt, RN–BC

Coordinated interventions Our pilot project has philosophical underpinnings. First, we believe that when patients are able to see their own primary care physicians very soon after discharge, and when the physician is given the necessary time, information, and compensation to best manage the patient, readmissions are prevented. Second, nurse case management and supplemental pharmacy education help avert many simple but common problems that often lead to readmission. Examples include patient errors in taking medications or inability to keep clinic appointments because of transportation issues. Finally, we believe that readmissions can be minimized only when hospitals, ambulatory care physicians, case managers, and payers work together in partnership; any single entity would be hard-pressed to achieve the same results. Fairview Southdale Hospital was chosen for the pilot because the number of annual admissions was adequate for concerted case intervention and statistical analysis. Under the program: • Every patient has an FPA nurse case manager. In most cases, a case manager speaks face-to-face with the patient in the hospital and by telephone afterward. Every patient is contacted within two business days of discharge. • Nurse case managers focus primarily on ensuring that patients understand and comply with their discharge plan: filling their prescriptions, understanding and taking their medications, scheduling and completing follow-up appointments, obtaining necessary laboratory tests, etc. While addressing the problem(s) that resulted in the hospitalization, case managers scrutinize all other patient needs as well. Additional needs might include advance care planning, transportation, safety, financial resources, immunizations (including

flu shots), smoking cessation, weight loss and healthy exercise counseling, depression assessment, and hearing and vision assessment. â&#x20AC;˘ Hospitalists (physicians who care for patients while they are hospitalized) advise all patients to visit their primary care physicians as soon as possible after discharge. Hospitalists dictate discharge summaries on the day of discharge and send them to primary care physicians within two business days. â&#x20AC;˘ A pharmacist at Fairview Southdale Hospital spends about 20 additional minutes with each patient before discharge, providing education regarding medications and disease management. This supplemental education exceeds what Medicare usually requires. â&#x20AC;˘ The hospital maintains a social services database on every patient. This might include such information as lack of English skills, transportation needs, nutrition needs, and level of family support. â&#x20AC;˘ UCare pays $50 above the usual reimbursement to clinics that are able to see patients for post-hospital checks within five business days. â&#x20AC;˘ Nurse case managers notify clinics the day patients are discharged so that patients can receive priority for clinic appointments.

Readmissions reduced significantly According to 2009 data compiled by UCare, 16.5 percent of FPA Medicare Advantage seniors were rehospitalized within 30 days of discharge from Fairview Southdale. This retrospective analysis included only patients with a discharge diagnosis that included diabetes, chronic obstructive pulmonary disease (COPD), or heart disease, even if these common problems were not related to the primary reason for hospitalization. In general, patients with one or more of these three diagnoses are sicker and would be expected to have higher readmission rates than patients without one of these diagnoses. Patients in this group were discharged home, to a skilled nursing facility (SNF), or to long-term care. After the first eight months of the pilot project in 2010, using an â&#x20AC;&#x153;apples-to-applesâ&#x20AC;? comparison, UCare reported that 11.7 percent of patients had been readmittedâ&#x20AC;&#x201D;a reduction of approximately 30 percent from the 2009 group. We designed our program to intervene with patients who were discharged home (and thus could be brought back to their primary care physicians). FPAâ&#x20AC;&#x2122;s own prospective data reveal that patients with all diagnoses who were discharged home had a 10.1 percent readmission rate in the first nine months of the program. Patients with all diagnoses who were discharged to an SNF or to long-term care had a 9.4 percent readmission rate. Although we have no baseline data for comparison with these latter two groups, we believe these readmission rates seem favorable when compared with state and national Medicare data.

Projected savings According to UCare data, these results could translate to a reduction of more than 30 readmissions a year, each costing an estimated $10,000, for Fairview Southdale Hospital. All it takes to recoup costs for the program, according to UCare, would be a 12 percent reduction in readmissions.

In addition to better care, this program could save $300,000 a year at this one hospital, for UCare patients alone. Net savings would equal $240,000 after subtracting program costs. Applying these results to all five Fairview metropolitan facilities, an estimated $680,000 a year could be saved on UCare Medicare Advantage seniors alone. Obviously, extending the pilot program to other insurers could yield much greater savings. In light of project results so far, UCare extended the project this year to patients at Fairview Ridges Hospital in Burnsville.

Nationwide, 20 percent of hospitalized Medicare patients are readmitted within 30 days.

In summary Many rehospitalizations among the Medicare population are due to factors that can be improved by using nurse case managers and pharmacists to educate and assist patients, and by expediting post-hospital follow-up visits with their primary care physicians. A pilot program at Fairview Southdale Hospital has prevented 30 percent of hospital readmissions in UCare Medicare Advantage seniors, generating considerable cost savings. Fairview and UCare plan to extend this pilot project to other facilities. William Nersesian, MD, MHA, is chief medical officer for Fairview Physician Associates. Barry Baines, MD, is the recently retired associate medical director of UCare. Becky Schmidt, RNâ&#x20AC;&#x201C;BC, is manager of care delivery and clinical operations for Fairview Physician Associates.

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10 ways NOT to get hit by a car from page 13

over your shoulder before moving left, having a mirror helps you monitor traffic without constantly having to look behind you. Never move left without signaling.

The Left Cross A car coming towards you makes a left turn right in front of you, or right into you. How to avoid this collision: Use a headlight, night and day. It makes you more visible. Wear something bright, even during the day. Yellow or orange reflective vests make a big difference, as do reflective leg bands. Don’t pass on the right. Slow down. If you can’t make eye contact with the driver (especially at night), slow down enough that you’re able to stop completely if you have to.

10 The Rear End, Part 2 A car runs into you from behind. The risk is greater at night and in rides outside the city, where traffic is faster and lighting is worse.

The Rear End, Part 1 You move a little to the left to go around a parked car or some other obstruction in the road, and you get hit by a car coming up from behind. How to avoid this collision: Never, ever move left without looking behind you first. Practice holding a straight line while looking over your shoulder until you can do it perfectly. You might be tempted to ride in the parking lane, dipping back into the traffic lane when you encounter a parked car. This puts you at risk. Instead, ride a steady, straight line in the traffic lane. Use a mirror. While you should always look back

MINNESOTA HEALTH CARE NEWS MAY 2011

A requisite starting point is the helmet. Wear one.

How to avoid this collision: Get a flashing red rear light. Wear a reflective vest or a safety triangle. Ride on streets with an outside lane wide enough to easily fit a car and a bike side by side. That way a car may zoom by without hitting you, even if the driver didn’t see you. Choose slow streets. The slower a car is going, the more time the driver has to see you. The risk of riding on Friday or Saturday night is much greater than riding on other nights. If you do ride on a weekend night, make sure to take neighborhood streets rather than arterials. Use your mirror. If it looks like a car approaching from behind doesn’t see you, hop off your bike and onto the sidewalk. This article is from the BicycleSafe.com website of Michael Bluejay, a writer, cyclist, and musician in Austin, Texas.

A philosophy of caring is good. A history of it is better. Caring. It would be nice if you could see it, like an amenity. Or tour it, like an apartment. But you can’t. All we can do is give you our definition: Caring is believing that everyone is someone who deserves to feel loved and valued, and be treated with dignity. That’s not just something we say. As the nation’s largest not-forprofit provider of senior care and services, it’s what we’ve been doing for almost 90 years.

www.good-sam.com

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

The Evangelical Lutheran Good Samaritan Society provides housing and services to qualified individuals without regard to race, color, religion, sex, disability, familial status, national origin or other protected statuses according to federal, state and local laws. All faiths or beliefs are welcome. Copyright © 2010 The Evangelical Lutheran Good Samaritan Society. All rights reserved. 10-G2016

break a vial habit

Model is for illustrative purposes only.

With FlexPen®, your patients aren’t limited by a vial and syringe. FlexPen® is a simple, patient-friendly insulin dosing option. And it’s available for the same copay as vial and syringe on most managed care plans.1* So, just add “FlexPen®” to your patients’ prescriptions and free both of you from the vial and syringe. For formulary access specific to your area, visit www.novomedlink.com. * Intended as a guide. Lower acquisition costs alone do not necessarily reflect a cost advantage in the outcome of the condition treated because there are other variables that affect relative costs. Formulary status is subject to change. Reference: 1. Data on file. Novo Nordisk Inc, Princeton, NJ.

October 2009