Minnesota Health care News October 2012 by Minnesota Physician Publishing

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October 2012 • Volume 10 Number 10

Childhood diabetes Renée Mijal, PhD

Indoor air quality Kathleen Norlien, MS

Should we tax pop? Roger Feldman, PhD

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CONTENTS

4 7 8

OCTOBER 2012 • Volume 10 Number 10

NEWS

INTERVIEW Presidential matters

CALENDAR

PEOPLE

PERSPECTIVE Roger Feldman, PhD University of Minnesota

10 QUESTIONS Laura Gilchrist PT, PhD St. Catherine University

BEHAVIORAL HEALTH Attention deficit hyperactivity disorder By Elizabeth Reeve, MD

24 26 28 30

President Barack Obama and Gov. Mitt Romney

National breast cancer awareness month

SPECIAL FOCUS: DIABETES Rising type 2 diabetes among youth By Renée Mijal, PhD, MPH, Tammy Didion, RD, LD, and Brandon Nathan, MD

Research update By Steven A. Smith, MD, and Elizabeth R. Seaquist, MD

Saving money on diabetes By Laurel Reger, MBA

ENVIRONMENTAL HEALTH Indoor air quality By Kathleen Norlien, MS, CPH

HOSPITALS Long-term acute care hospitals By Rahul Koranne, MD, MBA, FACP

www.mppub.com PUBLISHER Mike Starnes mstarnes@mppub.com EDITOR Donna Ahrens dahrens@mppub.com ASSOCIATE EDITOR Janet Cass jcass@mppub.com ASSISTANT EDITOR Scott Wooldridge swooldridge@mppub.com ART DIRECTOR Elaine Sarkela esarkela@mppub.com OFFICE ADMINISTRATOR MaryAnn Macedo mmacedo@mppub.com BUSINESS DEVELOPMENT DIRECTOR Juline Birgersson jbirgersson@mppub.com ACCOUNT EXECUTIVE Iain Kane ikane@mppub.com

MINNESOTA HEALTH CARE ROUNDTABLE

T H I R T Y- E I G H T H

SESSION

Background and Focus: The recent Supreme Court ruling on the Affordable Care Act clears the way for implementation of health insurance exchanges. States have the option of creating their own exchange by January 2014 or joining one created by the federal government. A health insurance exchange would provide consumers a place to compare and shop for health insurance coverage. In Minnesota this idea was first proposed as part of the Pawlenty administration’s healthAssuring they are meaningful care reform task force, and Gov. Dayton is a strong supporter of Thursday, November 1, 2012 creating a state-run program. 1:00 – 4:00 PM • Duluth Room Though simple and compelling at Downtown Mpls. Hilton and Towers first brush, creating a consumeraccessible, “apples-to-apples” website for comparing health insurance costs is challenging and very complex.

Health Insurance Exchanges:

Objectives: We will define what a health care insurance exchange is and, considering the detailed and proprietary design of health insurance coverage, how it can be meaningful. Health insurance policies contain terms like “medically necessary,” “investigative,” “cosmetic,” “not medically necessary,” and “contract/benefit exclusion”—all terms that are defined differently by different insurers. This alone makes it virtually impossible for anyone to compare plans effectively. Further, networks of providers vary, depending on whether you choose the “bronze,” “silver,” “gold,” or “platinum” option within a given insurer, as will access to hospital-based facilities, DME providers, and ancillary services. Throw in features like “deductibles,” “co-insurance,” “maximum out-of-pocket expenses,” “formulary design,” and “covered preventive services,” and you have a bewildering mathematical matrix. We will offer suggestions as to how an insurance exchange can address these issues and provide a meaningful, consumer-friendly comparison service. Panelists: Peter Dehnel, MD, President, Twin Cities Medical Society; Medical Director for Utilization Management, BC/BS MN Dan Maynard, President, Connecture Beth McMullen, Health Policy Director, Minnesota Business Partnership Manny Munson-Regala, JD, Deputy Director of the Health Insurance Exchange, Department of Commerce Charles Sawyer, DC, Senior Vice President, Northwestern Health Sciences University Dan Schuyler, Director, Leavitt Partners Sponsors: Connecture • Novartis • PhRMA 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

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

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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; email mpp@mppub.com. We welcome the submission of manuscripts and letters for possible publication. All views and opinions expressed by authors of published articles are solely those of the authors and do not necessarily represent or express the views of Minnesota Physician Publishing, Inc., or this publication. The contents herein are believed accurate but are not intended to replace medical, legal, tax, business, or other professional advice and counsel. No part of this publication may be reprinted or reproduced without written permission of the publisher. Annual subscriptions (12 copies) are $36.00. Individual copies are $4.00.

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NEWS

Survey Finds Seniors Optimistic About Health A new survey cosponsored by UnitedHealthcare (UHC) finds that most older Americans feel optimistic about their health, saying their best years are yet to come. The study, sponsored by the National Council on Aging, Minnetonka-based UHC, and USA Today, surveyed 2,250 U.S. citizens age 60 or older. It found that nearly 70 percent of respondents say their past year has been normal or better than normal, and more than 75 percent of seniors ages 60–69 say they expect their quality of life to stay the same or improve over the next decade. A large majority of seniors give themselves high marks when it comes to maintaining their health: 92 percent say they manage stress very well or somewhat well, and 84 percent say they are confident that they will be able to do what is needed to maintain

their health over the next five to 10 years. However, only 52 percent say they exercise or are physically active at least four days per week. Ten percent say their physical activity is limited to a few days per month; 11 percent say they are never physically active. “It’s encouraging that so many of our survey respondents feel confident and empowered to maintain their health as they age, but it’s important that this positive mindset doesn’t prevent them from taking the necessary steps to counter the epidemic of obesity among our senior population, such as exercising most days of the week to help maintain a healthy weight,” says Rhonda Randall, DO, chief medical officer, UHC Medicare and Retirement. The survey also finds a significant minority of seniors who face possible financial hardship and are not prepared for long-term care costs. Concerns about financial instability are most pronounced among low- and moderate-income survey respondents.

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– UCare member Duluth, MN

U of M Enlists Help To Find Clinical Trial Volunteers The University of Minnesota has enlisted a national research registry to help find volunteers for clinical trials. The partnership between The University of Minnesota Clinical and Translational Science Institute (CTSI) and ResearchMatch, a national group funded by the National Institutes of Health, will help U of M researchers connect with volunteers interested in participating in research studies. ResearchMatch gives potential participants information about clinical trails and other research they might be interested in, officials say. “Registering with ResearchMatch is an easy way for individuals to make a difference through research that is happening here at the University of Minnesota and other academic institutions across the country,” says Bruce Blazar, MD, a blood and marrow trans-

plant expert and director of the University’s CTSI. Minnesota ranks high among states in the amount of medical research being done. However, shortages of volunteers are an ongoing problem for researchers and clinical trials. Officials say ResearchMatch can be a useful resource for all kinds of research efforts. “Although data have shown that there are many individuals who want to join research studies, it can be hard to find the right match for them or their family members,” said Blazar. “The process of finding the right participant for the right clinical trial can be improved, and ResearchMatch is one way we’re improving that process.”

Eden Prairie Passes Community Health Initiative Eden Prairie passed a Healthy Eating Active Living resolution on Aug. 21, making it the second

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MINNESOTA HEALTH CARE NEWS OCTOBER 2012

Minnesota city to announce a policy of supporting healthy lifestyle strategies. A coalition of health groups called the Twin Cities Obesity Prevention Coalition (TCOPC) has been promoting Healthy Eating Active Living programs. TCOPC is sponsored by the Twin Cities Medical Society and funded by Blue Cross and Blue Shield of Minnesota. The first community resolution was passed by Eagan in March. “I think I can speak for all our physician members when applauding the Eden Prairie City Council and Mayor Nancy TyraLukens for their leadership and foresight in laying down a foundation for the future health and wellness of Eden Prairie residents,” says Peter Dehnel, MD, president of the Twin Cities Medical Society. The city council of Eden Prairie approved a group of strategies as part of the resolution that includes an emphasis on green space in planning housing developments; promotion of active living infrastructure, i.e., bike lanes, walking paths, and other activitypromoting community planning; and development of a healthy vending machine and concessions policy for city-owned facilities. The council also approved further development of community gardens, farmers’ markets, and “edible playgrounds,” which are gardens planted and tended by school-age children, who learn the benefits of gardening and healthy eating through the project. “In June, Eden Prairie introduced its first edible playground to teach children how food is produced and inspire kids to eat healthy and nutritious food,” says Eden Prairie Mayor Nancy TyraLukens. “Passage of this resolution furthers the city’s commitment to be a healthy eating and active living community.”

Report Calls Inactivity Cause of Poor Health A Mayo Clinic physiologist says that lack of exercise should be

treated as a medical condition. Michael Joyner, MD, writes in the Journal of Physiology that physical inactivity affects the health not only of obese people but also people of normal weight. Workers with desk jobs, patients immobilized for long periods of time after injuries or surgery, and women on extended bed rest can all experience serious medical conditions, such as atrophied bone or muscle, Joyner says. “I would argue that physical inactivity is the root cause of many of the common problems that we have,” Joyner says. “If we were to medicalize it, we could then develop a way, just like we've done for addiction … to give people treatments, and lifelong treatments, that focus on behavioral modifications and physical activity. And then we can take public health measures, like we did for smoking, drunken driving, and other things, to limit physical inactivity and promote physical activity.”

HealthPartners, Park Nicollet to Combine Organizations In one of the largest consolidations seen in the Twin Cities health industry in decades, HealthPartners and Park Nicollet Health Services have agreed to a merger. The move, announced Aug. 30, will make the new organization one of the largest health delivery systems in the state. HealthPartners’ unique position as both a health insurer and a delivery system may result in added scrutiny from regulators, who must approve the new arrangement. Bringing together two large provider groups in the metro area is historic, but not totally surprising at a time when rural Minnesota is seeing many small health systems being consolidated into larger groups. Health care reform and market pressures have already led metro-based systems such as HealthPartners, Allina

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News to page 6 OCTOBER 2012 MINNESOTA HEALTH CARE NEWS

News from page 5 Health, and Fairview Health Services to gobble up small to mid-size practices. The new agreement will create a 1,500-physician multispecialty group practice that is tied to HealthPartners’ insurance arm, although the clinics and hospitals involved will continue to work with other insurers as well. Officials say the two groups will have a combined, consumergoverned board of directors. The overall group will maintain the HealthPartners brand, but clinics and hospitals will continue with their current names for the near future. “HealthPartners and Park Nicollet share the same mission: making people healthier, making health care more affordable, and creating the best possible experience for our patients and members,” says Mary Brainerd, president and CEO of Bloomingtonbased HealthPartners, who will be CEO of the combined organization. “Separately, and in partnership, we’ve worked toward these

goals in the Twin Cities area for decades. Together, we’ll be better able to pursue this mission across our region for the benefit of the people we serve.” David Abelson, MD, president and CEO of St. Louis Park-based Park Nicollet, will lead the new organization’s care delivery system, which will be named the Park Nicollet HealthPartners Care Group. “Park Nicollet and HealthPartners are two of the strongest local collaborators in support of our common goal of improving access to high-quality, compassionate care for people in the Twin Cities,” Abelson says. “By combining our organizations, we’ll take that collaborative spirit much further, creating new potential for meeting the changing needs of our community at this important time in health care.” The combined operations will include Park Nicollet Methodist Hospital in St. Louis Park, four HealthPartners hospitals—Regions Hospital in St. Paul, Lakeview Hospital in Stillwater, Hudson

Hospital in Hudson, Wis., and Westfields Hospital in New Richmond, Wis.—and a large system of medical and dental clinics across the Twin Cities and western Wisconsin. Officials say they do not predict any layoffs or closures of facilities as a result of combining the two groups. The new agreement will be effective Jan. 1, 2013.

State Coalition Launches Healthy Minnesota 2020 A statewide coalition to improve the health of Minnesotans has approved a plan called Healthy Minnesota 2020. The plan was created by the Health Minnesota Partnership, a statewide initiative consisting of business, academic, nonprofit, and governmental leaders. The coalition has been looking at what factors contribute to health and how to address health issues in the state. The Minnesota Department of Health (MDH)

sponsored the coalition, and Health Commissioner Ed Ehlinger, MD, convened the group in January of this year. “Where we live, play, learn, and work has a huge impact on our health,” says Ehlinger. “Because of this, our goal is to improve the social, economic, and physical environments of our communities so that all Minnesotans have the opportunity to be healthy and reach their fullest potential.” The Healthy Minnesota 2020 plan will provide a framework for ensuring that every Minnesotan has a chance to be healthy, officials say. The coalition explored a range of factors that contribute to health, including social, economic, and environmental conditions. The framework it came up with recognizes that good health doesn’t come simply from health care providers or healthy eating, but is a result of many complex factors, including communities that promote healthy workplaces and schools.

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PEOPLE Ruby Tam, MD, has joined Northwest Family Physicians and will see patients at its office in Crystal. Tam received a master’s degree in chemistry at San Jose (Calif.) State University and worked for nine years as a process/project development scientist before going to medical school at Des Moines (Ia.) University. She completed her residency at Methodist Hospital in St. Louis Park. Jocelin Huang, MD, has joined Minnesota Oncology and began practicing at its clinics in

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Edina and Waconia in August. Huang received her medical degree from the University of Chicago Pritzker School of Medicine, and completed her fellowship in medical oncology and

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breast cancer; multiple myeloma; and lymphoma. Sue Sendelbach, PhD, RN, of Allina Health, has been appointed by Gov. Mark Dayton to the Minnesota Board of Nursing. Sendelbach is the director of nursing research at Abbott Northwestern Hospital in Minneapolis and has been a clinical nurse specialist in critical care there for more than 20 years. Sendelbach is active in local and

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national organizations dedicated to critical care, clinical nurse specialist issues, and care of patients with cardiovascular disease. Her fouryear board term began in June. The Minnesota Alliance for Patient Safety (MAPS) has named Marie Dotseth as its new executive director. Dotseth brings an extensive background in health care and health care policy to her new role in advancing MAPS’ safety agenda and providing education to Minnesota’s health care providers. She has worked with the National Institute of Health Policy at the University of St. Thomas, Children’s Hospitals and Clinics, Minnesota Department of Health, and Allina Health System, among others. Dotseth held an instrumental leadership role when MAPS was founded in 2000, serving as co-chair. Jewelia Wagner, MD, has joined the staff of Clinic Sofia, a women’s health care provider in the Twin Cities. She will be based at the clinic’s Edina location. Wagner received her medical degree from the University of Nebraska and completed her obstetrics and gynecology residency at the University of Kansas. Shoreview-based Chiropractic Care of Minnesota (ChiroCare) has named Vivi-Ann

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medicine, with some obstetric duties as well. Balaraman previously was chief resident of family medicine at Stamford (Conn.) Hospital. Balaraman received his medical degree at JJM Medical College in Davangere, India. He did his postgraduate training in ear, nose and throat at Command Hospital in Bangalore, India. St. Croix Orthopaedics, PA, has added two physicians: Nicholas Holmes, MD, and Eric Kirksson, MD. Holmes, a primary-care sports medicine physician, will provide care for patients at the practice’s new urgent care clinic in Lake Elmo. Kirksson, a physical medicine and rehabilitation physician, will treat patients at the Lake Elmo, Fairview Lakes, and Stillwater clinics. OCTOBER 2012 MINNESOTA HEALTH CARE NEWS

PERSPECTIVE

Obesity, diabetes, and a tax on pop Could economic sanctions on sugary drinks help curb disease?

Roger Feldman, PhD University of Minnesota

Roger Feldman, PhD, is the Blue Cross Professor of Health Insurance in the University of Minnesota’s Division of Health Policy and Management. He was a Marshall Scholar at the London School of Economics, served as a senior staff member of the President’s Council of Economic Advisers, and has served on the Panel of Health Advisers for the Congressional Budget Office.

Consumption of sugar-sweetened drinks is a major contributor to the current U.S. obesity and diabetes epidemics. In a recent issue of Health Affairs, a research team led by Columbia University’s Y. Claire Wang reported these stark facts:

Long-term benefit

Diabetes: deadly and rampant

Pop taxes have been criticized because they are regressive, meaning they fall more heavily on the poor, who consume more pop. But, according to a leading expert on obesity and nutrition, Yale University’s Kelly Brownell, the poor are disproportionately affected by diet-related diseases and would benefit most from reduced consumption of unhealthy food. Furthermore, a tax is among the least coercive methods of changing behavior. Rather than banning pop or restricting access to it, a pop tax nudges consumers to drink less pop.

And benefits from reducing calories would continue. Over 10 years, a penny-per-ounce tax would result, nationwide, in 95,000 fewer cases of coronary heart disease; 8,000 fewer strokes; 26,000 fewer premature deaths; and $17 billion dollars not spent on medical expenditures. (Those sav• The average American consumes almost 45 gallons of sugar-sweetened beverages annually. ings in medical expenditures are “discounted,” meaning that future savings are expressed in an • Consumption of sugar-sweetened beverages equivalent amount of today’s money.) has been linked to weight gain and diabetes. These would not be the only healthy conse• Women who consume at least one sugar-sweet- quences of taxing pop. People who drink two or ened beverage daily have more sugary soft drinks per an 83 percent to 98 perweek are twice as likely to cent increased risk of A 20-ounce bottle of pop develop pancreatic cancer as developing diabetes. nondrinkers, according to contains nearly University of Minnesota epi• A 20-ounce bottle of pop 17 teaspoons of sugar. demiologist Mark Pereira. contains nearly 17 teaspoons of sugar. Pros and cons of sanctions That’s right: three 20-ounce bottles of pop contain almost as much sugar as a chocolate cake. No wonder diabetes affects 25.8 million people of all ages in the U.S., according to the National Institutes of Health. And it’s increasing by almost 2 million people each year. Diabetes is a major cause of heart disease and stroke, and, according to the National Institutes of Health, is the seventhleading cause of death in the U.S. Diabetes is particularly rampant among the elderly and nonHispanic black adults, with prevalence rates of 26.9 percent and 18.7 percent, respectively. One way to reduce obesity The Centers for Disease Control and Prevention lists reducing the intake of sugar-sweetened beverages as a major obesity-prevention strategy. One way reduction could be accomplished would be by taxing such drinks. I estimate that a small tax, such as two cents per bottle, would reduce pop consumption by 5 percent. In Minnesota, that would represent 85 million fewer 12-ounce cans of pop consumed each year. Think of that as saving 2,550 calories per person each year. Short-term benefit Wang and her colleagues noted that some of the cut in calories from drinking less pop would be replaced by increased intake of nutritious drinks such as milk and juice. Even after allowing for calories obtained from milk and juice, an estimated 60 calories of every 100 pop-calories would not be replaced. Over the course of one year, this would represent almost one-half pound of body weight lost per person.

MINNESOTA HEALTH CARE NEWS OCTOBER 2012

New York City Mayor Michael Bloomberg caused a stir earlier this year by proposing to ban the sale of large sugary drinks in certain settings. His proposal was criticized by some as an intrusion on personal freedom. Another criticism of the proposed ban was that it would be hard to enforce and easy to evade. For example, people could avoid the ban by buying two regular-size drinks. Instead of banning large sodas, why not tax all sugar-sweetened soft drinks? A poll of New York City residents found that 72 percent would support a pop tax if the revenue were used for obesity prevention. Subsidizing healthy alternatives to pop would build support for a pop tax, especially if subsidies brought healthy foods into neighborhoods where they are not available. Worth considering A pop tax is not a silver-bullet cure for our obesity and diabetes epidemics. They have multiple causes, including the fact that many Americans work in sedentary jobs and have little time to shop for and prepare healthy food. Nevertheless, we need to use every weapon in our arsenal to fight these epidemics. A pop tax should be among those weapons.

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10 QUESTIONS

Researching nerve damage, improving cancer treatment Laura Gilchrist PT, PhD Dr. Laura Gilchrist is a professor in the Doctor of Physical Therapy (DPT) program at St. Catherine University, Minneapolis, and a clinical research scientist in the hematology and oncology program at Children’s Hospitals and Clinics of Minnesota. She specializes in the study of physical function in pediatric cancer patients. Not many people have professional expertise in both neuroscience and physical therapy. What led you to specialize in both fields? I started my professional career in basic neuroscience research, studying modulation of simple motor patterns like walking. I loved researching how the nervous system worked, but missed seeing the direct impact of my work. So, after completing a PhD in neuroscience, I looked for a way to apply my knowledge of the nervous system to patients. Physical therapy can directly improve someone’s function and quality of life by using neuroplasticity, the brain’s ability to form new pathways for sending messages to body parts. What kinds of medical conditions do you treat? Physical therapists treat patients who have movement disorders. Previously, I worked primarily with acute neurologic and cardiac disorders; currently, I work with children receiving cancer treatment. You are one of the few physical therapists in North America who studies nerve damage in children receiving chemotherapy. What can you tell us about this relatively new research area? This damage is called chemotherapy-induced peripheral neuropathy (CIPN). CIPN can produce weakness, shooting pains, numbness, lack of sensitivity to temperature, and/or tingling in the hands and feet that spreads to arms and legs. In children, it usually shows up during treatment, but in rare cases can appear months after chemotherapy is finished. These symptoms are serious in their own right and also because they may make it difficult for a patient to continue chemotherapy. CIPN is getting attention because for some pediatric cancers, survival rates now exceed 85 percent to 90 percent, which means that side effects of cancer treatment are more important than ever. Please tell us about the research you do at Children’s Hospitals and Clinics of Minnesota. My research addresses minimizing cancer treatment’s damage to the nervous and musculoskeletal systems. This includes determining which medications and treatment parameters minimize CIPN, plus rehabilitation techniques that improve function in patients who do develop CIPN. Currently, among children treated at Children’s Hospitals and Clinics of Minnesota, nerve damage is being recognized in more patients and earlier during chemotherapy, so that it can be appropriately addressed. A grant from the American Cancer Society supports our search for clinical indicators of persistent neuropathy in children whose cancer is cured. Ultimately, we aim to provide physicians and nurses with simple clinical indicators of CIPN symptoms that indicate a worse functional prognosis for children receiving cancer treatment.

Photo credit: Bruce Silcox

How do you interact with other medical professionals to care for patients? Physicians ask my research collaborators who are physical therapists to evaluate children when treatment decisions need to be made. For example, if a patient appears to be especially sensitive to [chemotherapy drug] vincristine’s side effects, the physician may have a therapist evaluate that patient’s neuropathy before determining the next dose. If the therapist can inform the physician that neuropathy is no worse than before the previous dose, the patient may be able to receive a full dose of chemotherapy.

MINNESOTA HEALTH CARE NEWS OCTOBER 2012

By interacting with physical therapists, physicians and nurses have learned more about gait and movement patterns that are worrisome, and are more likely to ask a therapist for an evaluation or to refer a patient for physical therapy. Does teaching physical therapy influence the way you provide patient care? Teaching in the DPT program forces me to make my clinical decisions explicit for students. That and exploring cases with students allow me to reflect on my clinical practice. What are some recent advances in physical therapy? It’s an exciting time. Therapists are using principles of neuroplasticity more than ever in rehabilitation strategies. Researchers are investigating ways to incorporate these principles into new treatment modalities, including robotics, virtual reality, and transcranial magnetic stimulation. Also, the field of regenerative medicine will change the way we treat patients in the future. For example, it may become possible to regrow damaged nerves in the spinal cord.

Sometimes, though, therapists need to recommend something that just isn’t fun, like the use of an orthotic or assistive device. Even then, the therapists are skilled at educating the patient and family on the reasons for the device, and help the child have a choice of color or decorations to make the device more tolerable. Please share a success story about your patients. It’s very satisfying to see a child or young adult who had a difficult time with neuropathy during treatment return to normal activities of life. I get to hear stories about how they are returning to normal activities such as playing soccer, competing in track, and going off to college.

By making exercises fun, therapists gain greater compliance.

How do you motivate pediatric patients to continue working hard to achieve their rehabilitation goals? I’ve learned so much from my therapist collaborators, who have great skill at adapting what could be a routine exercise into a game. For example, to strengthen ankle dorsiflexion (flexing the foot upward), a child might play tug of war with a sibling or therapist by using elastic tubing looped around the top of the child’s foot. By making exercises fun, therapists gain greater compliance.

How do you anticipate this work will change in the next 10 years? More patients will become involved with rehabilitation during cancer treatment. So often, patients are referred to physical therapy several years after treatment because they have persistent neuropathy and pain. By that time, the biomechanics of, say, the foot may have been damaged and they have suffered needlessly. Supportive care during chemotherapy, such as exercises to maintain mobility of the joint and the use of supportive orthotics, could prevent some of this suffering. Additionally, physicians will become more adept at determining which patients are at high risk of developing neuropathy from chemotherapy. There is fascinating ongoing research into determining genetic markers of susceptibility for specific side effects. A genetic profile could be done for each new patient, and his or her chemotherapy tailored to decrease side effects while still ensuring a cure.

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usan arrived at my office with three kids in tow, talking on her cell phone. I glanced at the clock: She was 45 minutes early for her appointment, which meant she must have forgotten what time to be here. Her 15-year-old, Sam, was here for his routine six-month visit for attention deficit hyperactivity disorder (ADHD). When they came in, the two youngest kids immediately started bickering over who was going to play with which toy. Sam busied himself on his cell phone, managing to send several text messages before he even sat down. Susan quickly pulled out Sam’s recent report card and expressed her dismay: three A’s, a C, and a D. Sam was bright, but his report card did not always show it. Sam chimed in that his poor grades were “because the class is boring and I don’t like the teacher.” Susan wondered if changing Sam’s medication would “solve the problem.” I wondered if she had followed up on my previous sugges-

Attention deficit hyperactivity disorder A lifetime condition that responds to treatment By Elizabeth Reeve, MD

tions to have her own symptoms evaluated. This family’s visit is a textbook example of ADHD across the lifespan.

Affecting children and adults ADHD has historically been thought of as a childhood disorder. We know now that 40 percent to 60 percent of ADHD children grow up to be ADHD adults. Unfortunately, only 5 percent to 10 percent of adults receive treatment for their symptoms. Treatment is worthwhile, however. Statistically, people with ADHD are at risk for additional mental health conditions, decreased income, underemployment, lower educational achievement, greater interpersonal conflict, and higher rates of substance abuse. In some studies, substance abuse is as high as 70 percent among adults with ADHD. During childhood and adolescence, ADHD increases the risk for early-age smoking, substance abuse, lower high school graduation

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Symptoms and subtypes rates, and increased teen pregnancy. ADHD’s personal impact changes family life. Parents of children with ADHD are more likely to miss work, often due to the need to go to school to pick up a child after a crisis. Children with ADHD have more frequent visits to the emergency room, more bike accidents, and, in later teen years, more motor vehicle accidents. On a day-to-day basis, family conflict in homes with ADHD children can be significant and disruptive.

Symptom category A. Six or more of the following symptoms of inattention have been present for at least six months to an extent that is inappropriate for developmental level:

Inattention • Doesn’t pay close attention to details/makes careless mistakes in schoolwork, work, or other activities. • Difficulty keeping attention on tasks or play activities. • Doesn’t seem to listen when spoken to directly. • Doesn’t follow through on instructions; doesn’t finish schoolwork, chores, or workplace duties (not due to oppositional behavior or failure to understand instructions). • Difficulty organizing activities. • Avoids/dislikes activities requiring sustained mental effort (schoolwork, homework). • Loses things needed for tasks and activities (toys, homework, pencils, tools). • Easily distracted. • Forgets to do daily activities.

What is ADHD?

ADHD is best described Symptom category B. Six or more of the folas a disorder of attention lowing symptoms of hyperactivity-impulsivity regulation rather than a have been present for at least six months to disorder of inattention. an extent that is disruptive and inappropriate Frustrated parents may for developmental level: lament the fact that their child (or perhaps their spouse) can focus “when they want to.” How can impaired attention, they ask, allow someone to play four hours of video games nonstop? The ability to focus and attend turns out to be a delicate balance among environment, motivation, and neurotransmission. Placed in different environments or given certain motivators, we all have variations in our attention spans. This explains why it takes us days to organize and complete our tax forms every April—and only a few minutes to get ready to go out when offered free movie tickets. Proper attention relies on three areas of brain function: arousal and alertness, processing, and memory. Typically, a person with ADHD has impairment in more than one of these areas, although ADHD may be an accurate diagnosis if one of these functions is significantly impaired.

Hyperactivity • Fidgets with hands or feet or squirms in seat when sitting still is expected. • Often gets up from seat when remaining in seat is expected. • Excessively runs around or climbs when/where it is inappropriate (adolescents or adults may feel very restless). • Difficulty playing or doing leisure activities quietly. • Is often “on the go” or acts as if “driven by a motor.” • Often talks excessively. Impulsivity • Blurts out answers before questions are finished. • Difficulty waiting for a turn. • Often interrupts. ADHD subtypes Combined. Six symptoms from category A and six symptoms from category B have been present for the past six months. Inattentive. Six symptoms have been present for the past six months from category A but not from category B. Hyperactive-Impulsive. Six symptoms have been present for the past six months from category B but not from category A.

Forty percent to 60 percent of ADHD children grow up to be ADHD adults.

Diagnosis An ADHD diagnosis depends on clinical data obtained during a physician’s visit. Testing by a psychologist or neuropsychologist may be helpful, but is not always necessary. Supplemental data from reliable resources is essential to confirm symptoms. This can come from Attention deficit hyperactivity disorder to page 23

OCTOBER 2012 MINNESOTA HEALTH CARE NEWS

H O S P I TA L S Now, there is another option: a long-term acute care hospital (LTACH). Bethesda Hospital, in St. Paul, is one of two LTACHs in the state. (The other is Regency Hospital, in Golden Valley.) LTACHs may be the least well-known type of health care facility. What exactly is an LTACH? Specialty hospital

Long-term acute care hospitals

LTACHs are licensed specialty hospitals that provide acute medical care over an extended period of time to critically ill patients who have complex medical conditions. You’ve left the hospital intensive care unit—now what? Currently, there are approximately 430 LTACHs in the United States. They are accreditBy Rahul Koranne, MD, MBA, FACP ed by the Joint Commission, an independent nonprofit organization that accredits and certifies more rom 2000 to 2005, I lived in Starbuck, Minn., than 19,000 health care organizations and programs and worked in a 20-bed hospital. There in the United States. weren’t many options available there for the LTACHs were created in the 1980s to enable sickest of the sick among our rural population. If a medically complex patients to be discharged from patient needed an intensive care unit (ICU), our hospital ICUs. This was done in part as a way to team would occasionally need to send that individual to the Twin control Medicare spending on high-utilization, critically ill patients. Cities. Once that patient was well enough to leave the ICU, options Such patients are the people that LTACHs are designed to serve. were limited if he or she still needed skilled medical care. Medicare data indicate that LTACH patients are “the sickest of the sick.” Patients don’t live permanently at an LTACH; the average length of stay for LTACH patients on Medicare is 25 days, although patients may stay for longer or shorter periods. This specialty hospital focuses on preparing a patient to 1) live independently and ultimately return to his or her home community or to 2) achieve the highest level of wellness possible before transferring to a less intensive level of care such as a skilled nursing facility, transitional care unit, or private home with home care services.

Admissions criteria LTACH patients require constant medical management by a physician and advanced nursing staff. Their conditions can include, but are not limited to, multi-organ or multisystem failure, including respiratory and cardiac complications; postsurgical or organ transplant complications; complex wounds; multiple injuries; traumatic brain injury; and acquired brain injury due to such causes as strokes, tumors, and infections. More than 40 percent of our patients need help being weaned from a ventilator; some require inpatient dialysis. Our patients are often referred directly from a hospital ICU by intensivists (physicians specializing in ICU care) or by hospitalists, physicians who see patients only in the hospital and help coordinate a patient’s transition away from the hospital ICU. Patients undergo a clinical assessment before being admitted to our LTACH, since they must meet certain criteria that confirm they need ongoing acute care. The top four criteria indicating a patient is ill enough to require LTACH services are: • The patient needs ongoing care at an acute hospital level.

MINNESOTA HEALTH CARE NEWS OCTOBER 2012

• The patient requires daily physician visits to monitor and change the care plan. • The patient has already been at a short-term hospital for more than five days. • A lower level of care has been unsuccessful, and the patient has been readmitted to the original hospital.

the longer a ventilator tube stays inserted in a patient’s airway, the greater that patient’s risk of developing a subsequent lung infection, called pneumonia. Ventilator weaning results in patients who are less likely to be readmitted to the hospital after LTACH discharge and who will be able to regain personal mobility. Ventilator weaning allows patients

Wide range of services LTACHs offer comprehensive, personalized LTACH patients are medical treatment and therapies designed to improve outcomes for medically complex “the sickest of the sick.” patients. They also provide a variety of medical and rehabilitation services that are not routinely offered at other types of post-acute facilities, such as care of complex wounds and injuries, and inpatient dialysis. to travel to physical therapy; free themselves from heavy, restrictive In addition, they offer comprehensive laboratory and radiology ventilator equipment; regain the ability to speak so they can clearly services on-site, medical specialists, and subspecialists. Our staff, for indicate their needs; heal more quickly; and, hopefully, have more example, includes pulmonologists, neurologists, psychiatrists, psychoice when it comes to choosing a less care-intensive facility when chologists, nephrologists, pathologists, geriatricians, physiatrists, they are ready to transition out of the LTACH. palliative care specialists, infectious disease physicians, and general When a hospital’s rate of ventilator-associated pneumonia is and plastic surgeons. The hospital also has in-house respiratory lower than national benchmarks, patients and families have a better therapy, pharmacy, laboratory, radiology, case management, and overall experience. Bethesda Hospital reported zero cases of ventilasocial service expertise. tor-associated pneumonia in calendar year 2011 and has received One of the core competencies offered by LTACHs is know-how national recognition for its ventilator-weaning protocol. in weaning a patient off a ventilator. (A ventilator is a machine that A few LTACHs, including ours, also offer neurological specialty assists a person’s breathing during surgery and often is needed after care that includes both brain injury services and medical behavioral surgery by critically ill patients.) Helping patients to no longer need care. Medical behavioral care is appropriate when various dementa ventilator is important for multiple reasons, including the fact that Long-term acute care hospitals to page 16

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Long-term acute care hospitals from page 15

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In addition, patients treated at LTACHs tend to be readmitted to shortterm acute care hospitals less often than patients treated in other post-acute care settings. A 2004 report to Congress noted that LTACH patients were readmitted to short-term acute care hospitals 26 percent less often than patients with similar conditions who were being cared for at skilled nursing facilities. Finally, a patient’s relatively longer length of stay at an LTACH allows patients and their families time to develop meaningful, lasting relationships with staff. This helps to build a strong sense of community within the LTACH.

LTACHs have been shown to reduce LTACHs have emerged health care costs in several ways. First, as a cost-effective safety net care provided at an LTACH costs less for post-ICU patients. than care in a hospital ICU. For example, among patients with tracheostomies —an incision in the front of the neck Cost-effective safety net through which a tube is inserted to facilitate breathing—Medicare As the health care system continues to work toward reducing costs spending for care is typically less when care is delivered in an and improving patient outcomes, LTACHs have emerged as a costLTACH than in a hospital ICU. Second, superior quality outcomes, effective safety net for post-ICU patients with complex medical such as lower rates of ventilator-associated pneumonia, mean conditions. that patients’ length of stay is shorter in an LTACH than in a Rahul Koranne, MD, MBA, FACP (Fellow of the standard ICU. American College of Physicians), is board-certified in Studies also show that LTACH patients are internal medicine and geriatrics and is the medical direcmore likely to be discharged to their home than are tor for Bethesda Hospital, HealthEast Care System Home individuals discharged from a short-term acute care Care, and HealthEast Care Navigation Strategy. facility like a hospital ICU.

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INTERVIEW

Presidential matters A discussion of health care with the two presidential campaigns PRESIDENT BARACK OBAMA Position on the ACA “The Affordable Care Act will make health care more affordable for families and small businesses and brings much-needed transparency to the insurance industry. “When fully implemented, the Affordable Care Act will keep insurance companies from taking advantage of consumers—including denying coverage to people with preexisting conditions and canceling coverage when someone gets sick. “Because of the new law, 34 million more Americans will gain coverage—many who will be able to afford insurance for the first time. Once the law is fully implemented, about 95 percent of Americans under age 65 will have insurance.”

With the Affordable Care Act’s (ACA) emergence as one of President Barack Obama’s signature accomplishments during his first term, health care was destined to be front and center in this year’s presidential race. Although the old axiom that the economy is always the first thing on voters’ minds remains true, in this election health care issues are also making an impact. And with the selection of Rep. Paul Ryan as Republican Mitt Romney’s running mate, the future of Medicare has become a major point of debate. With this in mind, Minnesota Health Care News has examined the two campaigns’ health-care policy positions. Here is a list of the candidates’ positions on top issues. All answers are taken from the official campaign websites unless otherwise noted.

How the ACA helps individuals and businesses “The ACA promotes better value through preventive and coordinated care, and eliminates waste and abuses. “The ACA also helps keep insurance premiums down. Insurance companies must publicly justify excessive rate hikes and provide rebates if they don’t spend at least 80 percent of premiums on care instead of overhead, marketing, and profits. As many as 9 million consumers are expected to get up to $1.4 billion in rebates because the President passed the ACA. “Millions of small businesses are now eligible for a tax credit to help pay for their health care premiums. The credit will increase to cover 50 percent of premium costs in 2014. “Under the ACA, help for small businesses—including the new insurance exchanges—will reduce small business health care spending by nearly 9 percent, according to independent estimates.”

Expanding coverage Starting in 2014, all Americans will have access to affordable health insurance no matter their circumstances—whether they change jobs, lose their job, decide to start a business, or retire early. Purchasing private insurance in the new state-based health insurance exchanges could save middle-class families who can’t get employer-provided insurance thousands of dollars. Young adults are now eligible to stay on their parents’ health insurance plans as they enter the workforce, until they turn 26. Since the health care law passed, 3.1 million young adults—traditionally the group least likely to be insured—gained insurance because of the ACA.

MINNESOTA HEALTH CARE NEWS OCTOBER 2012

GOV. MITT ROMNEY

Position on the ACA “The transformation in American health care set in motion by Obamacare will take us in precisely the wrong direction. The bill, itself more than 2,400 pages long, relies on a dense web of regulations, fees, subsidies, excise taxes, exchanges, and rule-setting boards to give the federal government extraordinary control over every corner of the health care system. The costs are commensurate: Obamacare added a trillion dollars in new health care spending. To pay for it, the law raised taxes by $500 billion on everyone from middle-class families to innovative medical device makers, and then slashed $500 billion from Medicare. “Obamacare was unpopular when passed, and remains unpopular today, because the American people recognize that a government takeover is the wrong approach. While Obamacare may create a new health insurance entitlement, it will only worsen the system’s existing problems. Obamacare will violate that crucial first principle of medicine: ‘do no harm.’ It will make America a less attractive place to practice medicine, discourage innovators from investing in life-saving technology, and restrict consumer choice.” Repealing and replacing the ACA “On his first day in office, Mitt Romney will issue an executive order that paves the way for the federal government to issue Obamacare waivers to all 50 states. He will then work with Congress to repeal the full legislation as quickly as possible. “In place of Obamacare, Mitt will pursue policies that give each state the power to craft a health-care reform plan that is best for its own citizens. The federal government’s role will be to help markets work by creating a level playing field for competition. “Mitt will begin by returning states to their proper place in charge of regulating local insurance markets and caring for the poor, uninsured, and chronically ill. States will have both the incentive and the flexibility to experiment, learn from one another, and craft the approaches best suited to their own citizens.” The Romney campaign says it will ease regulations on private insurers, promote high-risk pools, enact tort reform, and enable small businesses to form purchasing pools for insurance coverage. The campaign also gives a nod to the consumer-driven care model that employs health savings accounts (HSAs) for group plans by saying that Romney will “end tax discrimination against the individual purchase of insurance; unshackle HSAs by allowing

Birth control and women’s health “As part of the ACA … many insurance plans will be required to fully cover birth control without copays or deductibles as part of women’s preventive care. This step will help more women make health care decisions based on what’s best for them—not their insurance company—and could save them hundreds of dollars every year. “Certain religious organizations, including churches, We’ve extended will be exempt from the rules, and other religious organizathe life of Medicare tions will not have to pay for by almost a decade. their insurers to cover birth control. “Thanks to unprecedented new guidelines in the ACA, women will have access to a wide range of preventive health services—mammograms, cervical cancer screenings, and birth control—without a copay or deductible. The Affordable Care Act will also prevent insurance companies from discriminating against women so that being a woman is no longer considered a preexisting condition.” The future of Medicare [From the President’s weekly address, Aug. 25] “Thanks to the health care law we passed, nearly 5.4 million seniors with Medicare have saved over $4.1 billion on prescription drugs. That’s an average of more than $700 per person. And this year alone, 18 million seniors with Medicare have taken advantage of preventive care benefits like mammograms or other cancer screenings that now come at no extra cost. “Growing up as the son of a single mother, I was raised with the help of my grandparents. I saw how important things like Medicare and Social Security were in their lives. And I saw the peace of mind it gave them. That’s why, as President, my goal has been to strengthen these programs now, and preserve them for future generations. “That’s why, as part of the Affordable Care Act, we gave seniors deeper discounts on prescription drugs, and made sure preventive care like mammograms are free without a copay. We’ve extended the life of Medicare by almost a decade. And I’ve proposed reforms that will save Medicare money by getting rid of wasteful spending in the health care system and reining in insurance companies—reforms that won’t touch your guaranteed Medicare benefits. “Republicans in Congress have put forward a very different plan. They want to turn Medicare into a voucher program. That means that instead of being guaranteed Medicare, seniors would get a voucher to buy insurance, but it wouldn’t keep up with costs. As a result, one plan would force seniors to pay an extra $6,400 a year for the same benefits they get now. And it would effectively end Medicare as we know it.” “I’m willing to work with anyone to keep improving the current system, but I refuse to do anything that undermines the basic idea of Medicare as a guarantee for seniors who get sick.”

funds to be used for insurance premiums; and promote ‘co-insurance’ products.” Abortion and women’s health “Mitt believes that life begins at conception and wishes that the laws of our nation reflected that view. But while the nation remains so divided, he believes that the right next step is for the Supreme Court to overturn Roe v. Wade—a case of blatant judicial activism that took a decision that should be left to the people and placed it in the hands of unelected judges. “With Roe overturned, states will be empowered through the democratic process to determine their own abortion laws and not have them dictated by judicial mandate. “Mitt supports the Hyde Amendment, which broadly bars the use of federal funds for abortions. As president, he will end federal funding for abortion advocates like Planned Parenthood. He will protect the right of health care workers to follow their conscience in their work. And he will nominate judges who know the difference between personal opinion and the law.”

Mitt believes

Free market reforms that life begins at “Competition drives improvements in efficiency and effecconception. tiveness, offering consumers higher quality goods and services at lower cost. It can have the same effect in the health care system, if given the chance to work.” The Romney campaign says other steps to improve the free market for health care include: capping non-economic damages in medical malpractice lawsuits; empowering individuals and small businesses to form purchasing pools; preventing discrimination against individuals with preexisting conditions who maintain continuous coverage; and improving medical information technology systems. The future of Medicare “President Obama has had three years in office, during which time he has attacked every serious proposal to preserve and strengthen America’s entitlement programs while enacting cuts to Medicare and putting in place a bureaucratic board that one day may ration the care available through the program. “Mitt Romney … proposes that tomorrow’s Medicare should give beneficiaries a generous defined contribution, or ‘premium support,’ and allow them to choose between private plans and traditional Medicare. “Mitt’s plan honors commitments to current seniors while giving the next generation an improved program that offers the freedom to choose what their coverage under Medicare should look like. Instead of paying providers directly for medical services, the government’s role will be to help future seniors pay for an insurance option that provides coverage at least as good as today’s Medicare, and to offer traditional Medicare as one of the insurance options that seniors can choose. “With insurers competing against each other to provide the best value to customers, efficiency and quality will improve and costs will decline. Seniors will be allowed to keep the savings from less expensive options or choose to pay more for costlier plans.”

OCTOBER 2012 MINNESOTA HEALTH CARE NEWS

October Calendar 10

Flu Clinic Minnesota Visiting Nurse Agency (MVNA) will offer flu shots for adults and children age 3 and older. No appointment needed; bring your insurance card. Contact 612617-4600 or www.mvna.org for more information. Wednesday, Oct. 10, 5–7 p.m., Fairmount Ave. United Methodist Church, 1523 Fairmount Ave., St. Paul Aging Eye Forum Phillips Eye Institute eye specialists will discuss age-related vision issues and treatment options. Free parking. No charge for forum. To register, call (612) 775-8964 or email Elizabeth.albrecht2@allina.com. Thursday, Oct. 11, 6–8 p.m., Phillips Eye Institute, 2215 Park Ave., Minneapolis American Diabetes Association Expo Ask health care professionals your diabetes questions one-on-one, and take advantage of free health screenings. Check out the Bookstore, Family Fun Zone, and Healthy Eating Area, and pick up a Healthy Passport and pedometer. To register, call Molly at 763-593-5333 x6652, or email mduerr@diabetes.org. Saturday, Oct. 13, 9 a.m.–3 p.m., Minneapolis Convention Center, 1301 2nd Ave. S., Minneapolis

National Latino AIDS Awareness Day In 2003, the Latino Commission on AIDS and the Hispanic Federation joined forces to create National Latino AIDS Awareness Day, which initially involved just 100 cities. Minnesota joined the tradition in 2004. Further information about NLAAD can be found on the Minnesota Department of Health website, www.health.state.mn.us/.

Women’s HeartAdvantage Screening Help stop the most common cause of death in women—heart disease. Participate in a free heart screening hosted by HealthEast. There is no need to fast for this screening. Call 651-326-2273 for more information. Wednesday, Oct. 17, 10 a.m.–12 p.m., Keystone Senior Program, 2000 St. Anthony Ave., St. Paul

National Breast Cancer Awareness Month Did you know that there are more than 2.5 million breast cancer survivors in the United States? Although the chances of a woman contracting breast cancer in her lifetime are one in eight, death rates for this disease have been going down steadily, 2.7 percent annually in Minnesota alone. The key lies in early detection and smart lifestyle choices. Many risk factors for breast cancer are genetic and therefore not preventable, but some factors are avoidable lifestyle choices: • Drinking alcohol—More than two drinks per day will put a woman at 1.5 times the risk for cancer as a woman who drinks no alcohol. • Being overweight/obesity—While the links between weight and cancer are complex, women who carry most of their extra weight around their waist are at higher risk for cancer. • Lack of exercise—Studies have repeatedly shown that exercise can reduce the risk of breast cancer, and even exercise as moderate as brisk walking can make a difference. In addition to a healthy lifestyle, regular breast self-exams are encouraged. Women ages 20–39 should have a clinical breast exam (CBE) as part of a regular exam by a health expert at least every three years. After age 40, women should have a breast exam and a mammogram performed by a health expert every year. If you should feel anything unusual during a breast self-exam, contact a health professional right away. With early detection, your doctor can determine the most appropriate treatment for you, and the percentage of breast cancer survival can only increase. For further information about breast cancer, visit www.cancer .org/Cancer/ BreastCancer/ Oct. 22 Breast Cancer Support Group This group meets the third Monday of each month to discuss survivorship skills and reduce stress through mutual support. Free. No registration needed—come when you can. Call 763-236-6060 for information. Monday, Oct. 22, 7–9 p.m., Mercy Heart Ctr., 4040 Coon Rapids Blvd., Ste. 120, LL Conference Rm. 1, Coon Rapids

Hip Replacement Seminar If you are suffering from hip pain or having difficulty with lost mobility, this seminar may be for you. Dr. Kristoffer Breien will discuss recent advances in hip replacement surgery, including reduction in recovery time. Free. To register, call (651) 232-6704, or visit www.healtheast.org /orthorsvp. Wednesday, Oct. 17, 6–7:30 p.m., Orthopaedic Specialty Ctr., 1925 Woodwinds Dr., Woodbury

23–24

Food Day 2012 Come to a two-day event designed to build awareness of healthy, affordable, sustainably produced food. Oct. 23 will include a free food expo and panel discussions; Oct. 24 will feature an all-day film series. Free. Visit www.hfhl@umn.edu for more information. Tuesday, Oct. 23, 10 a.m.–3 p.m. and Wednesday, Oct. 24, 9 a.m.–8 p.m., Coffman Memorial Union, 300 Washington Ave. S.E., Minneapolis

Nov. 3 Brain Injury Consumer Conference The Minnesota Brain Injury Alliance presents a conference for individuals with brain injury and their loved ones. There will be workshops and sessions focusing on innovations in brain injury care, therapy, and rehabilitation. Free. To register, call (612) 378-2789 or visit www.braininjurymn.org. Saturday, Nov. 3, 1 p.m.–4 p.m., North Como Presbyterian Church, 965 Larpenteur Ave. W., Roseville

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

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MINNESOTA HEALTH CARE NEWS SEPTEMBER 2012

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

Model is used for illustrative purposes only.

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

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

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

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

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

Non-insulin • Once-daily

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

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

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

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

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

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

Attention deficit hyperactivity disorder from page 13

school report cards and from communication with teachers or a significant other. There are three types of ADHD: the inattentive subtype, the hyperactive/impulsive subtype, and the combined subtype. The particular subtype depends on which combination of symptoms someone has. Symptoms used to diagnose ADHD are adapted from the Centers for Disease Control and Prevention and are grouped into two categories, shown in the sidebar on page 13. Diagnostic standards require individuals to have six symptoms in one category to meet criteria for the inattentive or hyperactive subtypes, and six symptoms in each category to meet criteria for the combined subtype. Symptoms must be present before the age of 7 and cause day-to-day functional impairment. In addition, a diagnosis of ADHD requires that symptoms cannot be better explained by another condition. For example, children with autism often struggle with focus and inattention. Since these symptoms can be accounted for by autism, they do not count toward a separate diagnosis of ADHD.

Treatment Treatment is in two primary categories: pharmaceutical and nonpharmaceutical. Evidence suggests greater efficacy for pharmaceutical interventions, but nonpharmaceutical approaches are beneficial and should be incorporated into overall treatment strategy for all patients.

Particularly useful are behavioral approaches that help the patient develop skills in time management, organization, impulse control, and prioritizing. Pharmaceutical treatments for ADHD focus on medications from two major groups, stimulants and nonstimulants. Stimulants. Potential side effects include appetite suppression, weight loss, height suppression, bodily or vocal tics, mild increase in heart rate (tachycardia) and blood pressure, headaches, insomnia, irritability, and stomach upset. Nonstimulants. Unlike stimulants, which can be stopped and started abruptly without effecting efficacy, nonstimulants need to be taken daily and take weeks before they work at full efficacy. Patients who respond only partially to either class of medication may be prescribed both a stimulant and a nonstimulant, a common medical practice that is well tolerated by most patients.

Responds to treatment

ADHD is best described as a disorder of attention.

ADHD is a common but often undertreated disorder that should be recognized as a lifetime condition. Untreated, its long-term outcome can impact work, home, and family. Symptoms may show themselves differently as a patient ages, but continue to need, and respond to, treatment. Elizabeth Reeve, MD, practices child and adolescent psychiatry at Regions Hospitalâ&#x20AC;&#x2122;s Child and Adolescent Psychiatric Clinic in St. Paul. She was named 2012 Psychiatrist of the Year by the Minnesota Psychiatric Association.

Read us online

wherever you are!

www.mppub.com OCTOBER 2012 MINNESOTA HEALTH CARE NEWS

SPECIAL FOCUS: DIABETES

Rising type 2 diabetes among youth

An alarming trend By Renée Mijal, PhD, MPH, Tammy Didion, RD, LD, and Brandon Nathan, MD

Attention Diabetics

North Metro

We serve the portion of the diabetic community with low income and limited access to care. You may be in a position to help us help them.

Orthotics & Prosthetics Our fully trained and professional staff members ensure specialized care of diabetic feet. We take the time to determine the best plan of treatment for your unique conditions. By using an on-site fabrication lab for diabetic inserts, patients receive a truly custom product. Evaluation and follow-up adjustments are provided at no additional cost. We also offer a wide range of diabetic shoes from leading manufacturers including: • Dr. Comfort • Drew • Brooks

• New Balance • Orthofeet • Many more

If you are eligible for Medicare, Diabetic shoes and Inserts are covered from 80 to 100% and we will bill Medicare for you. Coverage for non-Medicare members varies by plan. We can help you ask the right questions to determine your benefits.

Three convenient Metro locations Fridley Coon Rapids Elk River 24-hour On-call

763-784-6647 Other services include: Artificial Limbs Custom and non-custom Braces Mastectomy and Compression

www.northmetro-op.com 24

here are two main forms of diabetes: type 1, formerly called juvenile diabetes, and the more common type 2, formerly called adult-onset diabetes. In type 1 diabetes, the body’s immune system attacks and destroys cells in the pancreas called beta cells. Beta cells produce insulin, a hormone that allows the body to use carbohydrates and helps to regulate the amount of sugar in the blood. Because the insulin-producing beta cells are destroyed, people with type 1 must take insulin for the rest of their lives to regulate blood sugar. In people with type 2 diabetes, the pancreas still produces insulin, but the cells in the body stop responding to it and do not use blood sugar appropriately. Over time, people with type 2 diabetes may have problems producing insulin and require supplemental insulin for the rest of their lives. Both types of diabetes result in high blood sugar levels and can be associated with lifelong complications such as kidney, eye, and heart disease.

MINNESOTA HEALTH CARE NEWS OCTOBER 2012

Do you ever have too many test strips? Do you ever end up throwing them away? We can take your unexpired & factory sealed boxes of test strips and even offer up to $20 per box of 100. We accept most brands and offer local pickup. We’ll get them into the hands of those that need them most.

For more information, please call

763-229-2795 Minnesota Diabetic Test Strips

How many kids have it?

More resources for parents

Children and Diabetes: (from the Centers for Disease Control and Historically, children diagnosed with diabetes Prevention): www.cdc.gov/diabetes/projects/cda2.htm typically had type 1 and almost never got type Tips for Teens: Lower Your Risk for Type 2 Diabetes: 2. However, during the past 30 years, the (from the National Diabetes Education Program): number of young children and youth with www.ndep.nih.gov/teens/LowerYourRisk.aspx type 2 diabetes has increased. Research findings Children & Adolescent Overweight (From the Minnesota Department presented at the 2012 American Diabetes of Health): www.health.state.mn.us/divs/hpcd/chp/cdrr/ Association Scientific Sessions showed that obesity/pdfdocs/childrenoverwightfactsheet.pdf the number of type 2 diabetes cases among Take Action Now to Prevent Diabetes Later (from the National Diabetes 10- to 19-year-olds increased 21 percent Education Program): Information for mothers who had diabetes during between 2001 and 2009. pregnancy about how to prevent diabetes in themselves and in their The exact number of young children and families. www.ndep.nih.gov/am-i-at-risk/gdm/take-action.aspx youth in Minnesota with either type 1 or type Youth Physical Activity Toolkit (from Centers for Disease Prevention 2 diabetes is unknown. However, using 2001 and Control): Information for families, schools, and other groups to help national study data, we estimate that 2,600 children and youth keep physically active www.cdc.gov/Healthyyouth/ of the 1.4 million Minnesotans 20 years or physicalactivity/guidelines.htm#1 younger have diabetes (approximately 18 in 10,000). Of those, we estimate that most type Social impact 2 cases occur among the state’s 720,000 10- to 19-year-olds, with • Managing diabetes, including activities like checking blood gluapproximately four of every 10,000 youth affected. cose levels during school, can make youth feel different from their Risk factors peers and complicate delivery of care. Age, ethnicity, family history, and obesity are risk factors for type 2 • Children who are obese (most youth with type 2 diabetes are diabetes. obese) are more likely to report lower social functioning than Age. Adolescents are the most likely age group to develop type 2 diabetes. Ethnicity. Native American, Asian/Pacific Islander, Latino, or African American youth aged 10 to 19 are more likely to have type 2 than similar-aged Caucasians. Family history. Nearly 100 percent of youth that develop type 2 diabetes have a biological mother, father, sister, or brother who also has type 2 diabetes. Obesity. Being obese increases the risk of developing type 2 diabetes. Data from the 2010 Minnesota Student Survey, a survey of public school students, indicates that 9 percent of ninth and 12th graders meet the criteria for being obese.

Impact

Many people with type 2 diabetes are not aware that they have diabetes.

Type 2 diabetes affects youth during adolescence and into adulthood. Since type 2 diabetes in youth has only recently begun to be seen in larger numbers, its consequences and lifelong burden are not fully understood. However, its burden during childhood and adolescence includes: Physical impact • By the time youth are diagnosed with type 2 diabetes, they frequently have protein in their urine. This can be an early sign of kidney disease.

healthy children. Emotional impact • Boys with type 2 diabetes are more likely to be moderately or Rising type 2 diabetes among youth to page 34

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

• Youth with type 2 diabetes tend to develop diabetes-related kidney disease more rapidly than do adults with diabetes. • Youth with type 2 diabetes are more likely to have high blood pressure, higher cholesterol and triglyceride levels, and other indicators of poor heart health as compared with peers in the general population, those with type 1 diabetes, and obese youth without diabetes.

EXERTstudy.org OCTOBER 2012 MINNESOTA HEALTH CARE NEWS

SPECIAL FOCUS: DIABETES

Research update U of M and Mayo Clinic— working together to conquer diabetes

year for which this information is available, iabetes is a disease with significant the estimated cost of diabetes-related and devastating physical, ecomedical expenses in the U.S. totaled $174 nomic, and social impact on indibillion a year. Closer to home, diabetes viduals and society. It is the No. 1 cause of By Steven A. Smith, MD, costs Minnesotans $2.68 billion per year. blindness and kidney failure, and the sevand Elizabeth R. Seaquist, MD An estimated one in three adults and enth-leading cause of death in the United one in six youth in the state have diabetes States. More than 25 million Americans or prediabetes. Prediabetes adversely have diabetes, and recent projections from affects health whether or not it progresses to diabetes, which in one the Centers for Disease Control and Prevention estimate that one in federal study was shown to occur in 10 percent of participants per three American adults may have diabetes by 2050. year over a three-year period. This means that 30 percent of prediaMedical expenses for people with diabetes are typically more betics were diagnosed with type 2 diabetes within three years after than twice those for people without the disease. One in three being diagnosed with prediabetes. Diabetes is a growing—and Medicare dollars is spent on diabetes, and in 2007, the most recent serious—epidemic.

Three-pronged approach

Cholesterol Do you know your numbers?

Ask your doctor

The h Goodd = HDL Cholesterol: Keep it high The Bad = LDL Cholesterol: Keep it low The Ugly = too much cholesterol can lead to heart attack and stroke Visit www.heart.org for more information about cholesterol and heart health

Minnesota Diabetes & Heart Health Collaborative

The Minnesota Diabetes and Heart Health Collaborative: Working together to keep you informed

www.mn-dc.org

MINNESOTA HEALTH CARE NEWS OCTOBER 2012

In addition to research into diabetes that is being conducted independently at the University of Minnesota and at Mayo Clinic, both institutions are collaborating on research to address the growing diabetes epidemic. In 2010, the two institutions launched the Decade of Discovery: A Minnesota Partnership to Conquer Diabetes, with the goal of making substantial progress by 2020. This partnership’s three-pronged approach aims to prevent, optimally treat, and ultimately cure type 1 and type 2 diabetes, related conditions in which levels of the sugar glucose within the body are not regulated appropriately. To accomplish this, more than $2 million has been invested in 10 research projects thus far. Projects include basic science research to discover previously unknown scientific information and refine current understanding of existing information, as well as applied research that takes information discovered and translates it into devices, medicine, and best practices to achieve prevention, treatment, cure, and optimal delivery of care.

Improving treatment Two projects aim to advance the development of an artificial pancreas for improved treatment of both type 1 and type 2 diabetes. An artificial pancreas is a device that automatically administers the correct amount of insulin to a patient. For such a device to work, it must operate 24/7 to automatically and continuously measure the amount of glucose in a person’s blood, use that measurement to determine how much insulin is needed minute by minute, and deliver the correct amount of insulin to the bloodstream on a minuteby-minute basis. Current technology is limited by the types of

Diabetes is the No. 1 cause of blindness and kidney failure. glucose sensors that are available and the ability to couple information those sensors collect about changes in a personâ&#x20AC;&#x2122;s blood glucose levels with changes in the rate of insulin administration. In one project, Dr. Yogish Kudva (Mayo Clinic) and Dr. Steven Koester (University of Minnesota) are developing a specialized electronic chip to improve glucose sensors. Currently available sensors in insulin pumps require a patient to insert the catheter of an insulin pump in a different location under his or her skin every three to seven days. The chip under development is intended to be inserted under the skin in a minor surgical procedure every few months. This should provide diabetic patients with a more sensitive and reliable form of blood glucose monitoring as well as decreasing the amount of time they spend maintaining their insulin pumps. In a second project, Mayo Clinic researchers Drs. Andy and Rita Basu are working with Dr. Kudva to learn more about how changes in blood glucose are reflected in changes in tissue glucose. Current technology measures the level of glucose that is in fluid within tissue under the skin. However, this is only an approximate measure of glucose levels in tissue because many factors affect how quickly glucose moves from blood to tissue, including diet, stress, and exercise. Since knowing how much glucose is in the blood is necessary to calculate an accurate insulin dose, we need to know more about how we can use the measurement of tissue glucose as a surrogate for blood glucose in the delivery of insulin. In this project, investigators will change blood glucose levels to see how quickly these changes appear in tissue glucose. Results of this research will be used to automate the insulin delivery system within an artificial pancreas.

Diabetes costs Minnesotans $2.68 billion per year.

Understanding the cause In a project that may help treat type 2 diabetes and may one day prevent it, Dr. Alessandro Bartolomucci (University of Minnesota) and Dr. John Miles (Mayo Clinic) are investigating a newly discovered naturally occurring peptide that increases fat breakdown and enhances weight loss. (A peptide is a molecule that that conveys messages within and between cells.) In addition, Dr. Brian Fife (University of Minnesota) and Dr. Govindarajan Rajagopalan (Mayo Clinic) are altering the immune system of a mouse to resemble that of a human in order to identify what triggers the destruction of the insulin-producing cells that occurs in type 1 diabetes.

Assessing success To determine the success of future strategies to prevent and treat diabetes, Decade of Discovery investigators compiled the Minnesota Health Atlas (www.mnhealthatlas.org), a comprehensive database that includes information about the health of those Minnesotans who have diabetes and those who are at risk for it. This collection of data provides insight into the prevention and treatment of diabetes across the state on a county-by-county basis. The Atlas project, led by Mayo Clinicâ&#x20AC;&#x2122;s Jeanette Ziegenfuss, PhD, and her team, in cooperation with public heath organizations, health care providers, and pharmacies, created a baseline snapshot of diabetes in the state that can be compared against future health statistics to assess the success of future interventions designed to improve diabetes prevention and care delivery.

Potential health benefit Decade of Discovery research and other research efforts at the University of Minnesota and Mayo Clinic have the potential to provide enormous individual and public health benefit by helping people with diabetes live healthier lives. In so doing, this research is expected to ultimately reduce the cost of health care for employers, the state, and, therefore, for taxpayers. Steven A. Smith, MD, is a professor of medicine in the Division of Endocrinology, Diabetes, Nutrition, and Metabolism at the Mayo Clinic. Elizabeth R. Seaquist, MD, is a professor of medicine in the Division of Endocrinology and Diabetes at the University of Minnesota, where she holds the Pennock Family Chair in Diabetes Research. The authors are Decade of Discovery collaborators.

Are you a Diabetic on Medicare? If so, Medicare as a covered benefit for qualified individuals will help pay for:

1 Pair of Extra Depth Shoes and 3 Pair of Diabetic Inserts. Foot Solutions is a Medicare approved supplier for this program. Please stop by for more information.

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OCTOBER 2012 MINNESOTA HEALTH CARE NEWS

SPECIAL FOCUS: DIABETES

Saving money on diabetes Diabetes is expensive. According to the American Diabetes Association (ADA), people with diabetes typically spend more than $13,000 annually on their health care—three times the amount spent by people without the disease. Fortunately, there are many ways to cut the cost of managing diabetes.

Reduce cost, not medicine

Don’t cut back on medicine People with diabetes who have trouble affording medical supplies should not reduce the amount of medicine they take, the frequency with which they take it, or how often they test their blood sugar (based on their doctor’s instructions). Instead, they may be pleasantly surprised to learn that their pharmacist or other members of their health care team can suggest ways to lower expenses. Here are cost-saving ideas to explore. • There are multiple treatments for diabetes. Ask if your treatment can be adjusted to cost less. • Request prescriptions for generic drugs and those covered by your insurer.

By Laurel Reger, MBA • Ask your doctor or pharmacist if it would be appropriate and cheaper to get 90-day prescription refills, or higher dosage pills that you could cut in half. Also ask if a combo-med (two medicines in one pill) would work for you. • Ask your clinic for free samples or manufacturers’ coupons for diabetes medicines and supplies. • Approximately 700 prescription drug discount programs are available. Some have restrictions and some may require people with diabetes to apply separately for each

Minnesota Optometric Association

Doctors on the frontline of eye and vision care Did you know? • Diabetic retinopathy can be controlled and diabetic patients need regular eye exams to maintain vision and good eye health. • Diabetes Type ll can also cause vision changes. • Glaucoma must be diagnosed in early stages in order to prevent vision loss. • All children entering school need a comprehensive eye exam, because vision screenings do not detect a number of eye disorders. • To maintain eye health, everybody from babies to boomers to older adults needs a regular eye exam by a family eye doctor. To locate an optometrist near you and find comprehensive information about eye health visit http://Minnesota.aoa.org

MINNESOTA HEALTH CARE NEWS OCTOBER 2012

Diabetic?

You may have PAD and not even know it. 50% of people with PAD don’t exhibit symptoms.

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Peripheral Arterial Disease (PAD) affects 1 in 3 people over 50 with diabetes. 9 of 10 cases go untreated which can lead to leg amputation. Typical symptoms are leg cramping while walking, pain in legs that disturbs sleep, color changes in skin of feet, and poor toenail growth. Diagnosis is easy – a simple, 10-minute, non-invasive ABI test compares blood pressure in the arm and leg. Find out now if you suffer from PAD.

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medication they take. Ask your doctor to find the right programs for you.

Prescription assistance programs • Minnesota RxConnect helpline (800) 333-2433 • Partnership for Prescription Assistance, www.PPARx.org

If you have health insurance

• PhRMA, www.RxHope.com

• Call your insurer (there’s a phone number on the back of an insurance card) to ask which diabetes supplies and equipment are covered. Most insurers cover at least some of the cost of disposable supplies, diabetic shoes or inserts, wheelchairs, lift chairs, and other items prescribed by your doctor. Certain items, including wheelchairs, are available free on short-term loan from Goodwill. • If you are eligible for Medicare Part D, compare plans carefully to select the best coverage for your diabetes medicines. Free help understanding your options is available by calling the Minnesota Senior LinkAge Line at (800) 333-2433 or by emailing senior.linkage@state.mn.us.

• Volunteers in Health Care, www.rxassist.org

If you have Medicare Medicare covers the following, but some limitations apply; check with www.medicare.gov for details. • Diabetes screening • Diabetes self-management training by an accredited education center • Medical nutrition therapy by a dietitian or nutrition team • Diabetes supplies • Free flu and pneumococcal shots • Foot exams • Therapeutic shoes prescribed by your doctor

mental health services, and more. • In the metro area, St. Mary’s Health Clinics offer free health care, medicines, and help acquiring other health services. Call (651) 2877777 to see if you are eligible. • United Way 2-1-1 is a free, confidential way to find health care, transportation, and additional services. Call 2-1-1, or (651) 2910211 from a cell phone, 24/7. Help is available in more than 100 languages, including Spanish, Hmong, Somali, and Russian. Whether you have health insurance or not, discount programs are available. • Contact the ADA for discount programs for diabetes medicines and blood glucose meters at www.diabetes.org (search “prescription assistance”) or call (800) DIABETES (342-2383). • UnitedWay has a drug discount program for everyone: go to www.familywize.org. • Many large pharmacies such as Walgreens and WalMart have discount cards and offer certain prescription drugs for $4 per refill. • Ask your employee benefits office, union, co-op, or membership organization (such as AARP) if it offers prescription drug discounts. Saving money on diabetes to page 33

• Insulin, medicines, and some supplies under Medicare Part D

If you don’t have health insurance • See if you qualify for programs providing lower cost prescription drugs, supplies, and services, at www.benefitscheckup.org.

In the next issue..

• Check www.MinnesotaHelp.info for local health care and prescription drug resources. • Most Minnesota counties have their own health-care discount programs. Contact your county social services or local public health agency to see what it offers.

Ask if your treatment can be adjusted to cost less.

• “Financial Help for Diabetes Care” lists resources for diabetes products, services, and insurance: www.diabetes.niddk .nih.gov/dm/pubs/financialhelp • Join a diabetes research study. Study participants may receive free medicines and services, incentive awards, or payment. Search www.clinicaltrials.gov to find research trials that may accept you.

• Shop around for the best prices; the cost of prescription medication can vary between pharmacies. Online tools like www .Medtipster.com help you find the lowest price at pharmacies in your area. Mail order pharmacies and those offering discount cards may also save you money. If you cannot afford to see a doctor, visit a free or low-cost clinic.

• Plantar fasciitis • Pacemakers for pain • Seasonal affective disorder

• Find a local community health center at http://findahealthcenter .hrsa.gov/ for free or low-cost services that may include dental care, OCTOBER 2012 MINNESOTA HEALTH CARE NEWS

E N V I R O N M E N TA L H E A LT H

Indoor air quality Keeping it healthy By Kathleen Norlien, MS, CPH

n 1644, English jurist Sir Edward Coke (1552–1634) was quoted as saying, “For a man’s house is his castle, et domus sua cuique tutissimum refugium” (and one’s home is the safest refuge for all). But this may no longer be true. Today’s homes can be plagued by indoor pollutants that include off-gassed chemicals from carpet and other manufactured home furnishings; cigarette smoke and other byproducts of combustion; and naturally occurring pollutants such as mold and radon. The quality of the air we breathe inside may worsen when homes are tightened up to save energy and in winter when windows stay shut and ventilation decreases. In fact, the Environmental Protection Agency (EPA) ranks indoor air as the fourth biggest source of exposure to contaminants, in part because people spend up to 90 percent of their time inside. The good news is that people can take steps to improve their indoor air quality, with even small changes resulting in improved health.

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

(651) 603-0720 • (800) 511-3696 30

MINNESOTA HEALTH CARE NEWS OCTOBER 2012

Pollution sources

Asthma and air quality

ent in the home; pesticides and other outdoor contaminants tracked inside on shoes; pollen; and other allergens such as dust mites. Dust mites breed in warm, moist environments and are typically found in greatest numbers in bedrooms. Someone allergic to dust mites could consider investing in mite-proof covers for the mattress and pillow in addition to regularly vacuuming, damp dusting, and washing bed linens in hot water and drying them on high heat. Keep clutter to a minimum for easier cleaning.

For the estimated 392,000 children and adults in Minnesota who currently have asthma, maintaining a healthy home can be a crucial part of asthma control. Indoor sources of air pollution may trigger asthma attacks and contribute to hospitalizations, unplanned doctor visits, and absences from school and work. Therefore, it is of utmost importance that homes be made healthy for people with asthma, especially if their asthma triggers are linked to contaminants in the environment.

Indoor air pollutants are radiological, chemical, or biological in nature. Biological pollutants include mold, pets, and pests. Chemical pollutants include formaldehyde and volatile organic hydrocarbons emitted by carpet, paint, furniture, and textiles; scented products such as air fresheners, cleaning products, and personal care products; asbestos; lead; and byproducts of combustion. Combustion byproducts include carbon monoxide (CO); nitrogen dioxide (NO2); and particulates from wood smoke, gas-burning appliances, and tobacco smoke. A radiological pollutant in Minnesota is most likely to be radon, a naturally occurring radioactive gas in the ground. Radiological. Radon typically seeps into a home through cracks and drains in the basement floor. It is the leading cause of lung cancer in nonsmokers, so it is prudent to perform the simple and relatively inexpensive test for it. If radon is found to be at an unsafe level, a radon-mitigation professional can install equipment that reduces the amount of the gas entering the home. More information on radon and how to test for it is at: www.health.state.mn.us/divs/eh /indoorair/radon/radontestresults.html

Biological. To prevent mold growth, keep your house dry; maintaining a relative humidity below 50 percent generally keeps mold from growing. Watch for leaks in the building envelope—roof leaks, wet basements, and leaking pipes under sinks— and fix them within 24 to 48 hours. Make sure that your home is well ventilated and use ventilation fans in bathrooms and kitchens. These fans should vent to the outdoors, not into an attic or other interior area, and can The EPA ranks be wired to operate by timer to ensure regindoor air as the ular use. Use carpet-free flooring in moisfourth biggest ture-prone areas such as kitchens, baths, source of and basements. Dehumidifiers are helpful exposure to in areas that become damp when it rains or when humidity is high, such as basements. contaminants. Maintain them with regular cleaning and by emptying reservoirs that collect water and changing filters as necessary. Refer to the owner’s manuals for more detailed instructions on how to operate and maintain all your appliances so they function effectively and don’t become breeding grounds for mold or other microbiological hazards. Pets can be problematic for people allergic to them, but keeping pets out of the bedroom and off furniture helps. Regular house cleaning helps too, by reducing the amount of pet hair in the home. Maintaining a clean house is also important because it reduces household dust, which can contain lead from lead paint that may be pres-

Chemical. Minimize the use of chemicals within your home. Used improperly— without carefully following directions or when mixed with other chemicals—they may be hazardous to your health. If you must work with harsh chemicals, use the correct type of protective gloves, eyewear, and other protective equipment. Always work with chemicals in well-ventilated areas. Avoid disturbing floor tiles or other home-building materials that may contain asbestos, as that releases fibers into the air that can cause lung cancer and Indoor air quality to page 32

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doors. Be sure to have working alarms for CO and smoke in your home as well as in atypical living spaces such as cabins, campers, and ice-fishing houses. Wood and gas stoves used in homes should be inspected and cleaned annually, and old stoves replaced with EPA-certified models. Wood Maintaining a burned in a wood stove, fireplace, or even outhealthy home can doors should be clean, dry, and not from a be a crucial part of chemically treated source such as broken furniture. This is because heat from the fire releases asthma control. harmful chemicals into the surrounding air. And since smoking is a known health hazard that contaminates the air around it, it should be done outdoors.

Indoor air quality from page 31

other diseases if inhaled in sufficient quantity. Instead of buying scented household cleaning products, clean with vinegar and baking soda. Unscented personal care products support indoor air quality better than scented ones. If you plan to buy paint or home furnishings, request they be manufactured of low-emitting materials, or purchase floor-model items that have already off-gassed in the store. Outside the home, offgassed chemicals responsible for that “new car smell” may contaminate air inside a new car or one parked in the sun. Ventilate the car’s interior as soon as you enter it or beforehand, if possible.

Combustion byproducts

Breathe easily

Finally, be mindful of the potential for tiny particles and other pollutants emitted into indoor air by sources of combustion. Byproducts of combustion can contain additional harmful chemicals that can be irritating or toxic. All combustion appliances, such as gas water heaters, driers, stoves, and fireplaces, should vent out-

The most efficient way to maintain healthy indoor air is to keep pollutants out of it. Do that by keeping your home dry, clean, and well maintained, and by minimizing combustion byproducts and the indoor use of chemicals. Checklists are available to help you identify air pollutants. Many of these checklists also provide low-cost solutions for getting rid of air pollutants, making your home a healthier place to live and a refuge where you can breathe easily.

Healthy homes checklists www.surgeongeneral.gov/library/calls/healthyhomes/checklist.pdf

Kathleen Norlien, MS, CPH (Certified in Public Health), is a research scientist with the Minnesota Department of Health asthma program.

www.extension.iastate.edu/publications/pm1622.pdf www.mngreencommunities.org/publications/download/ HealthyHome_checklist.pdf

Minnesota

Health Care Consumer September survey results ... Association

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 September survey.

3. How satisfied were you that other care providers understood and integrated the discharge information into your follow-up care?

40 30 18.9%

20 13.5%

Percentage of total responses

60 40 20

Very satisfied

Satisfied

Does not Unsatisfied Very apply unsatisfied

MINNESOTA HEALTH CARE NEWS OCTOBER 2012

60 50 40 30 20

16.2%

13.5%

10 0%

Yes

21.6%

24.3%

8.1%

Very useful

5.4% Useful

Satisfied

Does not Unsatisfied Very apply unsatisfied

73.0%

2.7%

0.0% Very satisfied

5. If readmission to the hospital occurred, how much do you feel a lack of clear information about follow-up care contributed?

40.5%

2.7% 0

67.6%

70 80

Does not apply

Barely useful

Useless

Percentage of total responses

54.1%

10.8%

100%

100

4. How useful was the follow-up care you received from the hospital after you got home?

Percentage of total responses

2. How satisfied were you with your understanding of the information you received at discharge for follow-up care?

1. Have you or a member of your family ever been discharged from a hospital?

60 50 40 30 20 10 0

10.8% 2.7% 100%

10.8% 2.7%

Very related

Does not Somewhat Unrelated apply related

(known as gap insurance) will decrease, which could increase premiums or reduce benefits.

Saving money on diabetes from page 29

How health care reform will affect costs Parts of the Affordable Care Act could benefit your diabetes care and lower what you spend to stay healthy. Here are a few examples: • Having diabetes no longer excludes you from getting health insurance. A preexisting condition insurance plan is now available that limits annual out-of-pocket expenses (www.pcip.gov/). In addition, insurance companies will no longer be able to drop people who get sick and start filing claims. In 2014, everyone will be allowed to buy private health insurance regardless of his or her health status. • Most people without access to health insurance will be able to comparison shop for insurance options on centralized exchanges.

• Individuals earning at least $200,000 and families earning more than $250,000 will see their Medicare payroll taxes increase. • Starting in 2014, people who do not buy health insurance as mandated by law will face a penalty of $95 or 1 percent of income. This increases to $695 or 2.5 percent of income by 2016.

Biggest savings

Diabetes is expensive.

• People age 65 and older on the Medicare Part D prescription drug plan will receive a discount on some drugs and will have their annual checkup, vaccinations, and screening tests fully covered. • Lifetime and annual limits on benefits will be dropped completely.

Exercise regularly, eat healthfully, lose as little as 10 pounds if you are overweight, and don’t smoke. A healthy lifestyle can prevent diabetes complications and may even reduce your need for medicines, supplies, and services. Don’t endanger your health by not following your treatment plan because of its cost. Talk to your doctor, pharmacist, diabetes educator, or anyone on your health care team—they’ll help you find solutions in these tough financial times. Laurel Reger, MBA, is a planner with the Minnesota Department of Health (MDH) and co-chairs the Minnesota Diabetes and Heart Health Collaborative, a voluntary group of organizations within the state that develops educational resources and advances best practices to support healthy behaviors.

• Deductibles and copayments for many preventive services and screenings will be eliminated. • Medicaid will be expanded to cover more people. Certain health care costs will increase under the Affordable Care Act. For instance: • Government subsidies to Medicare Advantage

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. Your privacy is completely assured; we won’t even ask your name. Members receive a free monthly electronic newsletter and the opportunity to participate in consumer opinion surveys.

www.mnhcca.org

Join now.

We want to hear from you! OCTOBER 2012 MINNESOTA HEALTH CARE NEWS

Preventive steps for parents

Rising type 2 diabetes among youth from page 25

severely depressed than are boys with type 1. • Binge eating is a frequent behavior among youth of both genders who have type 2 diabetes and appears to be associated with depression and lower reported quality of life.

The Minnesota Department of Health’s Office of Statewide Health Improvement Initiatives recommends these simple lifestyle changes to help reduce your child’s risk of developing diabetes: • Offer your child a variety of fruits and vegetables every day.

Symptoms to monitor Many people with type 2 diabetes, including youth, are not aware that they have diabetes. That’s because early in the course of the disease, few if any symptoms may be present. However, one risk factor for type 2 diabetes that can be detected easily is the presence of dark, velvety skin on the neck or in the armpits or groin. This can be a sign of insulin resistance (an early sign of/precursor to type 2 diabetes), as are high blood pressure and high cholesterol, both of which can be detected by a health care provider. If your child has any of these symptoms, talk with your health care provider about whether or not a screening test for diabetes is appropriate. As type 2 diabetes progresses, additional symptoms may appear and can progress to potentially life-threatening complications. If your child develops any of the following symptoms, contact your health care provider immediately: • Extreme thirst • Frequent urination

Binge eating is a frequent behavior among youth of both genders who have type 2 diabetes. • Limit your family’s consumption of fast food. • Limit your family’s consumption of sugary beverages such as pop and juice; encourage your child to drink water. • Encourage your child to engage in physical activity for at least one hour daily. • Limit the TV your child watches to between one and two hours per day. These lifestyle changes will not only help younger children and youth reduce their risk of developing type 2 diabetes, but will also help those already diagnosed with either type 1 or type 2 diabetes achieve optimal control of their blood sugar so they can live healthier, happier lives. Renée Mijal, PhD, MPH, is an epidemiologist and Tammy Didion, RD, LD, is a diabetes prevention planner. Both are with the diabetes unit at the Minnesota Department of Health. Brandon Nathan, MD, is an assistant professor of pediatrics at the University of Minnesota.

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

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

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

MINNESOTA HEALTH CARE NEWS OCTOBER 2012

Diabetes and Hearing Loss by the Numbers

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• Personalized hearing solutions, including custom fitting • 3-year warranty** on most hearing solutions • Free lifetime aftercare—an advantage no other major hearing aid retailer offers

*Our hearing test and video otoscopic inspection are always free. Hearing test is an audiometric test to determine proper amplification needs only. These are not medical exams or diagnoses nor are they intended to replace a physician’s care. If you suspect a medical problem, please seek treatment from your doctor. **ME200 not included. †According to The Better Hearing Institute.

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