Minnesota Physician December 2014 by Minnesota Physician Publishing

Vo l u m e x x v i i I , N o . 9 D e c e m b e r 2 014

Personalized medicine From double helix to health care By Jeffrey D. Briggs “Where the telescope ends the microscope begins, and who can say which has the wider vision?” Victor Hugo, Les Misérables

ersonalized, evidence-based medicine has been the goal of physicians ever since Hippocrates declared nearly 2,400 years ago that diseases should no longer be attributed to the influence of superstitions and supernatural forces. The founder of modern western medicine, however, didn’t have many diagnostic tools to work with in ancient Greece, just the four humors—black bile, yellow bile, phlegm, and blood—to determine the best treatment for a patient.

The perioperative surgical home A new model for improving patient care By J. P. Abenstein, MSEE, MD

he surgeon might be top notch, the quality of the nursing care exemplary, and the hospital rated among the nation’s best, but these do not guarantee the quality or efficiency of patient care. Patients undergoing surgery and other invasive procedures in U.S. hospitals often enter a system that—despite the high skills and extensive experience of the personnel, and all that modern med-

ical technology has to offer—can be fragmented, with inefficiencies that create a barrier to delivering high quality and safe medical care. It’s a problem that costs patients, hospitals, payers, and the health care system millions of dollars each year in inefficiency and waste; delayed and cancelled surgeries; postoperative The perioperative surgical home to page 10

Today, personalized medicine has remained the goal of every physician treating each individual patient. The diagnostic tools have changed. Hippocrates’ four humors have been replaced with, among other tools, the four chemical building blocks that comprise DNA to transform the value of medical care delivered to specific individPersonalized medicine to page 12

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December 2014 • Volume XXVIII, No. 9

Features The perioperative surgical home 1 A new model for improving patient care

MINNESOTA HEALTH CARE ROUNDTABLE

By J. P. Abenstein, MSEE, MD

Personalized medicine From double helix to health care

By Jeffrey D. Briggs

DEPARTMENTS CAPSULES

MEDICUS

INTERVIEW

Brooks Jackson, MD, MBA University of Minnesota Medical School

Public Health

Healthy lungs and air pollution By Jill Heins Nesvold, MS, and Cynthia Isaacson

Neurology

Pain and sleep disorders in Parkinson’s patients By Okeanis Vaou, MD

The New Face of Health Care

Expanding medical professional relationships

Gastroenterology 28 Accidental bowel leakage By Amy J. Thorsen, MD

Disease Management

Thursday April 23, 2015, 1:00-4:00 PM

Downtown Minneapolis Hilton and Towers

Diabetes education By Mary Beth Dahl, RN

Special focus: Senior and long-term care Polypharmacy in elder patients By Todd Stivland, MD

The aging spine By Christopher Alcala, MD

Know your rights 24 By Suzanne M. Scheller, Esq.

Background and Focus: With dramatic population growth, and as baby boomers become senior citizens, the demand for health care is exceeding the supply. Addressing the shortage of medical doctors involves creating new relationships between medical professionals. Training and licensure for Physician Assistants, Advanced Nurse Practitioners, Chiropractors, Respiratory Therapists, Physical Therapists, Home Care Providers, Dentists, and many other health care professions have become increasingly rigorous and provide expanded support to our health-care delivery system. Greater integration of these professions allows medical doctors to work to the top of their license but requires new pathways for communication and care coordination. Objectives: We will examine many of the new partnerships that are emerging between medical doctors and other medical professionals. We will look at the ways leveraging these new relationships can improve access to care while reducing costs and improving outcomes. We will consider points of resistance to forming these kinds of health care teams and what should be avoided in creating them. We will discuss what the proper oversight for these relationships should entail and how to maximize the coordination of care that they require. Sponsors Include:

Minneapolis Advanced Pain Specialists and Pediatric Home Service

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Minnesota Physician 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 the publication may be reprinted or reproduced without written permission of the publisher. Annual subscriptions (12 copies) are $48.00/ Individual copies are $5.00.

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capsules

Minnesotans Unsure How They Will Pay for Care as They Age According to the Minnesota Department of Health (MDH), 70 percent of people aged 65 and older will need long-term care eventually. However, a survey from the Minnesota Department of Human Services and the Minnesota Board on Aging shows that 32 percent of respondents in Minnesota don’t have a plan for how they would pay for that care, while 13 percent indicated they expect to use government programs to cover costs. The survey was conducted at the Minnesota State Fair from Aug. 21 to Sept. 1 and focused on retirement and long-term care planning concerns. A total of 2,624 people participated in the survey. According to officials, results have consistently shown that Minnesotans don’t know how they would pay for long-term care

and that losing health insurance and needing care are major concerns for survey participants. This year, almost 48 percent answered that this was their biggest concern. In addition, 34 percent of participants said running out of money was their biggest concern; 11 percent said it was being a burden to family; and 7 percent said it was not being able to save for retirement.

go to purchase a product to pay for long-term care, more than 40 percent said they didn’t know, while 29 percent would go to a financial advisor, 22 percent would go to an insurance agent, 11 percent would utilize the Own Your Future website, and 17 percent would use Senior LinkAge Line, a service of the Minnesota Board on Aging.

“The need for Minnesotans to prepare for their long-term care becomes more urgent when we consider that the numbers of Minnesotans over age 65 will double between now and 2030,” said Lucinda Jesson, Department of Human Services commissioner. “By 2030, one of every four Minnesotans will be over 65 compared to one in eight today.”

Medicare Proposes Covering Lung Cancer Screening

In 2012, the Dayton-Prettner Solon Administration started an initiative called Own Your Future to address the ongoing trend and help Minnesotans plan for longterm care and associated costs. When asked where they would

Minnesota Physician December 2014

The Centers for Medicare & Medicaid Services announced a proposal on Nov. 10 in which Medicare would cover annual low-dose CT lung cancer screenings for beneficiaries that are at a high risk for the disease. Beneficiaries must meet certain criteria to qualify. They must be between the ages of 55 and 74, have smoked at least a pack of cigarettes per day for 30 years or the equivalent, have no symptoms

of lung disease, and be a current smoker or have quit within the last 15 years. In addition, patients will be required to obtain a written order for their initial screening during a “lung cancer screening counseling and shared decision-making visit” with a physician, physician assistant, nurse practitioner, or clinical nurse specialist to discuss the potential harm and benefits of a CT scan. An estimated 4.9 million Medicare enrollees would meet the criteria. “Low-dose CT has been shown to reduce mortality when used to screen individuals who are at high risk for developing lung cancer because of their age and smoking history,” Charles Powell, MD, chief of Pulmonary, Critical Care, and Sleep Medicine at Mount Sinai in New York and chair of the American Thoracic Society’s Thoracic Oncology Assembly, said in a statement. “Thoughtful implementation of lung cancer screening with strict attention to monitoring of screening program adherence to standards for cen-

ters of excellence and with routine utilization of smoking cessation and multidisciplinary management will help to maximize the benefits and minimize the harms of screening.” Results from a study published earlier in 2014 concluded that annual low-dose CT scans for current and former smokers between the ages of 55 and 80 would double the proportion of lung cancers found at an early stage, from 15 percent to 33 percent. However, the additional screenings would cost $9.3 billion over five years.

Tobacco Treatment Specialists Allowed Reimbursement ClearWay Minnesota is focusing on getting more Certified Tobacco Treatment Specialists (CTTS) (professionals trained to treat those seeking to quit using tobacco) more involved in the health care system. Until recently, many CCTSs could not be reimbursed for their services, according to ClearWay. The organization collaborated with the Minnesota Department of Human Services to change this and allow health systems with CTTSs to receive reimbursement for tobacco cessation counseling covered by Medical Assistance and MinnesotaCare. “This change gives health systems another incentive to talk to their patients about how to quit,” said Amanda Jansen, senior cessation manager at ClearWay Minnesota. “This means it’s much more likely that low-income Minnesotans will receive treatment and will try to quit.” In order to be reimbursed, CTTSs must be employed by a physician, or the same provider organization that employs the physician. In addition, they must meet supervision requirements of a physician extender as defined by Minnesota Health Care Programs. The policy went into effect Nov. 1.

New Tool to Reduce Heart Procedure Complications Allina Health is employing a new strategy to reduce complications in heart procedures. According to the health system, 600,000 percutaneous coronary interventions (PCI) are performed each year. It is a common alternative to open heart surgery, in which thin tubes are threaded through patients’ arteries to access their hearts. However, a common complication during PCI is that patients bleed from the insertion site due to blood thinners used during the procedure. “That might not sound serious, but bleeding is associated with adverse events, including death,” said Craig Strauss, MD, MPH, a cardiologist at Minneapolis Heart Institute at Abbott Northwestern Hospital, and a researcher at the Minneapolis Heart Institute Foundation.

Pediatric Orthopaedic Experts for 91 Years

To help reduce complications, Allina Health cardiologists verified a PCI bleeding risk screening tool based on data from the National Cardiovascular Data Registry (NCDR) CathPCI Registry. The idea is that if a patient is identified as high risk, health care providers are aware of it and can take extra precautions to avoid bleeding after the procedure. The cardiologists collaborated with other health systems, including United Heart & Vascular Clinic at United Hospital in St. Paul and Metropolitan Heart and Vascular Institute at Mercy Hospital in Coon Rapids, to improve their PCI complication rates. Data collection and analysis were streamlined because the health systems use unified electronic medical records and participate in NCDR. Together, they retrospectively analyzed data from PCI patients who underwent the procedure between July 1, 2009, and Dec. 31, 2011, and verified the screening tool’s accuracy in predicting patients that had high, intermediate, and low bleeding risk. They Capsules to page 6

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December 2014 Minnesota Physician

Capsules from page 5

cardiology care.

then created a data dashboard for Allina Health staff to use and held informational sessions to stress the importance and benefits of the screening tool.

“We are excited to expand top-quality cardiology care in our community,” said Mary Ellen Wells, administrator at the Monticello clinic. “CentraCare and North Memorial currently partner on our campus to deliver renowned oncology care at the Monticello Cancer Center, and we are looking forward to joining forces once again to strengthen heart care in our community and provide patients with access to experienced cardiology specialists.”

Within one month of incorporating the tool, more than 75 percent of patients were being screened before PCI procedures. This resulted in a 5.3 percent decrease in patient complications after the procedure. Strauss anticipates the progress will result in significant reductions in costs associated with hospital readmissions.

Systems Team Up to Expand Cardiology Care in Monticello CentraCare Health–Monticello is partnering with North Memorial Heart & Vascular Institute and CentraCare Heart & Vascular Center beginning in January 2015 in order to expand its level of

The partnership will give patients local access to physician consultations, follow-up care, diagnostic tests, pacemaker clinics, and inpatient cardiology care. “North Memorial is committed to serving the cardiac and heart health needs of the Monticello community by providing coordinated care across a full spectrum of services,” said Kelly Macken-Marble, vice president of Population Health and Ambulatory Services at North Memorial. “Our goal is to keep patients well

while also ensuring they have the expert and highly specialized care close to home when they need it most.”

Hospitals Recognized For Cardiovascular Success Three Minnesota hospitals have been named to a list of the 50 Top Cardiovascular Hospitals by Truven Health Analytics, a national health care data company: St. Cloud Hospital, Mercy Hospital in Coon Rapids, and Mayo Clinic– St. Marys Hospital in Rochester. Truven conducted the independent study for its 16th consecutive year by evaluating more than 1,000 hospitals in the U.S. It identified 50 that had superior clinical outcomes in cardiovascular health through higher survival rates, lower costs, fewer complications, and shorter hospital stays.

formed at the level of the winners, almost 9,500 more lives could be saved, more than $1.1 billion could be saved, and nearly 3,000 additional bypass and angioplasty patients could be free of complications. “The study shows that 39 of the 50 hospitals in the 2014 study, 78 percent of the winners, are facilities within a larger health system,” said Jean Chenoweth, senior vice president for performance improvement and the 100 Top Hospitals program at Truven Health Analytics. “This indicates that the overall aptitude of hospitals to improve care deliverables increases when they work as a coordinated team to implement well established, proven and integrated best practices from one facility to the next. Again, as we find in the 100 Top Hospitals study, this also infers a significant correlation between hospital leadership and their organization’s outcome and quality achievements.”

The company estimated that if all cardiovascular providers per-

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Minnesota Physician December 2014

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Thomas Arneson, MD, MPH

Thomas Arneson, MD, MPH, board-certified in preventive medicine, has assumed the role of research manager at the Minnesota Department of Health Office of Medical Cannabis. He graduated from Mayo Medical School; served a preventive medicine residency at the University of Minnesota School of Public Health; and earned an MPH at the school. His role includes generating information about possible long-term health effects and the societal effects of cannabis use.

Amy Chang, OD, FAAO (Fellow of the American Academy of Optometry), has joined the physical medicine and rehabilitation clinic at Hennepin County Medical Center (HCMC), Minneapolis. She graduated from the State University of New York College of Optometry and completed a residency in acquired brain injury vision rehabilitation and primary care at the same instituAmy Chang, OD, tion. Previously, she was the neuro-optometrist FAAO at Womack Army Medical Center in Fort Bragg, N.C., where she developed the first vision rehabilitation clinic in the U.S. Army to offer treatment for wounded soldiers who had visual deficits after traumatic brain injury. Liat Goldman, MD, board-certified in physical medicine and rehabilitation, has joined Courage Kenny Rehabilitation Institute. She graduated from Tulane University School of Medicine, New Orleans; completed a physical medicine and rehabilitation residency at Temple University, Philadelphia; and served a fellowship in cancer rehabilitation at MD Anderson Cancer Center, Houston. Liat Goldman, MD

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Christopher Heck, MD, board-certified in cardiothoracic vascular surgery, has joined Essentia Health–Duluth Clinic full time after working there part time since 2011. Heck graduated from Mayo Medical School, completed a general surgery residency at the University of California– San Francisco School of Medicine, and completed a cardiothoracic surgery fellowship at Stanford University School of Medicine in Stanford, Calif.

Christopher Heck, MD

Stephen Ready, MD, board-certified in family medicine, has joined Ridgeview Chaska Clinic, part of Ridgeview Medical Center. Ready graduated from the University of Minnesota Medical School and served a residency in family practice at Fairview University Medical Center, Minneapolis.

Stephen Ready,

MD Andrew Schmidt, MD, FAAOS, board-certified in orthopedic surgery, has assumed the position as chief of orthopedics at HCMC. He is also a professor of orthopedic surgery at the University of Minnesota. Schmidt completed medical school at the University of California, San Diego; an orthopedics and rehabilitation residency at Oregon Health Sciences University, Portland; and a fellowship in total joint replacement at Stamatis Zeris, HCMC. Stamatis Zeris, MD, has joined HCMC’s MD adult psychiatry clinic. Board-certified in psychiatry, he completed medical school at Penn State College of Medicine in Hershey, Pa., and a psychiatry residency at the University of Washington, Seattle. December 2014 Minnesota Physician

Interview

Fostering a culture of scholarship  A s dean of the University of Minnesota Medical School, what are some of your responsibilities? My first role as dean is to support the threepart mission of our school: to prepare the next generation of health professionals, to conduct innovative research, and to provide top-quality care to patients. Obviously, there are many ways that my role touches each of these goals.

Brooks Jackson, MD, MBA University of Minnesota Medical School Dr. Jackson is vice president for health sciences and dean of the Medical School at the University of Minnesota. He came from Johns Hopkins University School of Medicine, where he served as director of pathology for 12 years. Dr. Jackson is the current chair of the Blood Products Advisory Committee for the Food and Drug Administration. In 1999, he received the Global Strategies for HIV Prevention Special Recognition Award and in 2004 he received the HIV Prevention Trials Network Service Award. Dr. Jackson earned his medical degree from Dartmouth Medical School and his MBA at Dartmouth College. He served his residency in clinical pathology at the University of Minnesota Hospitals, where he was a blood bank fellow in the hospitals’ department of laboratory medicine and pathology.

Minnesota Physician December 2014

It is my responsibility to foster a culture of scholarship at our school, where all faculty members are given the tools they need to conduct important research. I work to make sure our students are prepared for the new health care landscape and that they are effective collaborators as part of an overall health care team. I also have an active role in developing strong clinical partnerships, including our relationship with University of Minnesota Health, to be sure we meet the needs of this state.  Y ou went from medical school at Dartmouth to a residency at the University of Minnesota. What stands out in your memory about that transition? Several things really stood out for me about the University of Minnesota: the large size of the lab in the medicine/pathology department, the breadth and depth of research being performed, the emphasis on scholarship, and the beauty of the Twin Cities.  T ell us about some of your HIV research experiences. I have had an opportunity to lead teams of researchers addressing some of the most difficult questions related to HIV transmission. Our team revolutionized HIV prevention in developing countries and has looked extensively at HIV prevention and treatment in the United States, Uganda, and China. I am the principal investigator of the $500 million NIH-funded International Maternal Pediatric Adolescent AIDS Clinical Trials (IMPAACT) Network. My work resulted in new drug development and a project to prevent neonatal HIV transmission, saving thousands of infants from starting life with HIV infection.

 Y ou are the current chair of the Blood Products Advisory Committee (BPAC) for the Food and Drug Administration. Tell us about this work. The BPAC makes recommendations to the Food and Drug Administration regarding licensure of blood derivatives and diagnostic test kits as well as criteria for blood products and donor screening. It’s an important part of patient safety, and something I find connects well with my research and patient care focuses.  Y ou were part of a very successful research funding initiative at Johns Hopkins University School of Medicine. What were some of the keys to that success? There are some basic elements in any successful research enterprise. You need to ask the big questions and be persistent. You also need to be able to work with others to tap into the talent and expertise that will help you move the needle. More and more, the common element of major research efforts is a commitment to team science. Whether the research is in the basic sciences or part of a global clinical trial like the one I led, you can’t land the major grants and do groundbreaking work without the ability to lead a team.  P harmaceutical funding has played a large role in supporting medical research and continuing education initiatives in academic institutions. Concerns over potential conflict of interest and related ethical issues have significantly limited this funding. Is there a framework that would allow this funding and guarantee that there would be no ethical conflicts? Drug trials are an extremely important part of clinical research, and are often the key step in getting a discovery from the lab to the bedside. While conflict of interest is a concern, it is also something that we work hard to manage. There are federal and state regulations in place to ensure transparency and help avoid conflicts. In addition, at the University of Minnesota, we have many processes in place to help identify and manage potential conflicts to be sure there are no issues that could be detrimental to patient safety.

 E veryone hears about the high cost of medical school. What is rarely discussed is the much higher cost of providing the medical training. If it costs more to train a doctor than a medical school receives in tuition, how can this model be sustained? If we are going to meet the health care demands of our state, we need a combination of creative solutions and financial support. We are working to develop new models of teaching to prepare students to practice in an efficient, collaborative manner. We understand we aren’t going to solve the problem by simply enrolling more students. It will take an interprofessional, collaborative effort to make sure everyone has access to the care they need. At the same time, we are always working with our state and federal officials to try to increase funding for medical training. This needs to be a priority that we set as a state and as a nation.  As we move into 2015 and beyond, what needs to be added to the medical school curriculum? We need to find ways to close the gap between changes in medical practice and medical education. Our students need to be ready to work as part of a team, focused on

the health of patients and communities. We need to encourage more interprofessional training, clinical experiences modeling best practices for quality, and to instill an understanding and passion for public and community health initiatives.

You need to ask the big questions and be persistent.  What goals do you have for your tenure as dean of the medical school? I have six main goals that I want to achieve during my tenure as dean. (1) I want to increase our focus on scholarship and encourage the faculty to publish regularly in peer-reviewed publications. (2) I want to increase NIH funding for breakthrough research. (3) I will enhance educational programs to support career goals and meet workforce needs. (4) I am committed to integrating and expanding our clinical enterprise to provide better access to care, better coordination of care, more affordable care, better patient outcomes, and to better support our clinical research and

training activities. (5) I want to improve financial sustainability. (6) Last, I will work to increase the diversity of our students and faculty to better reflect the populations we serve.  W hat advice do you have for physicians in Minnesota about how they can utilize the resources and expertise provided by the medical school in their own practices? We hope physicians around Minnesota see the medical school as an asset in our efforts to train the next generation of physicians, to discover and deliver groundbreaking medical discoveries to patients, and to help create a healthier Minnesota. We ask physicians to partner with us in training students to become excellent doctors. In turn, we feel we provide valuable workforce resources and opportunities for continuing education. A strong medical school plays a vital role in the health of a state, just as strong clinical practices are important in our education and training efforts. We hope to be a good partner to physicians and we want them to reach out to us as a valuable part of their own teams.

University of Minnesota - Continuing Professional Development (formerly the Office of CME) Education is essential to achieving and sustaining quality healthcare. Through partnership with healthcare leaders, our educational activities help advance quality improvement and patient care initiatives.

2015 CPD Activities

(All courses in the Twin Cities unless noted)

LIVE COURSES Maintenance of Certification in Anesthesiology (MOCA) Training January 10 & April 18, 2015 Pediatric Dermatology Progress & Practices February 20, 2015 Fundamentals of Critical Care Support March, 2015 Integrated Behavioral Healthcare Conference: Building Partnerships & Teams for Better Care March 13, 2015 Cardiac Arrhythmias: An Interactive Update for Internal Medicine, Family Medicine & Pediatrics April 3, 2015

Psychiatry Update Spring 2015 April 9-10, 2015 Live Global Health Training (weekly modules) May 4-29, 2015 Midwest Cardiovascular Forum Controversies in Cardiovascular Disease May 16-17, 2015 Bariatric Education Days: Advances in Bariatric Care May 27-28, 2015

www.cmecourses.umn.edu ONLINE COURSES (CME credit available) www.cme.umn.edu/online • Adolescent Vaccination - AVAILABLE NOW! • Nitrous Oxide for Pediatric Procedural Sedation • Global Health - To include Travel Medicine & Refugee Health - Family Medicine Specialty - Pediatric Specialty For a full activity listing, go to www.cmecourses.umn.edu

Workshops in Clinical Hypnosis June 4-6, 2015 Topics & Advances in Pediatrics June 4-6, 2015

Office of Continuing Professional Development 612-626-7600 or 1-800-776-8636 • email: cme@umn.edu

Promoting a lifetime of outstanding professional practice December 2014 Minnesota Physician

The perioperative surgical home from cover

complications; and hospital readmissions. There are more than 51 million invasive procedures performed in this country each year and it’s estimated that surgical care accounts for more than half of hospital expenses. One postsurgical complication, such as pneumonia or a urinary tract infection, can wipe out the entire revenue from a surgical procedure. It’s a huge challenge that cries out for a new way of thinking about how to get patients in and out of the operating room and back to their families and lives. Our patients need us to deliver their care in a more modern, patient-centric, integrated, and efficient manner. A new practice model, the perioperative surgical home (PSH) is designed to address these problems. Like its associate, the patient-centered medical home in primary care, the PSH is aligned with the Nation-

al Quality Strategy to achieve the Triple Aim of improving health, improving the delivery of health care, and reducing the cost of care. Patient-centered care The PSH refers to an innovative patient-centered model of man-

It’s estimated that surgical care accounts for more than half of hospital expenses.

aging the three components of the surgical experience—preoperative, intraoperative, and postoperative—as one continuum of care beginning with the decision to have surgery and ending 30 days after discharge. In most health care organiza-

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tions, pre-, intra-, and postsurgical are treated as discrete episodes, usually managed by different teams of physicians, nurses, and other health care professionals and are often poorly integrated. The PSH integrates these three microsystems and manages them with

Minnesota Physician December 2014

the same cohesive team under the direction of physician leadership, while creating evidence-based standardization, improving coordination, and minimizing communication problems caused by handoffs from one team to another. Previously, we wanted the patient to be “cleared for surgery,” but we submit that this concept has to be replaced with “optimized for surgery.” We want the patient to be able to leave the hospital as soon as possible and return to his or her home. Raising awareness For example, the more coordinated team approach could safely reduce the number of preoperative tests, reducing cost while minimizing inconvenience and discomfort for our patients. Reduction of unnecessary preoperative testing and consultation also reduces complications secondary to the tests themselves or follow-up of incidental findings. Effective preoperative patient assessment can minimize medication interactions, leading to better outcomes, shorter hospital stays, and fewer readmissions. Studies are starting to bear this out. Physician anesthesiologists are committed to this innovative model of patient-centered care, and have made the study and adoption of the PSH model

a priority. Our training, as physician anesthesiologists, increasingly includes the practice of team-oriented medicine, system-based practice, and quality and safety improvement, as well as more focus on presurgical patient assessment and postsurgical pain management. Our professional association, the American Society of Anesthesiologists (ASA), has embarked on a number of projects to encourage pilot programs and studies that assess the effectiveness of the PSH practice model, and to help hospitals adapt its principles to their unique needs. We are working to raise awareness among physicians, nurses, other health care professions, and payers so they’ll understand the how-to of the PSH and appreciate its benefits. Our awareness efforts include reaching out to the public and prospective patients. In some locations that do not have this model of care, patients and their physicians are demanding this more patient-focused approach to patient care. In October 2013, the ASA House of Delegates strongly endorsed the development of the PSH model of care and a first-of-its-kind national learning collaborative targeting up to 50 participating organizations. Earlier this year we launched the learning collaborative and, to date, 43 organizations throughout the country have signed on. The collaborative participants create a network where interested organizations can learn from each other and from recognized experts. Working together, these health care facilities will pursue care redesign strategies to enhance the patient’s experience of surgical and procedural care, improve quality and outcomes, and reduce costs. The ultimate goal is to create an evidence-based road map for other health care

organizations to spread knowledge and best practices of the PSH model of care. The effectiveness of the PSH Early studies of the PSH model of care offer promising data documenting the effectiveness of this practice model and we’re committed to supporting additional research. In October, a study presented at ANESTHESIOLOGY 2014, the ASA annual meeting, showed significant benefits of a PSH. The study was conducted by researchers at Kaiser Permanente, the country’s largest HMO in a large hospital serving a diverse population of 300,000 patients. The researchers collected outcomes data for more than 500 patients who had undergone knee replacement surgery after implementation of a PSH. They found that patients in the care of a PSH team led by a physician anesthesiologist went home earlier, were highly satisfied, and incurred less cost than did patients who had surgery before the implementation of the PSH. For example, the average length of stay for patients in the PSH group was 1.9 days, versus 3.2 days before the PSH was instituted. In the PSH group, 94 percent of patients went home after being released from the hospital, and only 6 percent went to a skilled nursing facility. In the pre-PSH group, 20 percent went to a skilled nursing facility rather than directly home. In the PSH, the physician anesthesiologist-led team performed a variety of tasks before, during, and after the surgery. For example, prior to surgery, the anesthesia team meets with the patient to ensure appropriateness for surgery: assessing social support and home safety issues; encouraging smoking cessation, weight loss, and exercise; and adjusting medications. This is a logical role for this physician who also monitors and manages the patient during surgery, and oversees a safe and effective post-surgery management plan.

Good outcomes for knee replacement surgery rely heavily on effective physical therapy and the PSH has a preference for pain control that helps

roadblocks, and both state and federal regulations.

I particularly like the work of John Kotter from the Harvard Business School, who published extensiveOne postsurgical complication ... ly on the topic of can wipe out the entire revenue change from a surgical procedure. management. Within the context of the PSH, the first step patients begin physical therapy is to establish the burning platsooner. Under the PSH proform (the reason for change). In cess in the Kaiser Permanente this case, the burning platform study, more than 70 percent of is the dysfunction of the perioppatients began physical therapy erative environment; its high the day after surgery. No pacosts and complications. Once tients in the pre-PSH group did. the burning platform has been established, one needs to asThe study didn’t analyze semble a team, develop a vision, specific components of the and start communicating the PSH and how they individually concept. All too often, change might have affected outcomes, processes fail because of a lack and the study’s authors beof communication. A plan has lieve it is the overall concept of to be established and work patient-focused, shared decigroups created. Collaborative sion making, team-oriented and inclusive relations among care that makes the difference. all members of the care team, Clearly, more studies are needed to gather evidence that what works for knee replacement surgery is beneficial to patients having hysterectomies, hernia repairs, or heart surgery.

including surgeons, physician anesthesiologists, hospitalists, IT experts, decision support, nutritionists, and many more, are paramount to the success of the PSH model. The teams have to include all the stakeholders as they move forward. Process improvement methodologies such as LEAN and Six Sigma can be used by these teams as they redesign the perioperative process of individual hospitals. Medicine is always changing, however, and continued research, the work of ASA’s learning collaborative members, and our collective desire to improve care and reduce costs, should move us to act. J. P. Abenstein, MSEE, MD, is board-certified in anesthesiology and is a consultant in the Division of Cardiovascular and Thoracic Anesthesiology and an associate professor of anesthesiology at Mayo College of Medicine. He is president of the American Society of Anesthesiologists. Dr. Abenstein serves the MMA (Minnesota Medical Association) as an alternate delegate to the AMA.

Implementing the PSH model There is no one-size-fits-all PSH for all hospitals. Each hospital needs to analyze the model and determine how it fits with its patients, medical team, staff, culture, and facilities. The key principle is coordination and teamwork, along with the standardization of anesthesiology, nursing, surgical, and other health team protocols. To be effective, these protocols must be established prospectively. As with any change initiative there undoubtedly will be obstacles to putting PSH models in place. As anyone involved in medical care knows, the largest obstacle to change is overcoming the resistance of colleagues who simply do not want to change. They always have practiced in a certain manner, feel that the medical care they deliver is just fine, and see no need to change. Other obstacles include payment policies, administrative December 2014 Minnesota Physician

Personalized medicine from cover

uals. This is called genomics, an emerging medical discipline that involves advancing human health through genomic research. Laboratory to clinic Since the completion of the Human Genome Project in 2003, much has been made of the term “personalized medicine,” often called “individualized medicine,” and its promise to revolutionize medicine. A simplistic, overhyped view of the promises of genomics led to unrealistic expectations. Insights into human biology flowed almost immediately from the genome. Translation from medical science into clinical practice has taken longer. In the past decade, genomics has slowly moved out of the laboratory and into the clinic, giving physicians more precision in disease diagnosis and treatment. Now the double helix of

DNA is emerging as a valuable tool in the day-to-day practice of health care professionals. The cost and time to sequence the genome have dropped precipitously because of next-generation sequencing, bioinformatics’ capacity to capture and store big data, and widespread adoption of electronic medical records (EMRs). Personalized medicine is coming of age. Oncology is at the vanguard of this effort. Patients with metastatic lung, breast, or brain cancers, and patients with melanoma or leukemia now have new treatments available to them. Genome or exome sequencing provides a “molecular diagnosis” that allows physicians to tailor treatments specifically for the individual that can greatly improve the chances of survival. For many diseases, trial-and-error medicine can be replaced with specific therapies that target individual gene mutations.

For example, instead of a standard therapy to treat breast cancer, a better understanding of the genome allows physicians to identify and prescribe treatments developed specifically to fit an individual patient’s needs, such as testing for inherited genes like BRCA1 and BRCA2. Trastuzumab and ERBB2: In about one out of every five cases of breast cancer, genetic tests show that the tumor overproduces a protein in the ERBB2 gene, called human epidermal growth factor receptor 2 (HER2 or HER2/neu), which promotes the growth of cancer cells due to a genetic mutation. If a woman tests positive for HER2, she is considered a good candidate for the drug trastuzumab, a monoclonal antibody that binds with HER2 receptors. The treatment can cut her chance of a recurrence nearly in half. If the test is negative, using the drug could be wasteful and expensive, especially as the treatment poses the risk of

the patient having an adverse drug reaction. Oncology has not been the only area of medicine to benefit from mapping the human genome. Genotyping of drug-metabolizing enzymes has improved diagnosis, treatment modality decisions, and dosing of drugs for conditions as common and wide-ranging as anxiety and depression, coronary artery disease, and inflammatory bowel disease. This has dramatically reduced harmful side effects, adverse drug interactions, and ineffective treatment. Pharmacogenomics in practice This “therapeutic revolution,” said Richard Weinshilboum, MD, director of Mayo Clinic’s Pharmacogenomics Program, “has brought us to pharmacogenomics, where we’re scanning the genome to try to cure, even prevent diseases. The future is not around the corner. It’s now. The goal is to deliver the right

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Minnesota Physician December 2014

drug at the right time in the right dose to the right person, and eliminate treatments that don’t work.” The drugs available today to treat cancer, heart disease, and other conditions are powerful agents that work as intended in most patients. Yet, in some people, a particular drug at the standard dose might not work well enough or may even trigger a serious adverse reaction. One reason for this lies in a person’s genes. By using a patient’s unique genetic makeup as a factor when prescribing a drug, a physician can maximize treatment effectiveness while avoiding potentially life-threatening side effects. Here are a few examples of pharmacogenomics in practice. Carbamazepine and HLA-B*1502: The drug carbamazepine (used for epilepsy) is known to have the potential for adverse side effects in some populations. People with a gene called HLA-B*1502, that is most commonly found in families of Chinese, Southeast Asian, or Indian descent, have an increased risk of Stevens-Johnson syndrome if they take carbamazepine. Stevens-Johnson syndrome is a rare, serious disorder of the skin and mucous membranes, and is a medical emergency that usually requires hospitalization. Recovery can take weeks to months, depending on the severity of the condition. Avoiding carbamazepine for patients with the HLA-B*1502 variant may prevent Stevens-Johnson syndrome. Tamoxifen and CYP2D6: Tamoxifen is used to treat breast cancer, but some women have a variant of the CYP2D6 gene that does not convert tamoxifen to the active form (endoxifen) in the body. If these women take tamoxifen, they do not achieve therapeutic levels of the active drug and therefore, do not get the full benefits of this drug. If these women are identified prior to drug initiation, they may be prescribed an alternative medication, or get

an increased dose of the drug so it will function appropriately. Prenatal genomic testing Noninvasive prenatal genomic testing is another success story in genomic medicine. It has revolutionized prenatal screening for aneuploidy in a very short time. “Test performance is significantly better than current primary screenings for autosomal aneuploidy,” said Diana Bianchi, MD, executive director for the Mother Infant Research Institute at Tufts Medical Center, Boston. “And this has resulted in significant decreases in invasive procedures.” Speaking at Mayo Clinic’s Individualizing Medicine (IM) Conference 2014, Bianchi also noted that in the past two years, noninvasive prenatal testing for trisomy disorder, such as Down syndrome, has begun to rapidly replace traditional amniocentesis methods. Individualized medicine is being used in the microbiome, as well. Fecal microbiome transplants are proving to be a highly effective treatment for recurrent Clostridium difficile infection. Treatment and prognosis of Mendelian diseases, in which a single gene is broken, such as cystic fibrosis or Huntington’s disease, also have benefited from genomics. In 1990, the medical community knew about 61 such monogenic traits. By 2013, the single gene for 4,800 such diseases had been identified. More are being identified all the time.

the National Human Genome Research Institute’s (NHGRI) goal of $1,000 for whole genome sequencing. The current cost ranges from $4,000 to $6,000 and continues to drop. The gene sequencing company Illumina announced earlier this year that its new HiSeq X Ten system would crack the $1,000 barrier. And these are whole human genomes it plans to sequence— not just the protein-coding exomes. Time also is no longer a barrier. The first complete human genome sequencing took 13 years. Now, it can be accomplished in two to three days. Sequencing isn’t the problem. The sequencing can be done in a few days, the three to five million variants in a person’s genome can be identified, but who and how does someone determine what is clinically relevant? The problem is in understanding the data. At Mayo Clinic’s Individualizing Medicine Conference 2013,

This message was repeated at the 2014 conference. When discussing next generation sequencing in clinical cancer diagnostics, Christopher Corless, MD, PhD, associate director of the Oregon Clinical & Translational Research Institute, said the problem is, how do we provide knowledge with the data? The cost isn’t the problem, but the data is difficult to interpret. “Everyone can sequence,” Corless said. “But we need to turn that data into knowledge.” Reimbursement Much of the power of genomics, however, remains wedded to the laboratory and a handful of large institutions, such as Minnesota’s own Mayo Clinic. The issues are complex: the cost and time of research and development, the length of Personalized medicine to page 38

Healthcare Planning and Design

Too little is still known about common, complex diseases, such as diabetes, Alzheimer’s, and cardiovascular disease. Are there genetic components in the complicated combination of family history, environment, and personal behavior? Much still needs to be learned. New technologies, lower costs New technologies have created next-generation sequencing, bringing the cost closer to

Eric Green, MD, PhD, director of NHGRI, called it the “$1,000 genome and the $100,000 analysis.”

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Disease Management

he October 2014 issue of Minnesota Physician included an article on the importance of diabetes self-management education (DSME) and how it can help people with diabetes and prediabetes gain the knowledge and skills needed to successfully manage their disease. This month we’d like to introduce you to a new program in Minnesota that can help you and your patients become more involved with the benefits of DSME. The free program, known as Everyone with Diabetes Counts (EDC), is part of the Centers for Medicare & Medicaid Services (CMS) health-care quality improvement initiatives. The program is sponsored by the Lake Superior Quality Innovation Network (LSQIN), which is composed of three quality improvement organizations: Stratis Health of Minnesota, MetaStar of Wisconsin, and MPRO of Michigan. The organizations recently partnered to form LSQIN and establish a re-

Diabetes education Getting you and your patients more involved By Mary Beth Dahl, RN gional network to promote and lead CMS quality improvement initiatives. LSQIN’s work is grounded in foundational principles that align with the goals of the CMS Quality Strategy: eliminating

help optimize health care and its positive impact on patients. What is Everyone with Diabetes Counts? Everyone with Diabetes Counts is an exciting new program that

Minnesota’s largest underserved diabetes population is rural. disparities, strengthening infrastructure and data systems, enabling local innovation, and fostering learning organizations. On a local level, these initiatives offer an opportunity for providers and community partners to participate in quality improvement initiatives that

Minnesota Physician December 2014

offers community-based diabetes self-management education to Medicare consumers with diabetes and prediabetes. Classes will be taught by certified trainers using evidence-based curriculum including Stanford’s Diabetes Self-Management Program (DSMP) or the Diabetes Empowerment Education Program (DEEP) curriculum from the University of Illinois. The weekly group sessions typically run for six weeks and will be conveniently located in familiar community settings such as recreation centers, churches, senior residences, etc. Participants are guided, with their peers, to effectively self-manage their diabetes by learning about nutrition, exercise, self-monitoring, and diabetes community resources and support, among other important topics. There is no cost to eligible Medicare consumers to participate in the EDC program. This program is not intended to replace the certified, reimbursed DSME programs offered by many clinics, hospitals, and health systems, but to augment them by engaging patients in a supportive community environment that encourages everyone with diabetes to take an active role in their health. Combining traditional DSME with EDC will offer a one-two punch to the epidemic of diabetes in our state. The goal of the EDC program is to leverage and promote diabetes education in order to

engage and empower Medicare consumers and their families to effectively manage their diabetes. Ultimately, EDC aims to improve clinical outcomes related to A1C, lipids, eye exams, weight, blood pressure, foot care, tobacco cessation, and the promotion of diabetes self-management education. Where is the greatest need in Minnesota? In Minnesota, 19.2 percent of Medicare beneficiaries (91,229) have diabetes based on Medicare fee for service (FFS) Part B claims data. The average number of beneficiaries with diabetes by county is 1,048, with a minimum of 55 (Lake of the Woods in northwestern Minnesota) and a maximum of 17,330 (Hennepin in the Twin Cities). Total number of beneficiaries includes those enrolled at any point during calendar year 2013. Diabetes diagnosis included beneficiaries with a Part B claim for diabetes in calendar year 2013. Percent of beneficiaries with diabetes was calculated as the number of beneficiaries with a diabetes diagnosis divided by the total number of beneficiaries in the geographic area. Because Minnesota’s largest underserved diabetes population is rural, we have decided to focus a majority of our efforts in rural Minnesota but also will work with key need areas in the Twin Cities metro area. The top two counties (non-metro) with large rural populations of Medicare beneficiaries near an urban hub are: St. Louis County (urban hub: Duluth) in northeastern Minnesota (5,269) and Olmsted County (urban hub: Rochester) in southeastern Minnesota (4,545). The top 20 counties with the highest percentage of Medicare beneficiaries with diabetes do not fall into the seven-county metro area. Seven out of the 20 are contiguous counties in southeastern Minnesota (Houston, Fillmore, Mower, Olmsted, Dodge, Winona, and Steele) with a total FFS Medicare beneficiary population of a little over 12,200. Over 150 identified ZIP codes within these 20 coun-

Table 1: Top 20 Minnesota counties with the highest percentage of Medicare* consumers with diabetes Beltrami

Kandiyohi

Benton

Mahnomen

Carlton

Mower

Cass

Nicollet

Clay

Nobles

Cottonwood

Olmsted

Dodge

Pennington

Fillmore

St. Louis

Houston

Steele

Hubbard

Winona

*Fee for Service

ties fall into a rural risk category and may be targeted for the EDC program (see Table 1 above). More communities may be targeted, as additional data and stakeholder partnerships are explored. What are the plans for EDC? In Minnesota, implementation of EDC will focus on high-need areas in Greater Minnesota and underserved areas of the Twin Cities. We currently are meeting with clinics, providers, certified diabetes educators (CDE), community organizations, faith-based organizations, and many other stakeholders to further develop the EDC program across the state of Minnesota. The first classes in the EDC program—a partnership between the Arrowhead Area Agency on Aging and Stratis Health—are tentatively scheduled to take place in Carlton County in January 2015. We currently are working with local CDEs and community organizations to promote the program and help identify more areas where access to CDEs and diabetes education is limited and may require the Medicare consumer to travel a distance to receive education and support. We know managing diabetes is a complex and time-consuming process that falls mainly on the patient. According to the National Diabetes Education Program, nearly 80 percent of patients’ diabetes care is given by a primary care provider versus other health care avenues. That means the primary care setting plays a crucial role in

guiding patients with diabetes to the interventions that are most beneficial. The challenge for primary care is to expand the delivery of diabetes knowledge, care, and support beyond their walls and into the community, in a way that is meaningful to the patient. How can I participate? Stratis Health currently is recruiting ambulatory care clinics and individual providers in rural and metro areas to take part in Everyone with Diabetes Counts. There is no cost to providers or the patients they refer to the program. Participation is voluntary and requires clinics/providers to refer Medicare patients with diabetes or prediabetes to EDC classes, sign a participation agreement pledging to submit diabetes and cardiac clinical data on the referred Medicare patients, and be actively involved in the project. Benefits for providers include increased patient compliance, technical assistance in areas such as quality data benchmark reports, electronic health record standardization, and quality improvement initiatives, including Physician Quality Reporting System (PQRS), value-based modifier, and meaningful use. As a supplement to this work, clinics and providers also may participate in a virtual Diabetes and Cardiac Collaborative geared toward increasing staff knowledge and skills related to diabetes and cardiac measures, best practices, patient engagement strategies,

The evidence-based self-management education classes offered by EDC are designed to give patients the tools to problem-solve and cope with day-today challenges. Their treatment adherence will be reflected in improved diabetes and cardiovascular performance scores for your practice. It’s a program where everyone wins, and it is being offered at no cost to you or your patients. To receive more information, please contact mdahl@stratishealth. org.

Prescription pad sample for referring patients to the EDC program

and process improvements. All clinic/provider participants are encouraged to take part in learning sessions, which are done online, over the phone, and/or in person. Information will be shared through a variety of channels including webinars, teleconferences, e-newsletters, in-person workshops and meetings, videos, and social media.

Mary Beth Dahl, RN, is a program manager at Stratis Health. She leads the Reducing Disparities in Diabetes Care: Everyone with Diabetes Counts (EDC) initiative by addressing barriers and improving access to education programs on diabetes self-management across Minnesota.

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Public Health

ndoors or out, unhealthy air is a concern for everyone; especially those with lung disease. Air pollution affects some groups disproportionately. Neighborhoods located near busy roads and factories are exposed to large sources of dangerous pollutants and often are comprised of low-income families and people of color. Poor air quality on the job or inside the home also poses an increased risk, including: increased respiratory diseases like asthma; chronic obstructive pulmonary disease (COPD); lung cancer; increased respiratory symptoms; decreased lung function; increased respiratory morbidity as measured by absenteeism from work or school; cardiovascular disease; birth defects; and premature death (Pope et al., 1995; Pope and Dockery, 1999). In addition, many individuals have asthma, COPD, or other diseases that place them at even greater risk. Particulate matter pollution There now is considerable epidemiological evidence supporting the relationship between poor

Healthy lungs and air pollution An indoor/outdoor problem By Jill Heins Nesvold, MS, and Cynthia Isaacson air quality due to particulate matter and increased morbidity and mortality. Particulate matter comes from a variety of sources, including: pollen, mold, dust mites, pet allergens, dust, oil smoke, combustion by-products, smog, and smoke. The large number of deaths and other health problems associated with particulate pollution was first demonstrated in the early 1970s. Particulate matter pollution is estimated to cause 22,000 to 52,000 deaths per year in the United States. Inhaling particulate matter has repeatedly been shown to impact health. The size of the particle is a main determinant of where in the respiratory tract the particle

will come to rest when inhaled. Large airborne particles are filtered in the nose and throat via cilia and mucus, but particulate matter smaller than about 10 micrometers (referred to as PM10) can penetrate and settle into the deepest part of the lungs such as the bronchi or alveoli and cause health problems. Similarly, particles smaller than 2.5 micrometers (PM2.5) tend to penetrate into the gas exchange regions of the lung, and very small particles (<100 nanometers) may pass through the lungs to affect other organs. The World Health Organization (WHO) estimates that “... fine particulate air pollution (PM2.5), causes about 3% of mortality

from cardiopulmonary disease, about 5% of mortality from cancer of the trachea, bronchus, and lung, and about 1% of mortality from acute respiratory infections in children under 5 years, worldwide.” Risks to those with lung disease People who have a preexisting lung disease such as asthma often feel even greater effects from inhaling particulate matter. When particulate matter enters the lungs it acts as an irritant, and in some cases, an allergen, that causes irritation and inflammation in the airways. According to recent studies, this leads to increased exacerbations and hospitalizations. People with asthma who have even short-term exposure to PM10 have increased asthma symptoms, increased use of asthma medications, and even instances of asthma deaths. Research by Pope in 2000 shows a strong relationship between PM10 and COPD exacerbations. An association between relatively low levels of particulate matter and increased

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Minnesota Physician December 2014

hospitalizations for COPD also has been shown by Chen (2004). Since the effect of ultrafine particulate matter inhaled is a harmful inflammatory response, reducing the particulate matter in the air breathed by individuals with COPD would reduce the inflammatory response and COPD exacerbations. Many COPD patients are elderly, which increases their risk from particulate matter. Elders already are more susceptible to chronic lung and cardiovascular disease and aging is accompanied by changes in the lungs, including how the lungs handle ultrafine particulate matter. Indoor air pollution also may be more important for the elderly since they spend more time indoors.

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Indoor air pollution Indoor air pollution can pose a threat. Indoor particulate matter in the home can be created from mold, dust mites, pet allergens, dust, non-vented or malfunctioning combustion appliances, woodburning appliances, and tobacco smoke. Studies by Dick et al. (2001)

on indoor sources of ultrafine particulate matter (PM3) show that gas stoves produce large amounts of ultrafine particulate matter. In addition, due to a lack of adequate air filtration and ventilation the presence of dirt, contaminants, moisture, and warmth, which encourages the growth of mold, can trigger allergic reactions and asthma. Children with asthma who have a parent who smokes in the home had much more severe symptoms and increased hospitalizations and emergency department visits. The Centers for Disease Control and Prevention reports that the percentage of children exposed to secondhand smoke was higher among children with asthma than those without asthma in 2007–2010. Additionally, children from Mexican-American families, girls, children whose family are 35 percent below the poverty line, and children ages six to 11 all had greater amounts of exposure to secondhand smoke. Outdoor air pollution While indoor air pollution levels often are two to five times

the fuels we burn (e.g., gas and diesel) and vapors from products like gasoline and paint solvents to react together and form ozone. Temperature and wind also are factors in ozone pollution. Warmer temperatures increase ozone pollution. Ozone, as well as the chemicals that form ozone, are easily transported by the wind, even thousands of miles. Consequently, some ozone pollution comes from other areas and communities. Climate changes and weather make particulate matter stay around longer. Based on the Minnesota Pollution Control Agency’s 2013 report to the legislature, all areas of Minnesota currently meet fine particulate matter standards. There can be occasional exceedances of the daily standard due to stagnant weather conditions. Poor outdoor air quality also exacerbates asthma in both children and adults. A map developed by the Minnesota Department of Health shows asthma

greater than outdoor levels, we should be equally concerned about outdoor/ambient air quality. Outdoor air pollution comes from a variety of sources, including cars, buses, trucks, ships, trains, wildfires, industry, and activities such as smoking or campfires. There are several primary issues with outdoor air quality and particulate matter including ozone and climate change. PM2.5 can be emitted directly or formed in the air from gases. On a typical day, roughly half of the PM2.5 in urban air is directly emitted from combustion sources such as soot and the other half is formed from chemical reactions in the air. Particle pollution varies by time of year and location, and is affected by changes in weather such as temperature, humidity, and wind. The most common form of air pollution is ground-level ozone—an irritant for the lungs. Ozone is a major component of smog. Ground-level ozone forms readily in the atmosphere during warm, sunny days. Sunlight causes chemicals from

Healthy lungs and air pollution to page 34

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December 2014 Minnesota Physician

Neurology

arkinson’s disease (PD) is a neurodegenerative disease of the nervous system that affects motor function with symptoms of bradykinesia, tremors, muscle rigidity, and unsteady gait. PD also causes non-motor symptoms such as mood, cognitive, sleep, and autonomic disorders. Sleep disorders are seen in all stages of Parkinson’s disease, such as REM behavior disorder, insomnia, fragmented and interrupted sleep, obstructive sleep apnea, restless legs syndrome, and excessive daytime sleepiness to name a few. Pain is a common underreported symptom that interferes with quality of life, but which adequate pain treatment may improve. The prevalence of pain is variable, but may be present in up to 80 percent of PD patients in early as well as advanced stages of PD.

Types of pain A systematic review of the different types of pain in PD aids

Pain and sleep disorders in Parkinson’s patients

or trunk and by muscle spasms. It is commonly seen in young PD patients and usually involves the feet. Dystonic pain is worse in periods when the medication wears off, such as early mornings. Dystonia also may be present in the middle and end of levodopa dosing or just during the peak effect of levodopa.

Improving quality of life

Radicular or neuropathic pain is usually localized to a single nerve distribution and not related to PD. Chronic use of levodopa though, increases the risk of peripheral neuropathy.

By Okeanis Vaou, MD in its effective treatment, and prevents unnecessary investigations and treatments. The risk factors for experiencing pain are female gender, advanced PD stages, depression, and younger age. Five different types of pain have been described: • Musculoskeletal • Dystonic • Radicular or neuropathic • Central • Akathisia The most frequent pain,

musculoskeletal, is recalled in 46.4 percent of patients with PD. It is described as a form of aching or a cramping ache that tends to present more commonly as shoulder or back pain, and usually appears in the patient’s most affected side. Musculoskeletal pain is possibly caused by stiff muscles, immobility, deformities of posture, and awkward mechanics of gait, and also can be associated with rheumatologic or orthopedic disease.

Central pain is characterized as a boring, burning, and constant generalized vague pain. Patients with motor fluctuations are at higher risk of experiencing central pain. This type of pain is also seen in other central nervous disorders, such as stroke. Patients usually in the “off” state may report symptoms of visceral pain, abdominal pain, and feeling flushed or hot. Being in this state increases the patient’s anxiety and

Dystonic pain is caused by dystonic posturing of the limbs

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Minnesota Physician December 2014

discomfort level. A more rare type of central pain seen in PD patients is mouth and genital burning pain, usually perceived by PD patients in the “off” state. Akathisia is a rare type of pain, described as an inner restlessness and inability to remain still. It is seen more commonly in more advanced stages of PD. Restless legs syndrome can be confused with akathisia, but the former condition is characterized with an urge to move the legs at rest, and improves with movement. Understanding the pain Understanding basal ganglia pathways in the brain has helped, to some extent, in explaining the pathogenesis of pain in PD. The cortical-basal ganglia-thalamic circuit affected in PD patients is involved in pain processing. Serotonin and norepinephrine, which are also affected in PD, have been implicated as possible modulators of pain in the setting of depression, and are believed to exert effects on descending pain pathways. A multidisciplinary approach to treating pain is needed with analgesic agents, muscle relaxants, physical therapy, and exercise, especially in musculoskeletal and neuropathic pain. Optimization of dopaminergic treatment, which limits motor fluctuations, will treat dystonic, musculoskeletal, and central pain. In one study, deep brain stimulation resulted in 90 percent improvement in pain. Although pain is so frequently seen in patients with PD, at least half remain untreated. This occurs because most patients are unaware that pain is one of the many non-motor symptoms of PD they should discuss with their treating physician. Many physicians also do not recognize pain as a PD symptom. This points to the necessity of increased awareness in both patients and physicians for early recognition and optimal treatment of pain in PD patients.

Sleep disturbances Common non-motor symptoms of PD are sleep disturbances, seen in all stages of the disease. It is now recognized that sleep disorders, in particular REM behavior disorder, predate the motor symptoms of PD and may be used in the future as an early symptom to diagnose the disease sooner. Some sleep

index of this patient population is average to low. The treatment remains the same as for the rest of the population with OSA. The best diagnostic tool for OSA is a nocturnal polysomnogram and treatment options include CPAP, a mandibular advancement device, and surgery. The treatment option depends on the severity of OSA and the patient’s CPAP

A multidisciplinary approach to treating pain is needed. disorders in PD are a result of dopaminergic medication and some a symptom of the disease itself. Nocturnal sleep disturbances are seen in 60 percent to 98 percent of patients. There are several sleep disorders that can present in PD patients: • Sleep fragmentation • Obstructive sleep apnea • Restless legs syndrome • Periodic limb movements in sleep

tolerability and compliance. Restless legs syndrome (RLS) and periodic limb movements in sleep (PLMS) are also responsible for disrupting sleep in PD patients, and were found to occur more frequently in this population. RLS is an urge to move the lower limbs when relaxing or at rest, which is alleviated with movement. PLMS are frequent and periodic limb movements during sleep,

and are usually associated with RLS. Dopamine agonists as well as other medication, such as gabapentin and opioids, are used for effective treatment of both of these conditions. REM behavior disorder (RBD) is another common sleep disorder seen in PD. RBD involves the presence of muscle tone and activity during REM sleep, which leads to dream enactment. Complex and violent behaviors can be seen in RBD, and can lead to serious injuries of both the patient and his or her bed partner. It can precede the onset of motor symptoms of PD by an average of 12.7 years and is commonly seen in neurodegenerative diseases, such as Lewy body dementia and multiple systems atrophy. One study estimated that RBD can be seen in 33 percent of PD patients. Polysomnography is the most reliable test to diagnose RBD. In patients with mild symptoms, Pain and sleep disorders in Parkinson’s patients to page 36

• REM behavior disorder • Excessive daytime sleepiness Sleep fragmentation with frequent awakenings is the most common sleep complaint in patients with PD, and usually leads to excessive daytime sleepiness and fatigue due to reduction in total sleep time. Fragmented sleep has many causes, such as frequent urination, REM behavior disorders, pain and muscle stiffness, obstructive sleep apnea, and periodic limb movements in sleep. Treatment with dopaminergic medication can improve sleep by alleviating muscle tightness and rigidity, and improve early morning function. Sleep disorders should be assessed and treated in order to aid in consolidated sleep. Obstructive sleep apnea (OSA) has been seen to be more frequent in PD patients. Twenty percent to 50 percent of PD patients have OSA. It is unclear why OSA is more prevalent in the PD population especially when the average body mass

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December 2014 Minnesota Physician

Special Focus: Senior and long-term care

arly in my career, I treated a 98-year-old patient named Bill. He had several chronic diseases and lived in the local nursing home. One night, I received a call from the nurse reporting that Bill was unresponsive, had not eaten in 24 hours, and appeared to be actively dying. I discontinued all 12 of his medications and said I would see him in the morning, not very hopeful that he would last the night. To my surprise, when I walked in his room, instead of an empty bed stripped of its sheets, there was Bill, sitting up and looking bright-eyed! He said, “Hi Doc, how are you today? I feel better than I’ve felt in years!” I explained about the call the night before reporting that he was dying and that I had stopped all his medications. He looked me square in the eye and said, “Don’t ever start those again!” He lived for another year and a half without his insulin, without his digoxin, and without his other 10 medications. He did,

Polypharmacy in elder patients Are seniors overmedicated? By Todd Stivland, MD however, ask to get his “pee pill” back. Primum non nocere: First, do no harm. As physicians, we’ve made this pledge for centuries, and when treating the frail and elderly, it is especially important to remember this axiom. Our training revolves around diagnosing conditions and treating them, usually with medication. We have become very good at treating conditions; however, we often miss the importance of treating the whole person. As a result, patients often collect medications and chronic diagnoses for years. It is not uncommon to see an elder patient on 20 or

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more medications. This problem is reinforced by our training, our drive to help, and the ever-increasing pressure from quality measures that demand that specific numbers for blood pressure, cholesterol, and blood glucose control be achieved. The resulting polypharmacy is becoming one of the most common reasons for hospitalizations and adverse effects in elder patients. A case study Rose presents in clinic accompanied by her primary caregiver, a family member, who provides most of her daily care. She requires complete assistance with bathing, dressing, and feeding and she is incontinent of urine and stool. She awakens several times during the night, agitated, crying, and screaming. During the day, she has wide mood swings from laughing to crying, sometimes throwing objects and striking out at her caregiver. The symptoms have fluctuated since she moved in with the family member six months ago. Past medical history is otherwise unremarkable. Here is a list of the medications that Rose is taking: • Seroquel 12.5 MG bid • Ativan 0.5 mg TID prn • Colace prn • Detrol XL daily • Trazodone 50mg QHS • Celexa 10mg daily • Tylenol #3 one TID

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This is a fairly common history and medication list. Now let’s add one more piece of history; let’s assume Rose is 6 months old. The history still fits, but none of us would consider any of these medications at all appropriate. When treating a pregnant mother or

children, doctors are extremely cautious with medications. Why, then, are we so cavalier about medications for the frail and elderly, and so hesitant to discontinue them? We have excellent data to suggest that many of the medications used to treat chronic diseases interact with each other adversely, and are much more slowly metabolized in elder patients, often providing only minimal, if any, benefit. Discontinuing medication Sometimes patients and their families are convinced that certain medications will have benefits far beyond what is realistic, and that stopping them is the equivalent of passive suicide. When properly informed, most patients and their families dealing with chronic illnesses or end-stage dementia will opt for comfort care medications only. It’s often easiest to reduce medication meant only for long-term prevention, such as statins. Also, medications with appreciable toxic effects often can be discontinued without significant issues. Other medications designed for treating psychiatric conditions or early Alzheimer’s, such as atypical antipsychotics and benzodiazepines, often can be minimized with appropriate behavioral care plans. Up to 30 percent of memory care residents currently are on antipsychotics and benzodiazepines, despite a black box warning for these medications. Alzheimer’s and polypharmacy Nowhere is addressing polypharmacy more important than in the area of treating Alzheimer’s disease. Alzheimer’s is expected to be the most expensive diagnosis in America by the year 2020. We currently have very little research on the effects of medications at the end of life, particularly with Alzheimer’s. The first step in any medication review for an elder patient should be to develop a clear care plan. It is especially important in patients with Alzheimer’s and other neurological degenerative diseases to involve the patient when possible, all

family members, and the care staff when crafting a care plan. The plan should include DNR/ DNI status, a Minnesota POLST form, and an agreement about aggressive treatments vs. comfort care. Unfortunately, patients with end-stage dementia often are unable to make their own wishes known. Educating the family or caregivers about the course of the disease and the possible risks and benefits of medications is extremely important. Once there is an agreed-upon care plan, you should review the medication list with the family and address the risks and benefits of each drug. It is important to become familiar with the AGS Beers criteria, which outlines potentially inappropriate medication use in elders. When addressing medication reduction for patients with advanced dementia, the following tips are a good starting point. • Alzheimer’s: There is no good evidence that it is beneficial to continue Aricept in the advanced stages of Alzheimer’s, so for that reason the patient should be weaned. It is a common cause of diarrhea and any patient on Aricept with bowel issues should have a trial period off the medication. Namenda also has very limited data showing any benefit in advanced Alzheimer’s patients and they can usually be weaned. However, there may be some behavior benefits to continuing it. • Diabetes: Avoid glyburide and sliding-scale insulin due to a high risk of hypoglycemia. Also, sliding-scale insulin is very difficult to administer with residents in assisted living. Tight glucose control is no longer the goal and blood sugar can be controlled with lower doses of medications such as Lantus or Levemir. • Hyperlipidemia: Statins can cause muscle pain and weakness and likely have no benefit in the final stages of life and should be

discontinued in most memory care patients. Zetia has never been shown to have preventive value and should be stopped as well.

It is not uncommon to see an elder patient on 20 or more medications. • Atrial fibrillation: Amiodarone is very toxic and rhythm control is less important than rate control, so amiodarone can be discontinued in most patients. Digoxin also is very toxic and should not exceed 0.125mg/day and often can be weaned completely if the heart rate is controlled. Discontinuing Warfarin is a more difficult decision. The risk of an elderly patient falling, along with the discomfort of routine blood checks and bruising, need to be weighed against the risk of a vascular event. • H ypertension: Tight blood pressure control may actually decrease central profusion and increase falls. A systolic blood pressure goal of 150 to 160 is optimal. My experience has been that adding or subtracting the third or fourth blood pressure medication has little effect on blood pressure readings. I have actually seen readings improve with discontinuation of antihypertensives. • P ain control: Avoid NSAIDS due to the high rate of GI bleeding. Use caution with narcotics and do not order prn scheduling due to the fact that patients usually cannot express pain well and staff are not able to consistently monitor the needs. Scheduled methadone can be very effective in this population. Of note, patients with low body fat will not absorb Fentanyl patches well.

sants due to their high anticholinergic effects. Also be cautious when prescribing Prozac and Wellbutrin because they can cause agitation and weight loss. The atypical antipsychotic medications pose particular difficulties. Since behavior management is such a significant issue there is pressure to start and continue these medications. However, there is strong evidence that atypical antipsychotics increase the risk of sudden death and falls. If a patient is on any atypical antipsychotics, they should be closely monitored and periodically weaned off of them. This level of care may require educating the nursing staff and the patient’s family. As dementia advances, aggressive behavior often will “burn out” and patients will do fine on lower doses or can even go off behavior medication entirely.

Benzdiazepines should be avoided and only used when all other options have been tried. Conclusion In summary, we owe it to our elder patients to become as good at stopping medications as we are at starting them. Just because we were not the original prescribing provider does not mean we shouldn’t be the one who discontinues medication. In treating this high-risk, vulnerable group of elder patients, we should never follow guidelines made for the general population, if they are not appropriate at the end of life. Finally, I like to remember the words of Samuel Shem, MD (The House of God): “The delivery of medical care is to do as much nothing as possible.” Todd Stivland, MD, is the owner and CEO of Bluestone Physician Services, based in Minnesota, which offers on-site medical care to frail, elderly, and special-needs residents in assisted living communities, group homes, and memory-care facilities.

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sychiatric medications: • P Avoid tricyclic antidepresDecember 2014 Minnesota Physician

Special Focus: Senior and long-term care

ging is one of life’s true constants. We get wrinkles, walk more slowly, and watch our hair turn gray. The spine is no exception to the rest of our body. This article will cover some of the most common spinal pathologies seen in our daily practice: lumbar spinal stenosis, kyphosis, and osteoporosis. Spinal stenosis As the body ages, intervertebral discs progressively collapse due to a dehydration process of the nucleus pulposus. The facet joints overgrow, as with any other arthritic joint, and the ligamentum flavum becomes redundant. These all are part of the pathophysiology of a wellknown condition called lumbar spinal stenosis. These changes cause a decrease in the dimension of the lumbar spinal canal. This may cause low back, buttock, and leg pain. In addition, lumbar spinal stenosis may be associated with a forward

The aging spine Common pathologies By Christopher Alcala, MD

slippage of the cephalad vertebrae over the caudal vertebrae, which is called degenerative spondylolisthesis. Ninety percent of the diagnosis of lumbar spinal stenosis can be predicted through a comprehensive medical history and physical examination. Pain that is aggravated by standing and walking, relieved by sitting and lying down is classic for what is called neurogenic claudication. It’s of vital importance to differentiate from vascular claudication. The best study available to evaluate these patients is magnetic resonance imaging (MRI). If the patient cannot undergo an MRI, then the next best option is comput-

erized tomography with myelogram (CT myelogram). However, these studies are done in the supine position. That is why flexion/extension radiographs are important in the evaluation of lumbar spinal stenosis patients to rule out an associated degenerative spondylolisthesis. Why is this important? It changes the surgical treatment option from a simple decompression to a fusion procedure. It is uncommon for patients with severe stenosis to present with weakness or proprioception changes on physical examination. If they do, they should be evaluated promptly by a spine surgeon. Even more rare is the patient who develops

cauda equina syndrome due to lumbar stenosis. When this happens, it’s more likely an acute exacerbation due to a new disc herniation in a chronically narrowed canal caused by lumbar spinal stenosis. Not every patient with lumbar spinal stenosis needs surgery, but quality of life is of great concern. In addition, age is not a contraindication to having spine surgery. How old is too old for surgery nowadays? We don’t know. This complicated answer may lie in a zone between physiological age, a patient’s comorbidities, and the extent of surgery required. Every patient’s diagnosis, symptoms, and surgical needs are different. Even if surgery is not an option, there are other treatments available: physical therapy with attention to posture and mechanics; isometric exercises; and core and extremity strengthening. Physical therapy helps patients maintain an optimal level of physical fitness

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Minnesota Physician December 2014

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and muscle strength, which is important because it helps unload the spine. When patients have an acute exacerbation with mostly leg pain, they may benefit from epidural steroid injections. These injections may offer substantial pain relief in the short or long term depending on the case. Where there is severe stenosis without a neurological deficit, odds are that an epidural steroid injection may give some pain relief for only a short period of time. There is a wide array of surgical options for patients, depending on their specific diagnosis. Is there a need for a fusion in addition to a decompression? Is there any instability or deformity in the spine that needs to be addressed? The number one goal of surgery for patients with lumbar spinal stenosis is to reduce pressure on the nerves or decompress the spine. This holds true even when the stenosis is associated with degenerative scoliosis or

spondylolisthesis. The levels that show gross instability on X-ray prior to surgery should be fused to avoid recurrence of symptoms. This is achieved either with an interbody fusion, posterolateral fusion, or both. In order to increase fusion rates we use instrumentation in the form of screws and rods. Every patient will have different surgical needs and options. Managing lumbar degenerative scoliosis is beyond the scope of this article. Advances in spine surgery Spine surgery is one of the most constantly evolving fields in medicine. In the last few years, hundreds of new hardware products have been introduced to the market. Still, it is our responsibility to base our treatment decisions in evidence-based medicine. This means not doing what one article recommends, but looking at the literature as a whole and selecting the highest level of evidence in order to

ther group. Although we did not guide treatment. There are new surgical techniques that include find that the minimally invasive group was doing clinically betinterspinous devices, artificial ter than the open group, patient discs, and more. Still, a very satisfaction was slightly higher. specific group of patients may be candidates for these options, but certainly Age is not a contraindication not the majority.

to Recently, there has been great interest in minimally invasive spine surgery. Studies have shown that minimally invasive fusion procedures may decrease hospital stay, blood loss, and immediate postoperative pain level. Still, it has not been shown to be clinically superior to open surgery. Recently, I did a study at our institution comparing open and minimally invasive lumbar interbody fusions in more than 100 patients. We found that, indeed, the patients that had a minimally invasive fusion had less blood loss, spent less days in the hospital, and had disability scores that were comparable to the open group. We did not have infections in ei-

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having spine surgery. Nevertheless, there was no statistically significant difference at a one-year follow-up. This is consistent with the findings of similar studies. In other words, the most important aspect of undergoing surgery is not if it is minimally invasive. It is that the pathology responsible for the patient’s symptoms is being addressed in a safe and reproducible way. Kyphosis In addition to the risk of developing lumbar spinal stenosis, the aging spine goes through a series of changes that produce a The aging spine to page 32

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December 2014 Minnesota Physician

Special Focus: Senior and long-term care

ong-term care (LTC) has changed. Some may have historically characterized it as a social model to keep residents comfortable as they transitioned toward death. However, today’s long-term care is a medical model with an array of options for families and their loved ones depending on the medical needs of the resident. Short-term rehabilitative stays, adult foster care homes, memory care, and continuing care models are designed to meet different care needs. Each individual model of care has its own patient regulations and rights and it can be daunting to understand them. In addition, younger and/or disabled individuals also live in long-term care settings, not just the elderly. The physician is often the connecting link for the resident, because residents travel back and forth between acute, outpatient, and long-term care. This article provides an overview of the difference between a patient and a resident as it applies to

Know your rights A look at LTC resident protection regulations By Suzanne M. Scheller, Esq.

their follow-up care; a patient’s and resident’s rights; and communication among providers. Patient or resident? “Patient” rights generally refer to the rights of those in an inpatient hospital or outpatient clinical setting. The term “residents” refers to those living in a nursing home where their care will continue upon discharge as a patient. See Minn. Stat. § 144.651, subd. 2. Often there is an immediate disconnect between the inpatient/outpatient care models and the long-term care models because providers may not recognize the true nature of the facility and the care provided.

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Minnesota Physician December 2014

The state of Minnesota issues several different licenses to facilities that provide care. The figure on page 25 shows the care options available, with the nursing home offering the most care on the left and gradually moving to less care as you move through the circles to the right. Generally speaking, facilities that are not nursing homes do not necessarily provide coordinated care. The distinction of primarily defining a person as a “patient” or “resident” is critically important for physicians to understand. If the person is primarily a “resident” of a skilled nursing facility or veteran’s home, certain protocols and rights attach to the care he or she should receive upon return to that facility after hospitalization. If a person is primarily defined as a “patient” without regard to whether they live in a long-term care setting, how does that affect the patient’s continuation of care once she or he leaves the hospital? The physician may presume that a faxed order upon discharge ends up in the hands of a registered nurse or other staff member, but that may not be the case. In Minnesota, a rented apartment with home health services can be designated as “assisted living,” and that does not necessarily mean that coordinated care services are in place. When physicians make recommendations for care, they should ask about the specific living circumstance of their patient and if there is formal continuation of care. They should not assume that because their patient lives in an assisted living, memory care, residential care home, or senior housing that their recommendations are going to someone other than the patient themselves.

Patient and resident rights Many laws and regulations exist to protect patients and residents of long-term care on both the federal and state level, whether they live in a facility or at home. Compiling these laws into a meaningful reference for physicians is challenging since they come from several sources and vary depending on the care setting. Federal regulations from the Social Security Act and Medicare/Medicaid funding afford rights for skilled nursing facilities. It is important to note that these federal regulations do not specifically include assisted living and other facility models, although the argument can be made for their inclusion. In Minnesota, Bills of Rights exist for many different long-term care facilities and home settings. One important issue to consider, which will not be discussed in depth in this article, is that long-term care residents, whether living in a nursing home, assisted living, or other care setting are protected by Fair Housing laws, which adds another layer when deciding on appropriate placement and care. Among the key rights of patients and residents are that the resident retains the right to refuse treatment and to go against the physician’s recommendations, including placement in a facility. The resident also retains the right to choose his or her own doctor and medical professional, even in a nursing home or assisted living setting. Minnesota statutes Here are some of the pertinent rights for individuals receiving services in a skilled nursing facility, assisted living, or home setting. Patient/Resident Bill of Rights. Minn. Stat. § 144.651. For persons receiving care in a hospital, outpatient, and nursing home settings, the following summarizes the individual’s rights: • To be informed about treatment, alternatives, risks, and prognosis. Subd. 9.

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• To participate in planning of treatment and for a family member or chosen representative, upon reasonable inquiry, to be notified of his or her condition. Subd. 10. • To receive care with reasonable regularity. Subd. 11. • To refuse treatment, if competent, with documentation of information and likely results provided. Subd. 12. • To be free from maltreatment and to be free from chemical and physical restraints, with exceptions. Subd. 14. • To approve or refuse release of records, upon notification of a request, to any individual outside the facility and to select someone to accompany them when records are discussed. Subd. 16. • To communicate privately with persons of their choice, including mail without interference and access to a telephone where they can speak privately. Subd. 21. • To purchase services from a supplier of their choice, with the supplier ensuring the purchases meet medical needs. Subd. 24. • To meet with and receive visitors without interference, unless disruptive; to be given the opportunity to disclose his or her whereabouts to others; and to designate a person to act as next of kin regarding visitation and health care decisions. Subd. 26. • To participate in a resident advisory and family council, as a resident or family member. Subd. 27. • To be assured of privacy for spousal visits. Subd. 28.

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• To not be arbitrarily discharged. To receive written notice of discharge no later than 30 days before discharge. To voluntarily relocate prior to 30 days. Subd. 29. o But see 42 CFR § 483.12(a) (2), which states that discharge from a nursing home is only available on six grounds, with all grounds being documented in the clinical record and balanced against other laws that say the resident must be allowed to return after hospitalization if the resident requires facility services:

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Home Health Care Bill of Rights. Minn. Stat. § 144A.44. For persons receiving care at home, which includes assisted living settings, the following summarizes the individual’s rights. • To receive care according to a suitable and current plan of care. • To be told the type of services, frequency of visits, alternative choices, and consequences of refusing services. • To participate in any decisions about changes in the service plan.

• To be told, before services are initiated, sources of payment, if known. • To freely choose providers. • To be served by properly trained and competent people. • To know provider’s reasons for termination of services, with at least 10 days’ notice. • Additional Assisted Living Home Care Bill of Rights. Minn. Stat. § 144A.441. o To reasonable, advanced notice of changes in service, including at least 30 days’ notice of termination, except for lack of payment, which is 10 days’ notice. Hospice Bill of Rights. Minn. Stat. § 144.751. For persons receiving hospice care, regardless of setting, the following summarizes the Know your rights to page 26

Resident’s needs cannot be met by the facility. Resident no longer needs facility’s services. Resident is a danger to the safety of others in the facility. Resident is a danger to the health of others in the facility. Resident fails to make or ensure payment for care, but must receive notice. Facility ceases to operate.

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• To have reasonable access to advocacy services. Subd. 30. • To request and consent to the use of a physical restraint, as a resident, family member, or agent, upon signed consent and a written order from the attending physician regarding medical symptoms, including fear of falling, and proper use of the restraint. Subd. 33.

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December 2014 Minnesota Physician

Know your rights from page 25

individual’s rights: • To be told in advance the services that will be provided and consequences of refusing services. • To refuse services or treatment. • To know grounds for termination of services, with at least a 10-day notice of termination. • To know in advance of receiving care the source of payment for the services. • To know of other services available, including end of life services. • To freely choose providers. • To be served by those who are trained and competent. • A person may not be asked to surrender rights as a condition of receiving care. Rights as Duties of the Facility. As previously mentioned, skilled nursing facilities are

governed by federal regulations. Many protections or “rights” also may be considered expectations of the resident as to care standards based on the duties of the facility. Some of these pertinent rights are included below. Skilled Nursing Facility/ Nursing Facility Resident Expectations and Rights. For residents of a skilled nursing facility or nursing facility (i.e., nursing homes), the Omnibus Budget Reconciliation Act (OBRA) found at 42 CFR §483 provides the most comprehensive picture of a residents’ rights and the facility’s duty to the resident. One of the main governing rights of nursing home residents is that: Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. 42 CFR § 483.25.

Below are highlights of other expectations for the resident supported in law: • Pressure Sores. A resident having pressure sores must receive necessary treatment to promote healing, prevent infection, and prevent new sores. If a resident enters a facility without a pressure sore, the facility must ensure that one does not develop, unless it is clinically unavoidable. 42 CFR § 483.25(c). The Centers for Medicare & Medicaid Services (CMS) defines “avoidable” and “unavoidable” as: o “Avoidable” means: The resident developed a pressure ulcer and that the facility did not do one or more of the following: “evaluate the resident’s clinical condition and pressure ulcer risk factors; define and implement interventions that are consistent with resident needs, resident goals, and recognized standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate.” o “ Unavoidable” means: The resident developed a pressure ulcer even though the facility had evaluated the resident’s clinical condition and pressure ulcer risk factors; defined and implemented interventions that are consistent with resident needs, goals, and recognized standards of practice; monitored and evaluated the impact of the interventions; and revised the approaches as appropriate. • Accident Prevention. A facility must ensure that the resident environment remains as free of hazards as is possible and receives adequate supervision and assistance devices to prevent accidents. 42 CFR 483.25(h). oM innesota Statute § 626.5572, subd. 3 defines an “accident” as a sudden, unforeseen, and unexpected occurrence or event which:

Minnesota Physician December 2014

Is not likely to occur and which could not have been prevented by exercise of due care; and If occurring while a vulnerable adult is receiving services from a facility, happens when the facility and the employee or person providing services in the facility are in compliance with the laws and rules relevant to the occurrence or event. • Coordination of Records and Care. o Nursing Home Assessment Available. The facility must conduct initially and periodically a comprehensive, accurate, standardized, reproducible assessment of each resident’s functional capacity. 42 CFR § 483.20. o Physician’s Orders upon Admission. At the time each resident is admitted, the facility must have physician orders for the resident’s immediate care. 42 CFR § 483.20(a). o Medical Records upon Transfer. Documentation of the resident’s medical records must be made available upon resident transfer. 42 CFR § 483.12(a)(3). o Clinical Records. The facility must maintain clinical records that are complete, accurate, and readily accessible. 42 CFR § 483.75(1). • Notification to Physician. The facility must immediately inform the physician when there is an accident with potential for injury and a significant change in the resident’s physical, mental, or psychosocial status. 42 CFR § 483.10(b)(11)(i). • Comprehensive Care Plans. According to 42 CFR 483.20(k), the facility is required to develop a comprehensive care plan that is prepared by an interdisciplinary team that is

to include the attending physician and a registered nurse with responsibility for the resident. The care plan should include: o Services to maintain the resident’s highest practicable well-being (483.25). o Any services required but not provided due to the exercise of rights under § 483.10, including right to refuse treatment (483.10(b) (4)). • Professional Services. The services provided or arranged by the facility must meet quality standards and be provided by qualified persons in accordance with the resident’s care plan. 42 CFR § 483.20(k). Communication and coordination of care Some of the common problems I see with my clients relate to lack of coordination of care. Long-term care has become much more specialized, as in the case of home care service providers coming into nursing homes to provide specialty care, such as wound care. This kind of specialized care requires a strong communication system among the three main providers: 1) providers performing activities of daily living, 2) providers performing specialty care, and 3) primary care providers such as physicians and nurse practitioners. If any one of these providers doesn’t share information with the other, the resident is at risk. Now more than ever, the physician and nurse practitioner are in danger of not knowing the true condition of the resident, yet they are ultimately responsible for the resident’s care. If I were a primary care physician, I would ask for a patient’s care plan to ensure that my orders and recommendations were going full circle. I would request additional clinical records to see if there were any other conditions that I should be aware of and I would reiterate the need for other providers to notify me of changes in a resident’s condition.

More and more, I am seeing the long-term care community point the finger back at the doctor or nurse practitioner for failing to check on a wound, adjust a medication, or follow-up on a condition during a routine monthly visit. However, the physician may not have been notified of a change in a resident’s condition. The physician does not know to check on certain conditions if he or she is not told. Likewise, the primary care physician often questions the poor care of the facility when the patient deteriorates in health. In both instances, poor communication is generally at the heart of the disconnect. This is why coordination of care is so important. Physicians should understand the health status and living circumstances of a patient so he or she can provide the best care. The physician cannot expect the long-term care provider to operate as an acute-care facility with staffing ratios, training, and equipment that allows for the level of care found in a hospital. Longterm care providers must keep physicians informed as quickly as possible regarding changes in a resident’s condition. Above all, both the physician and long-term care provider must ensure coordination of care when a “patient” transfers back to being a “resident.” It is most important for physicans to understand the level of care that each resident’s living circumstances offers so that there is a continuation of care. Suzanne M. Scheller, Esq., practices

elder law and advocacy at Scheller Legal Solutions LLC, with a focus on nursing home litigation, financial exploitation, and public policy. She is also a founding board member of the Minnesota Elder Justice Center, former president of the Elder Law Section of the Minnesota State Bar Association, and a visiting faculty member at Hamline University School of Law.

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Star-Crossed Lovers: The Music of Romeo and Juliet Jan 29-31 Osmo Vänskä, conductor

A Winter’s Tale: Featuring Dvořák’s New World Symphony Feb 5-6

Christopher Warren-Green, conductor / Augustin Hadelich, violin

All the World’s a Stage:

A Midsummer Night’s Dream and More Feb 12-14 Yan Pascal Tortelier, conductor / Gil Shaham, violin

The Tempest: Featuring Narration by Joe Dowling Thu Feb 19-21 Osmo Vänskä, conductor / Lilli Paasikivi, mezzo / Joe Dowling, narrator

minnesotaorchestra.org 612.371.5656 / Orchestra Hall Media Partner:

December 2014 Minnesota Physician

Gastroenterology

Accidental bowel leakage

patient may reluctantly tell you she doesn’t leave the house until she knows her bowels are empty. Another patient may tell you his wife complains about cleaning his soiled underwear. Both patients may complain of anal itching, burning, or “hemorrhoid problems.” But, more likely, they are too embarrassed to mention these issues to you at all.

Accidental bowel leakage (ABL), also known as fecal incontinence or bowel control problem, refers to the unintended passage of liquid, solid stool, or mucous from the rectum. Nearly 18 million adults in the United States, or one in 12, suffer from bowel leakage (Whitehead et al., Gastroenterology 2009). The Mature Women’s Health Study, which surveyed 1,096 women age 45 or older, found that fecal incontinence occurred in 18.8 percent of the women studied, when defined as at least one episode of leakage per year (Brown et al., International Journal of Clinical Practice 2012). Patients underreport bowel leakage to

Patients shouldn’t suffer in silence By Amy J. Thorsen, MD their doctors because of shame, fear, and embarrassment. Often, patients with this condition do not understand what is happening to them or even what to call it. In the Mature Women’s Health study, only 30.9 percent had heard of the term “fecal incontinence” and only 40.3 percent were familiar with “bowel incontinence.” Accidental bowel leakage can affect adults of all ages and backgrounds. Its prevalence is higher in women, but that may be because it is significantly underreported in men. Risk factors include chronic diarrhea, irritable bowel syndrome, chronic neurologic disease or injury, chronic disease such as diabetes,

and previous vaginal delivery. Individuals who have suffered from chronic constipation also are at risk. Chronic straining can eventually weaken the pelvic floor muscles and nerves, and fecal impaction can lead to overflow incontinence. Opening a dialogue with your patients Patients are embarrassed to admit to their physician that they are having difficulty controlling bowel movements. A patient may hint to the doctor that they are “having issues with diarrhea,” or their “hemorrhoids are acting up.” A more detailed history about the nature of the complaint may uncover the true

symptom of stool leakage. Accidental bowel leakage is commonly seen in women with urinary incontinence, and patients often are more comfortable discussing their bladder symptoms. If a patient seems hesitant to discuss bowel issues, asking about pad usage and undergarment changes, and what kind of staining is causing these changes, may uncover the diagnosis of ABL. Uncovering the diagnosis of accidental bowel leakage is extremely difficult in male patients. When male patients seek treatment, they usually complain of perianal itching and burning. If they admit to multiple trips to the bathroom to keep clean, or admit to stool staining on underwear, a diagnosis can be established. Conservative treatment options Conservative treatments may help many adults with ABL. Patients who have diarrhea should have a medical workup of its cause, including a colonos-

Don’t miss the SPCO performing masterworks from Beethoven, Mendelssohn and Stravinsky this winter. With 12 venues throughout the Twin Cities, we’re sure to be near you!

Beethoven’s Fourth Symphony

Friday, January 9, 8:00pm Saturday, January 10, 8:00pm Ordway Music Theater, Saint Paul Sunday, January 11, 2:00pm – BEST AVAILABILITY Ted Mann Concert Hall, Minneapolis Led by SPCO musicians Stravinsky: Danses concertantes Adams: Shaker Loops Beethoven: Symphony No. 4

Beethoven’s Second Symphony

Steven Copes

Thursday, January 15, 7:30pm Temple Israel, Minneapolis Friday, January 16, 10:30am – BEST AVAILABILITY Saturday, January 17, 8:00pm Ordway Music Theater, Saint Paul Sunday, January 18, 3:00pm St. Andrew’s Lutheran Church, Mahtomedi Steven Copes, violin Led by SPCO musicians Prokofiev: Symphony No. 1, Classical Mendelssohn: Violin Concerto in E Minor Beethoven: Symphony No. 2

Minnesota Physician December 2014

copy and possibly stool studies. Increasing dietary fiber can improve continence in patients with loose or constipated stools. Although the average American consumes 15 grams of fiber per day, the Academy of Nutrition and Dietetics recommends 20 to 35 grams of fiber per day. Dietary fiber should be increased slowly to avoid abdominal discomfort from bloating. Drinking plenty of water helps fiber tolerance and avoids constipation. Keeping a diary of bowel activity and diet may help patients identify trigger foods that cause diarrhea and ABL. Lactose and fructose are common triggers, so avoiding dairy products or fruits high in fructose, such as apples, peaches, and pears may help. Artificial sweeteners in diet drinks, gum, and candy also can cause problems. Other foods that patients should avoid include cured or smoked meats, spicy foods, alcoholic beverages, caffeinated foods and drinks, and greasy or fatty foods. Reviewing a patient’s med-

ications also may reveal contributing factors to a change in stool consistency. For patients who have ongoing loose stools after implementing dietary changes, prescribing antidiarrheal medications such as loperamide or diphenoxylate may help improve stool consistency. Biofeedback therapy is a noninvasive, conservative option that is available to most patients. The therapy typically incorporates pelvic floor exercises, dietary counseling, and toileting strategies. Although strengthening exercises targeted toward the external sphincter and levator ani muscles are important, many patients also benefit from learning to relax these same muscles completely during the process of defecation, allowing more complete evacuation and preventing subsequent seepage. Patients receiving biofeedback therapy are generally seen by a nurse or physical therapist in an office setting for three to four weekly sessions. Seventy percent to 90 percent of patients will see improvement in their symptoms

after biofeedback therapy.

the anus and the vagina. It works best in younger women whose muscle still contracts well. Symptoms of ABL will improve substantially in 80 percent of patients after overlapping sphincteroplasty. More recent studies suggest, however, that results may deteriorate over time.

Advanced treatment options For those patients who fail to improve under these conservative treatments, anorectal physiology testing may help select the next step in ABL treatment. Testing includes anorectal manometry to assess sphincter function; endoanal ultrasound to evaluate sphincter anatomy; and defecography to identify rectal prolapse, enteroceles, rectal intussusception, and rectoceles.

• Rectal prolapse surgery. Tissue that prolapses out the rectum can cause leakage and stretch the anal sphincters. A variety of surgeries can repair rectal prolapse and lead to significant improvements in ABL and quality of life. An abdominal rectopexy, which can be performed with minimally invasive techniques, aims to restore rectal support with either suture or, occasionally, mesh. Perineal surgery, most often reserved for the frail and elderly, involves resecting prolapsing tissue to prevent further anal

Advanced treatment options for ABL continue to develop. Current treatments include: • Overlapping sphincteroplasty. This involves surgically repairing an anal sphincter injury after traumatic vaginal delivery. A disrupted sphincter complex may take the appearance of the letter “U.” The surgery restores the sphincter to its typical “O” appearance, with an overlap of the ends to help bulk the perineum between

Accidental bowel leakage to page 30

Fairview Health Services Opportunities to fit your life

Read us online

Fairview Health Services seeks physicians to improve the health of the communities we serve. We have a variety of opportunities that allow you to focus on innovative and quality care. Be part of our nationally recognized, patient‑centered, evidence‑based care team.

Wherever you are!

We currently have opportunities in the following areas: • Dermatology • Allergy/ • Immunology Emergency

• Hospitalist • Geriatric • Medicine Hospice

• Dermatology

• Hospitalist • Internal Medicine

• Psychiatry • Orthopedic • Surgery Rheumatology

• Emergency • Medicine Family Medicine

• Med/Peds • Hospice

• Sports Medicine • Pain Medicine

Medicine

• Endocrinology

• General Surgery • Family Medicine • Geriatric • General Surgery

• Pediatrics • Ob/Gyn

• Ob/Gyn • Urgent Care • Internal Medicine • Psychiatry • Orthopedic • Med/Peds

Medicine

Surgery

• Vascular Surgery • Rheumatology

Visit fairview.org/physicians to explore our current opportunities, then apply online, call 800‑842‑6469 or e-mail recruit1@fairview.org

Sorry, no J1 opportunities.

www.mppub.com

fairview.org/physicians TTY 612- 672-7300 EEO/AA Employer

December 2014 Minnesota Physician

Accidental bowel leakage from page 29

sphincter stretching. Occasionally, the prolapsing tissue is actually internal hemorrhoids or mucosal prolapse. Both can be treated by a simple inoffice procedure. • Artificial anal sphincter. An inflatable cuff is surgically placed under the skin around the anus. The cuff is inflated by pressing on a balloon reservoir in the labia or scrotal area to maintain bowel control and deflated to allow bowel

movements. This device is usually reserved for patients who have significant injury to the anal sphincter from trauma. Although 80 percent to 90 percent of patients will have improved continence of stool, up to 50 percent of patients will require revisional surgery, making the artificial bowel sphincter a less common option. • Solesta. This therapy involves injecting a crosslinked hyaluronic acid gel in the lower rectum/ anal canal to bulk up the

tissues, enabling it to close more efficiently. The procedure is not painful and is well-tolerated by patients. Patients may require a second treatment one to three months later for optimal effect. Patients with immune system problems or inflammatory bowel disease are not candidates for this procedure. • Sacral neuromodulation (InterStim). This therapy involves implanting a device similar to a pacemaker, which stimulates the pelvic nerves to work better. Patients are first tested with a temporary device for one to two weeks to be sure it works for them. Both the test phase and implantation of the device are performed as outpatient procedures, and only light sedation is needed. Sacral neuromodulation has a high success rate in decreasing episodes of ABL, and also may improve symptoms of urinary incontinence and overac-

tive bladder (OAB). Future treatment options The future promises more exciting options for those with ABL. Treatments in development include a magnetic sphincter to help keep the anus closed; mesh slings that enhance the length of the anal canal; methods of neuromodulation that may not require surgical implantation of a device; and an expanded list of materials injected into the anus to prevent leakage. Researchers are even studying the use of stem cells to regenerate new muscle for the injured anal sphincter. Now is the time to start the discussion about accidental bowel leakage. With the expanding list of available therapies, treatments can be tailored based on an individual’s symptoms, anatomy, and needs. Patients do not need to suffer in silence. Amy J. Thorsen, MD, is a board-certified colon and rectal surgeon and practices with Colon & Rectal Surgery Associates in Minneapolis.

AdvAnced PrActice Providers

(PA or NP) Our longstanding, independent, highly reputable clinic with busy schedule is recruiting:

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Minnesota Physician December 2014

Health Care Team: Work collaboratively with 3 F/P physicians to care for our patients. 4 days/week – can flex up to 5 as a float to our satellite clinics. 8:30-5 weekdays, also added to Saturday rotation (8-noon) Ready Care and holiday rotation. Full benefits. Ready Care / Float: Work in our Ready Care either 8:30-5 to 11-7:30, depending on needs. Also added to Saturday rotation (8-noon) Ready Care and holiday rotation. This could be a 4- or 5-day position, depending on candidate’s needs. Full benefits. Applicants must be licensed to practice in Minnesota and certified and accredited by organizations recognized by the State of Minnesota. Tri-County Health Care s a private, not-for-profit corporation providing personalized care to patients in west central Minnesota since 1925. We have modern, state-of-the-art facilities and are committed to the highest standards of care.

For more information about these opportunities please call or e-mail:

Judy M. Erdahl, Provider Relations Coordinator Tri-County Health Care, 415 N. Jefferson St., Wadena, MN 56482 218-631-7462 • Fax 218-631-7503 • Email Judy.erdahl@tchc.org

Urgent Care We have part-time and on-call positions available at a variety of Twin Citiesâ&#x20AC;&#x2122; metro area HealthPartners Clinics. We are seeking BC/BE fullrange family medicine and internal medicine pediatric (Med-Peds) physicians. We offer a competitive salary and paid malpractice. For consideration, apply online at healthpartners.com/careers and follow the Search Physician Careers link to view our Urgent Care opportunities. For more information, please contact diane.m.collins@healthpartners.com or call Diane at: 952-883-5453; toll-free: 1-800-472-4695 x3. EOE

Family or Internal Medicine Physician An ideal balance between your professional and personal life. Provide comprehensive care in a clinical and hospital practice. ER coverage available, but not required. GRHS is a progressive 19 bed Critical Access Hospital with two clinics. Glenwood is a family oriented community with an excellent school system. Recreational opportunities include boating, hiking, excellent fishing and hunting. We are halfway between Fargo and the Twin Cites. For more information Call Kirk Stensrud, CEO 320.634.4521 Mail CV to: Kirk Stensrud, CEO 10 Fourth Ave SE Glenwood, MN 56334 Email CV to: kirk.stensrud@glacialridge.org

www.glacialridge.org healthpar tners .com ÂŠ 2014 NAS (Media: delete copyright notice)

MN Physician 4" x 5.25" 4-color

General Adult Psychiatry Be part of a broad-based mental health practice that is uniquely team-oriented! Hutchinson Health is seeking a sixth psychiatrist with a focus on general adult inpatient and outpatient care. Call responsibilities are 1 in 6. Compensation (salary plus productivity) and benefits are highly competitive. Our Mental Health services include a 12-bed inpatient unit and an outpatient clinic. The psychiatric staff includes two Fellowship-trained in child and adolescent, one Fellowship-trained in geriatrics, 10 other mental health professionals, and two chemical dependency professionals. Hutchinson Health, 50 miles west of the Twin Cities, includes a 66-bed acute care hospital, a 30-physician multi-specialty clinic, and several outpatient and specialty clinics. It serves 35,000 as the primary health care provider.

Hutchinson Health is an approved National Health Services site. Patient safety and evidence-based care are at the core of all clinical processes.

For further information, contact Hutchinson Health Human Resources (320) 484-4685 or hr@hutchhealth.com December 2014 Minnesota Physician

The aging spine from page 23

forward stooped posture called kyphosis. A combination of factors, including intervertebral disc dehydration with subsequent loss of height, posterior paraspinal muscle weakness, and vertebral insufficiency fractures, may create the “perfect storm” to aggravate this condition. Life is a kyphotic journey. We will progressively lean forward throughout life. Often, the result is a global imbalance of the spine. Patients with such an imbalance try to compensate by retroverting their pelvis, extending their hips, and flexing their knees in order to achieve a horizontal gaze and keep their head above the pelvis. This may, in some cases, cause problems such as back pain caused by posterior musculature fatigue. Rarely, it may cause weakness or numbness in the extremities; this may require urgent and thorough evaluation and treatment to prevent serious, permanent loss of function. Physical

therapy and anti-inflammatory medications are typically the initial recommendation. Epidural steroid injections may be helpful in diagnosing and treating a lumbar radiculopathy. Bracing may be counterproductive since it has been shown that it may weaken the paraspinal muscles, and does not halt the progression of the

of poor bone mineral density, which may be in the range of osteoporosis. Vertebral compression fractures have been shown to increase mortality rates in older patients, hence the importance of treating this condition early. Frequently, a patient is diagnosed with an atraumatic compression fracture not caused by a tumor or in-

Flexion/extension radiographs are important in the evaluation of lumbar spinal stenosis. deformity in adults. In cases of severe deformity, neurological deterioration and/or significant pain, patients may be candidates for reconstructive spine surgery. Osteoporosis Vertebral insufficiency fractures were previously mentioned as a factor that may contribute to kyphosis. Nevertheless, they often present as back pain. Weak vertebral bodies are the clinical result

fection and he/she gets a brace for six to 12 weeks. Still, it is of paramount importance to make sure these patients get an osteoporosis/metabolic workup and start medical treatment as soon as possible. This will decrease the chance of having an additional skeletal event during their lifetime, and sometimes prevent or at least better manage the inevitable changes of the normal aging processes of the spine. During the acute healing phase of a fracture,

which includes the first two to three months, teriparatide is ideal since it does not generate the bone uncoupling effect of bisphosphonates and, in theory, may accelerate the bone healing process. Afterward, patients should start or continue their usual anti-osteoporosis therapy as indicated by the physician that is treating their condition. The aging spine may be a complex and broad topic. Thorough evaluation of the patient’s medical condition, symptoms, and imaging studies are key to providing successful treatment. Population aging is expected to be among the most prominent global demographic trends of the 21st century. Therefore, we will consistently see a higher incidence of these spine pathologies in the years to come. It is important to know how to recognize them and treat them appropriately. Christopher Alcala, MD, is boardeligible in orthopedic surgery and practices at Twin Cities Spine Center.

It’s your life. Live it well.

Olmsted Medical Center, a 160-clincian multispecialty clinic with 10 outlying branch clinics and a 61 bed hospital, continues to experience significant growth. Olmsted Medical Center provides an excellent opportunity to practice quality medicine in a family oriented atmosphere. The Rochester community provides numerous cultural, educational, and recreational opportunities. Olmsted Medical Center offers a competitive salary and comprehensive benefit package.

Opportunities available in the following specialties: Pain Management Rochester Northwest Clinic Child Psychiatrist Rochester Southeast Clinic Family Medicine Pine Island Clinic General Surgery Call Only – Rochester Hospital

Send CV to: Olmsted Medical Center Administration/Clinician Recruitment 102 Elton Hills Drive NW Rochester, MN 55901 email: dcardille@olmmed.org Phone: 507.529.6748 Fax: 507.529.6622

www.olmstedmedicalcenter.org

Minnesota Physician December 2014

Family Practice with OB Our independent, physician-owned clinic is seeking a BC/BE physician with OB for our family practice facility. 1:9 Calls. Competitive salary/benefits, with opportunity for ownership within 1 year. Paid malpractice, health and dental insurance, 401(k), CME and more. Cloquet is an historic, vibrant community just 15 minutes from Duluth and 10 minutes from Jay Cooke State Park. Adjacent to the St. Louis River, Cloquet has hiking, biking and ATV trails; skiing; boating; fishing; parks; and the only white water rafting in Minnesota. Residents enjoy locally performed plays, concerts and the arts; community festivals; dining and more.

Send CV to: jturonie@raiterclinic.com 218.879.1271 • www.raiterclinic.com 417 Skyline Blvd. • Cloquet, MN 55720

Here to care At Allina Health, we’re here to care, guide, inspire and comfort the millions of patients we see each year at our 90+ clinics, 12 hospitals and through a wide variety of specialty care services throughout Minnesota and western Wisconsin. We care for our employees by providing rewarding work, flexible schedules and competitive benefits in an environment where passionate people thrive and excel.

Opportunities for full-time and part-time staff are available in the following positions: • Dermatologist

Make a difference. Join our award-winning team. Madalyn Dosch, Physician Recruitment Services Toll-free: 1-800-248-4921 Fax: 612-262-4163 Madalyn.Dosch@allina.com

EOE/AA

• Medical DirectorExtended Care & Rehab • Geriatrician/ Hospice/ (Geriatrics) Palliative Care • Ophthalmologist • Internal Medicine/ Family Practice

• Psychiatrist

Applicants must be BE/BC.

WE CHOSE MERCY FOR THE PRACTICE; WE’RE STAYING FOR THE COMMUNITY!

3.5x4.75_AD_MN_Medicine.indd 1

Mercy and North Iowa offer: • Premier rural health care network in northern Iowa and southern Minnesota; • Centers of Excellence: Bariatric, Breast Imaging; • Family-friendly communities with plenty of parks, great schools and activities; • Culture: museums, nature centers, The Legendary Surf Ballroom; • Half-way between Des Moines and Mpls/St. Paul

US Citizenship required or candidates must have proper authorization to work in the U.S. Physician applicants should be BE/BE. Applicant(s) selected for a position may be eligible for an award up to the maximum limitation under the provision of the Education Debt Reduction Program. Possible recruitment bonus. EEO Employer.

Family Medicine (with and without OB) Opportunities in the following North Iowa communities: • Ackley/Iowa • Emmetsburg Falls • Hampton • Algona • Lake Mills • Mason City • Britt • Clear Lake • Osage • Cresco

Competitive salary and benefits with recruitment/ relocation incentive and performance pay possible.

For more information: Visit www.USAJobs.gov or contact

For more information:

Cindy Scott: 641-428-5551, scottcl@mercyhealth.com www.mercynorthiowa.com

Nola Mattson, STC.HR@VA.GOV Jonna Quinn, D.O., OB/GYN, joined Mercy 2013 Mark Lloyd, D.O., Family Medicine, joined Mercy 2014

Human Resources 4801 Veterans Drive, St. Cloud, MN 56303

(320) 255-6301 December 2014 Minnesota Physician

Healthy lungs and air pollution from page 17

prevalence rates can increase to 21 percent to 43 percent of the population in ZIP codes nearest the interstates compared to the Minnesota asthma average of one in 14 people. Improving air quality Fortunately, many ways to improve air quality, indoors and outdoors, exist. When counseling your patients with new or existing lung disease, consider air quality. • Ventilate, ventilate, ventilate. Keep in mind, however, that mold spores, ragweed, and other pollens can enter your home through open windows, on shoes and clothing, and through ventilation systems. • Change furnace filters at least every three months using a pleated electrostatic filter that is designed to catch small particles. Filters should have a 1–10 particle size rating system; the higher the number the

better it will be at capturing smaller particles. • Use a HEPA (high efficiency particulate accumulator) vacuum and dust with a wet cloth or mop to capture dust and dirt. • If your patients have existing lung disease or other health concerns, suggest that they stay away from campfires, fireplaces, smoke, and other sources of particulate matter in the air. • Discuss the link between exercising outdoors and air quality with your patients. When we exercise, we breathe deeper, causing the particulate matter, ozone, and other pollutants to go deeper and settle into our lungs. Patients can monitor the air quality index (AQI), which tracks two pollutants: ozone (smog) and particle pollution. The AQI is designed to help you understand what local air quality means to your health (www.pca. state.mn.us/index.php/air/ air-quality-and-pollutants/

general-air-quality/air-qual ity-index/current-air-qua lity-index.html). • Driving vehicles that run on alternative fuels reduces pollution: The leading outdoor air pollution is vehicle exhaust. Using E85 fuel in a flex fuel vehicle can reduce ozone-forming pollutants and evaporative emissions. Using biodiesel in diesel vehicles also can reduce particulate pollution. There are more than 250 E85 stations in Minnesota and biodiesel is blended into all diesel fuel by state law. Another clean air option is plug-in vehicles, powered in part or whole by electricity. Details on all alternatives are available (www.CleanAir Choice.org). • You also may want to refer your patients to community resources. The American Lung Association’s HelpLine, at (800) 586-4872, can answer questions about indoor and outdoor air quality. The Lung HelpLine is open seven days a week,

7 a.m. to 11 p.m. (Central) and is staffed with experienced health care professionals. In addition, the American Lung Association has tools to assess your home’s air quality (www. lung.org/healthy-air/). The EPA also has home-assessment tools (www.epa.gov/ iaq/). Unhealthy air can be a problem for everyone from the young to the elderly, to those with lung disease to those at risk, and for people in both urban and rural settings. Research shows that unhealthy air at work, school, or in the home can lead to lung disease or increased complications for those who already have lung disease. More research will continue to learn more about the link between air quality and lung disease to help in future prevention and treatment. Jill Heins Nesvold, MS, is the director

of respiratory health for the American Lung Association in Minnesota, North Dakota, and South Dakota. Cynthia Isaacson is the communications manager for the respiratory health department at the American Lung Association in Minnesota.

Physician Practice Opportunities Avera Marshall Regional Medical Center is part of the Avera system of care. Avera encompasses 300 locations in 97 communities in a five-state region. The Avera brand represents system strength and local presence, compassionate care and a Christian mission, clinical excellence, technological sophistication, an array of specialty care and industry leadership.

Avera Marshall Regional Medical Center

Currently we are seeking to add the following specialists:

300 S. Bruce St. Marshall, MN 56258

• General Surgery

• Internal Medicine

• Radiation Oncology

• Family Practice

For details on these practice opportunities go to http://www.avera.org/marshall/physicians/ For more information, contact Dave Dertien, Physician Recruiter, at 605-322-7691 • Dave.Dertien@avera.org

www.averamarshall.org 34

Minnesota Physician December 2014

Family Medicine

Stevens Community Medical Center’s Starbuck Clinic is looking for a family medicine physician. Enjoy the beautiful area lakes, quiet atmosphere and all that West Central Minnesota has to offer. Starbuck Clinic is home to Staff Care’s 2013 Country Doctor of the Year. Dr. Bösl and Greg Rapp, PA provide full clinic services in the picturesque town of Starbuck, MN on Lake Minnewaska. Dr. Bösl would like to transition into retirement. If you would enjoy the serenity of a rural lake community plus the comfort of an independent practice, this is your opportunity!

For more information, contact John Rau, CEO or Dr. Robert Bösl. Morris location

Starbuck location

320.589.7655 jrau@scmcinc.org

320.239.3939 rbosl@hcinet.net

John Rau, CEO

Dr. Robert Bösl

www.scmcinc.org

Visit us on Facebook and Twitter.

Sioux Falls VA Health Care System

Working with and for America’s Veterans is a privilege and we pride ourselves on the quality of care we provide. In return for your commitment to quality health care for our nation’s Veterans, the VA offers an incomparable benefits package. The VAHCS is currently recruiting for the following healthcare positions in the following location.

Sioux Falls VA HCS, SD Primary Care (Family Practice or Internal Medicine) Psychiatrist Endocrinology

Pulmonologist Oncologist Cardiologist (part time) Physician Assistant (Mental Health)

Sioux Falls VA HCS (605) 333-6852 www.siouxfalls.va.gov

Applicants can apply online at www.USAJOBS.gov

EOE

We’re looking for you - Family Physician - Flight Surgeon - Internist - Pediatrician - Psychiatrist - General Surgeon - Neurological Surgeon - Trauma Surgeon

In the U.S. Air Force, the power of being a physician reaches new heights. Work on the most time-sensitive cases. See medical advances as they happen. Be a hero to heroes. And do it all at 30,000 feet.

1-800-588-5260 December 2014 Minnesota Physician

Pain and sleep disorders in Parkinson’s patients from page 19

pharmacologic treatment is not necessary. However, when the symptoms become more severe, treatment is indicated for the safety of the bed partner and the patient. Clonazepam and melatonin have been proven effective in treating the symptoms of RBD. The use of serotonergic antidepressants have been observed to increase the risk of RBD. However, this should not affect the treating physician’s decision to treat depression if it is affecting the patient’s quality of life. Depression is frequently seen in patients with PD and typically predates the onset of motor symptoms. A frequent sleep complaint in the PD population is excessive daytime sleepiness (EDS). Depending on which study you look at, this is seen in 15 percent to 50 percent of patients. It is more common in patients who have more advanced disease, in men, and in patients

with dementia or depression. Individuals who have been on chronic dopaminergic treatment feel more sleepy during the day. It has been found that it is the total amount of levodopa and dopaminergic medications

sleep more during the day and less at night. Patients who feel sleepy during the day should be cautioned about driving, as they have an increased risk of traffic accidents. Treatment of exces-

Patients who feel sleepy during the day should be cautioned about driving. that increase the risk of excessive daytime sleepiness. PD itself tends to cause symptoms of fatigue and sleepiness possibly through impaired arousal systems. Fragmented sleep with frequent awakenings due to nocturnal disturbances such as RLS, OSA, PLMS, as well as the need for frequent urination, also contributes to daytime sleepiness. Many patients experience muscle contractions and cramping during the night, as well as difficulty with position changes in bed, which disrupts their sleep. Many patients with advanced PD and dementia

sive daytime sleepiness should start by identifying the cause and assessment of the patient for a potential sleep disturbance. Side effects of dopamine agonists should be considered and decreased or stopped. The patient should be kept awake during the day, either by increased mental or physical activity and if necessary, by stimulants such as modafinil, methylphenidate, or amphetamines. For adequate sleep at night, a hypnotic may be added to the daytime stimulant if warranted.

St. Cloud/Sartell, MN We are actively recruiting exceptional full-time BE/BC Family Medicine physicians to join our primary care team at the HealthPartners Central Minnesota Clinics - Sartell. This is an outpatient clinical position. Previous electronic medical record experience is helpful, but not required. We use the Epic medical record system in all of our clinics and admitting hospitals.

A leading national consumer magazine recently recognized our clinic for providing the best care in the Twin Cities based on quality and cost. We are currently seeking new physician associates in the areas of:

Our current primary care team includes family medicine, adult medicine, OB/GYN and pediatrics. Several of our specialty services are also available onsite. Our Sartell clinic is located just one hour north of the Twin Cities and offers a dynamic lifestyle in a growing community with traditional appeal.

• Family Practice • Urgent Care

HealthPartners Medical Group continues to receive nationally recognized clinical performance and quality awards. We offer a competitive compensation and beneﬁt package, paid malpractice and a commitment to providing exceptional patient-centered care.

Please contact or fax CV to:

Joel Sagedahl, M.D. 5700 Bottineau Blvd., Crystal, MN 55429

Apply online at healthpartners.com/careers or contact diane.m.collins@healthpartners.com. Call Diane at 952-883-5453; toll-free: 800-472-4695 x3. EOE

763-504-6600 Fax 763-504-6622

healthpartners.com

www.NWFPC.com

Okeanis Vaou, MD, is board-certified in neurology, is board-eligible in sleep medicine, and is a movement disorder specialist. She practices with Noran Neurological Clinic.

Family Medicine

Join the top ranked clinic in the Twin Cities

We are independent physicianowned and operated primary clinic with three locations in the NW Minneapolis suburbs. Working here you will be part of an award winning team with partnership opportunities in just 2 years. We offer competitive salary and benefits. Please call to learn how you can contribute to our innovative new approaches to improving health care delivery.

Conclusion As a whole, PD is a neurodegenerative disease with both motor and non-motor symptoms. Most of the motor symptoms such as tremor, bradykinesia, rigidity, and unsteady gait are well known. The non-motor symptoms, however, are less known to physicians and become more troublesome as the course of PD progresses and they affect the patient’s quality of life. Pain and sleep are non-motor symptoms that when treated may improve a patient’s daily activities and thus delay transfer to a nursing home. Therefore more awareness needs to be raised for these common yet underreported, unrecognized, and undertreated symptoms.

Minnesota Physician December 2014

MN Physician 4" x 5.25" 4-color

Family Medicine & Emergency Medicine Physicians

Great Opportunities

• Immediate Openings • Casual weekend or evening shift coverage • Set your own hours • Competitive rates • Paid Malpractice

The perfect match of career and lifestyle. Affiliated Community Medical Centers is a physician owned multispecialty group with 11 affiliate sites located in western and southwestern Minnesota. ACMC is the perfect match for healthcare providers who are looking for an exceptional practice opportunity and a high quality of life. Current opportunities available for BE/BC physicians in the following specialties: • ENT • Family Medicine • General Surgery • Geriatrician • Outpatient Internal Medicine

763-682-5906 | 763-684-0243 michelle@whitesellmedstaff.com www.whitesellmedstaff.com

BC/BE Family Practice Mercy Family Clinic – Lake Mills, Iowa (Outpatient only) Manage your own outpatient practice

• Hospitalist • Infectious Disease • Internal Medicine • OB/GYN • Oncology • Orthopedic Surgery

• Pediatrics • Psychiatry • Psychology • Pulmonary/ Critical Care • Rheumatology • Urgent Care

F O R M O R E I N F O R M AT I O N :

Kari Lenz, Physician Recruitment | karib@acmc.com | (320) 231-6366 www.acmc.com |

Join the Leader in Correctional Health Care FEDERAL BUREAU OF PRISONS

Full-Time Psychiatrist – FMC Rochester, MN Full Time Clinical Director – FCI Sandstone, MN Learn more at: www.bop.gov

This outstanding practice opportunity provides approximately 75-100 outpatient visits per week. Become part of a 9-hospital and 43-clinic Mercy Health Network–North Iowa. Services include: Primary Care–for men, women and children of all ages, Laboratory, X-ray, EKG, Podiatry Clinic, Behavioral Services-Individual and Family Counseling Lake Mills is a family oriented community of approximately 2,000 people. Located just 35 miles from Mason City, Iowa and 117 miles from Minneapolis, MN, it is home to many high quality businesses, an industrious labor force, excellent municipal facilities and an equitable tax structure. An abundance of amenities include a new aquatic center, a beautiful golf and country club, and four city parks. Outdoor activities abound and the excellent school system was one of 64 nationwide to be named a “Service Learning Leader.”

Practice where your skills are appreciated, where physicians are highly respected members of the community, where you and yours will flourish as you become rooted in a lifestyle second to none.

Jonna Quinn, D.O., OB/GYN, joined Mercy 2013 Mark Lloyd, D.O., Family Medicine, joined Mercy 2014

Send CV to: scottcl@mercyhealth.com (888) 877-5551 or (641) 428-5551 www.mercynorthiowa.com Mercy Medical Center–North Iowa

1000 4th Street SW, Mason City, IA 50401

December 2014 Minnesota Physician

Personalized medicine from page 13

multiple clinical trials, building and managing big data, and the need to standardize EMRs. For physicians and their patients, however, the issue usually comes down to a more fundamental question: “Will insurance cover it?” Whether or not an insurance plan covers genetic testing depends on several factors, but the most important are the strength of evidence supporting a test’s analytical and clinical validity, and clinical utility. Private insurance companies make their own decisions about what to cover and how much to reimburse for a genomic test, but private insurers often follow the decisions of Medicare, as the nation’s largest provider of health insurance. Medicare decisions, made by the Centers for Medicare & Medicaid Services (CMS), tend to reimburse for tests that are reasonable and necessary for diagnosis or treatment of an illness or injury.

However, CMS does not typically reimburse for experimental or investigative tests, including genetic predisposition tests, except in the presence of signs and symptoms of disease. According to Teresa Kruisselbrink, a certified genetic counselor at Mayo Clinic, she can get insurance coverage of a genetic test about 90 percent of the time if it is prescribed by a physician as being “reasonable and necessary,” is properly coded, and has been “demonstrated to provide healthy outcomes.” Kruisselbrink also added, “Predictive and predisposition testing will not be covered.” A representative from Aetna, Michael Kolodziej, MD, explained, “Insurance coverage is driven by evidence. We have to determine if there is value in the test. We need more evidence to establish medical necessity of genomic testing.” Insurance companies also are reluctant to pay for whole genome or whole exome se-

quencing if a particular disease is known to exist in a particular location of the DNA. “Most people don’t need genetic testing,” Kolodziej said. “But when they do, it’s usually for testing in a specific panel.” New coverage is being added all the time, but the progress is slow. The reimbursement system—both governmental and private payers—is designed to make policy decisions on treatments for large groups of people (chemotherapy for breast cancer patients, for example). Genomics leads to new specialized treatments offering superior results for a smaller pool of patients. While insurers wrestle with questions of safety and efficacy of new treatments, patients must decide how much they want to cover out-of-pocket for genomic testing. Conclusion When genetic information informs a patient of an increased risk for a disease and that

person makes lifestyle changes to reduce that risk, genomics has been translated into efficacy. If a gene variation influences how a patient processes a medication and the physician prescribes dosing instructions accordingly, a person’s medical care now is safer and more accurate because of genomics. Genomics will not simplify care, but it—in addition to family history, lifestyle, and environmental factors—allows physicians to continually customize a patient’s health management. Personal, customized medicine for each patient was, after all, what drove Hippocrates so many millennia ago and has driven every physician since. Jeffrey D. Briggs is a science writer based in Rochester, Minn., and covers biomedical research for Discovery’s Edge, Mayo Clinic’s research magazine. Carolyn Rohrer Vitek, MS, Education Program Manager, Center for Individualized Medicine, Mayo Clinic, contributed information for this article.

Behavioral Health Assistant Medical Director – Outpatient Care Minneapolis/St. Paul, Minnesota HealthPartners Medical Group is a large, successful, award-winning multispecialty physician practice in Minneapolis/St. Paul, Minnesota. Our Behavioral Health Division seeks a high-energy, visionary psychiatric leader for all HealthPartners Behavioral Health outpatient sites and services throughout the Twin Cities metropolitan area. Our ideal candidate is an engaging, adaptable, forward-thinking leader who focuses on collaboration and creativity while effectively analyzing our internal data in order to achieve national benchmarks for quality of care, patient satisfaction and affordability. In partnership with the Director of Outpatient Professional Services, you will ensure excellence in the care, patient satisfaction and stewardship of mentally ill and substance abuse patients while continuously improving our systems, encouraging the professional growth, satisfaction and interdisciplinary teamwork of our providers and staff, and promoting integration and collaboration efforts with HealthPartners’ primary and specialty care divisions and the community. You will be responsible for the clinical quality, productivity and efficient use of outpatient clinical care resources, performance improvement processes and outcomes, and documentation/billing/compliance for our clinicians. As liaison with our outpatient primary and specialty care physicians, we will rely on you for communication and networking, as well as mentoring and professional consultation to our clinical directors. Board certification in psychiatry with at least two (2) years of administrative and five (5) years of clinical experience is strongly preferred; Minnesota medical licensure and unrestricted credentialing eligibility are required. Forward your CV and cover letter to lori.m.fake@healthpartners.com, or apply online at www.healthpartners.com/careers. Call (800) 472-4695 x1 for more information. EOE

Minnesota Physician 38 Minnesota Physician 8.5" x 5.25" B&W

December 2014

GET READY FOR

ICD-10

STAY ON THE ROAD TO 10 STEPS TO HELP YOU TRANSITION The ICD-10 transition will affect every part of your practice, from software upgrades, to patient registration and referrals, to clinical documentation and billing. CMS can help you prepare. Visit the CMS website at www.cms.gov/ICD10 and find out how to: •

Make a Plan—Look at the codes you use, develop a budget, and prepare your staff

•

Train Your Staff—Find options and resources to help your staff get ready for the transition

•

Update Your Processes—Review your policies, procedures, forms, and templates

•

Talk to Your Vendors and Payers—Talk to your software vendors, clearinghouses, and billing services

•

Test Your Systems and Processes—Test within your practice and with your vendors and payers

Now is the time to get ready. www.cms.gov/ICD10

Official CMS Industry Resources for the ICD-10 Transition

www.cms.gov/ICD10

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