Minnesota Physician May 2014 by Minnesota Physician Publishing

Vo l u m e x x v i i I , N o . 2 M a y 2 014

Seeing sepsis Early identification saves lives By Scott Davis, MD, FCCP, FCCM, and David Larson, MD, FACEP

evere sepsis—a rapid onset of organ dysfunction caused by an overwhelming immune response to infection—is a deadly threat to patients. Yet the urgency with which it must be detected and treated has been underestimated. According to the Sepsis Alliance, nearly one million new cases of sepsis occur each year in the U.S., a number expected to increase by 9 percent every year. Sepsis is involved in nearly one in five deaths in U.S. hospitals, and 258,000 Americans die from it each year, more than the number of U.S. deaths from breast cancer, prostate cancer, and AIDS combined. Severe sepsis and septic shock are the highest cost of inpatient care in the U.S., estimated at $20 billion a year.

Fixing Medicare? Another patch on payment reform By Sen. Al Franken

innesota has great doctors. As senator, I’ve visited with physicians and patients across our state, and heard many powerful stories of medical discovery, triumph, heartache, and healing. It’s clear that our doctors, in partnership with other care providers, work very hard to help Minnesotans. That’s why I’ve also

worked hard to support doctors who provide high-value health care. Minnesota is No. 1 in the nation when it comes to the quality of health care we provide, according to the U.S. Department of Health and Human Services. However, instead of being rewarded for this Fixing Medicare? to page 10

Early detection saves lives Historically, the mortality rate for patients who developed severe sepsis was 40 percent to 60 percent. Research has shown, however, that protocols for early recognition of severe sepsis that include lactate testing and rapid treatment reduce morbidity and mortality. Our organizations, along with several others across the state, are working with the Minnesota Hospital Association through the Centers for Medicare & Medicaid Services Leading Edge Advanced Practice Topics to Seeing sepsis to page 12

Alcohol is more harmful to an unborn baby than cocaine, marijuana or heroin. Drinking during pregnancy can cause Fetal Alcohol Spectrum Disorders (FASD) which permanently harm the way your baby learns and behaves.

- ZERO ALCOHOL FOR NINE MONTHS.

May 2014 • Volume XXVIII, No. 2

Features Seeing sepsis

Early identification saves lives

MINNESOTA HEALTH CARE ROUNDTABLE

By Scott Davis, MD, FCCP, FCCM, and David Larson, MD, FACEP

Fixing Medicare?

Another patch on payment reform By Sen. Al Franken

DEPARTMENTS CAPSULES 4 MEDICUS 7 INTERVIEW

Rhonda Degelau, JD Minnesota Association of Community Health Centers

Cardiology

Otolaryngology

Neurology

Better care, fewer complications By Charles C. Gornick, MD, FHRS, FACC

Sleep-disordered breathing By Larry A. Zieske, MD, FACS

Back pain By Bret Haake, MD, MBA

PROFESSIONAL UPDATE: RHEUMATOLOGY Finding the link By Rekha Mankad, MD, FACC; Eric L. Matteson, MD, MPH; and Sharon L. Mulvagh, MD, FACC, FAHA, FASE, FRCPC

Special Focus: Community health Preparing Minnesota for Alzheimer’s 20 By Olivia Mastry, JD, MPH

Collaborating on mental health 22 By Pat Conway, PhD, MSW; Heidi Favet, CHW; and Molly Johnston

A team approach to research

By Kathleen Call, PhD; Sheila Riggs, DDS, DMSc; Deborah Hendricks, MPH, RN, APHN-BC; and Bernard L. Harlow, PhD

Improving care transitions 26 By Janelle Shearer, RN, MA, and Kim McCoy, MPH, MS

Background and focus: As tools and techniques for treating chronic illness have expanded, so have methods and mechanisms of provider reimbursement. More people now have access to care, and with this comes a heightened awareness of the impact of social determinants on health. The transition to rewarding physicians for maintaining a healthier population is slow but the promise is clear. Treating chronic illness remains an area of high-volume use and, improperly managed, quickly becomes an area of high cost. Objectives: We will evaluate changes that health care reform is bringing to chronic illness care. We will examine new community-based partnerships that are forming to address prevention, compliance, and better identification of risk. We will look at specific diseases and how workplace solutions, insurance companies, clinics, hospitals, long-term care facilities, and home care providers are working together to lower costs Please send me ____ tickets at $95.00 per ticket. Mail orders to Minnesota Physician Publishing, 2812 East 26th Street, Minneapolis, MN 55406. Tickets may also be ordered by phone 612.728.8600 or fax 612.728.8601.

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Account Executive Stacey Bush | sbush@mppub.com Account Executive Iain Kane | ikane@mppub.com 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

Nationwide Study Ranks Health of Counties A County Health Rankings and Roadmaps report released by the University of Wisconsin Population Health Institute illustrates a broad range of health status in Minnesota counties. The report, which ranks counties by overall health using a formula that measures residents’ health status and longevity, has been released annually since 2010. Counties are ranked in two categories—health outcomes and health factors. Health outcomes include the rate of collective number of years of life lost due to people dying before the age of 75, the percentage of people who report being in fair or poor health, and the rate of low birthweight infants. Health factors include health behavior, clinical care, social and economic factors, and physical environment. Carver was the top-ranking county for health outcomes, with McLeod and Waseca

Minnesota Physician May 2014

counties ranked second and third. Mahnomen County had the lowest ranking, with Mille Lacs and Cass counties in the bottom three. For health factors, Olmsted County was ranked highest, with Washington and Carver counties close behind. Mahnomen County was again ranked the lowest, with Clearwater and Beltrami counties ranking just slightly better.

Test Promoted to Detect Alzheimer’s, Dementia Earlier

Variations were evident even in counties in close proximity. For example, in the metro area, Hennepin County was ranked number 54 in health outcomes and 27 in health factors, while Dakota County ranked 14 and 7, respectively.

Rosenbloom and other local neurologists say that often, by the time patients get a diagnosis, they have already experienced serious damage from the disease, reports the Star Tribune. This makes intervention and treatment difficult.

The research adds to knowledge gained by 50 community health boards in Minnesota, serving multiple or individual counties and cities, according to Ed Ehlinger, MD, Minnesota Commissioner of Health. “These rankings can help advance the conversation between communities and local health departments, which are constantly adjusting strategies to meet local needs,” he said.

“[If] you’re diagnosing these diseases when these patients are already mistaking their medications, having motor vehicle accidents, losing their way from home—that’s a failure,” said Rosenbloom. “We have got to get to these patients earlier.”

Michael Rosenbloom, MD, and his colleagues at the HealthPartners Center for Memory and Aging, are promoting the use of a tool called the Mini-Cog to screen for Alzheimer’s disease and other neurological disorders.

The Mini-Cog is a five-point, two-part test. Patients are asked to memorize three words, which are each worth one point. They

then draw the face of a clock with the hands at 11:10, which is worth two points. Finally, they are asked to repeat the three words from the first part of the test. Patients who score three points or lower are recommended for further testing. According to Terry Barclay, neuropsychologist and clinical director at the Center for Memory and Aging, almost 26 percent of patients over the age of 70, who were formerly undiagnosed for dementia, failed the MiniCog in a study of 8,000 patients at the Minneapolis VA Health Care System. Failing the test “is associated with a significant increase in emergency room visits, hospitalizations, phone calls to the clinic … no-show rate and canceled appointments compared to those who pass the screen,” Barclay wrote in an email to the Star Tribune. The tool is being used and studied in different capacities across the state by HealthPartners Care Group, Allina Health, and Essentia Health Duluth, and is being promoted by ACT on Alzheimer’s.

MNsure Exceeds Goal for 2014 Entrollment More than 169,200 Minnesotans signed up for health insurance through MNsure as of midnight March 31, the end of the 2014 open enrollment period. The final number exceeded the exchange’s enrollment goal by about 35,000, according to state officials. Among the enrollees, about 47,000 signed up for private health insurance, 34,200 enrolled in MinnesotaCare, and nearly 88,000 registered for Medical Assistance. MNsure officials have said they are in the process of determining how many of Minnesota’s 400,000 previously uninsured citizens are now covered through the exchange. About 25 percent of enrollees are Minnesotans age 19 to 34, a group specifically targeted by MNsure. “We had significant concerns about not getting some of those younger folks,” said Julie Brunner, executive director of the Minnesota Council of Health Plans. “I’m pleased that the distribution is as wide as it is.” Scott Leitz, interim CEO of MNsure, noted that enrollment numbers will continue to rise as more than 36,000 people who began the process on the exchange’s website by the deadline complete enrollment. “I want to emphasize that we will be reaching out to those consumers who made attempts to enroll and were unsuccessful as late as 11:59 [p.m., March 31], provided they completed the online enrollment attempt form or we can otherwise see them in the MNsure system,” Leitz said. In addition, those eligible for the Medical Assistance and MinnesotaCare programs; members of Native American tribes; smallbusiness owners; and people who experience a change in jobs or marital status, or the birth of a child, may continue to enroll past the March 31 deadline. “MNsure has made major improvements in its functionality and customer service during the past three months,” said Gov. Mark Dayton. “More work lies ahead to continue those improvements. However, MNsure has now demonstrated its capacity to improve the lives of many thousands of Minnesotans

by offering them access to better health care at more affordable costs.”

Neurosurgical Patient Monitoring Program Gets Accreditation Abbott Northwestern Hospital’s program to monitor neurosurgical patients has received accreditation from the Neurophysiologic Intraoperative Monitoring Laboratory Accreditation Board of the American Board of Registration of Electroencephalographic and Evoked Potential Technologists (ABRET). The hospital has one of 17 such accredited programs in the nation and the only one in Minnesota. “If you have the opportunity to use intraoperative monitoring in specific situations, it is one more safety measure to alert the surgeon for the risk potential of neurological deficits during surgery,” said Abbott surgeon Mahmoud Nagib, MD. Before surgery, technologists tape half-inch needle electrodes on a patient’s body, just under the skin. A technologist and physician monitor the patient’s nervous system during the procedure and advise the surgeon if readings change, to help protect motor and sensory pathways. Abbott uses this intraoperative monitoring in about 30 percent of all neurosurgery and orthopedic spine surgeries. Typically, the surgeon determines if it will be used. “Patients can advocate for it. If they’re having surgery, they should ask their surgeons about the risks and whether their nerves should be monitored,” said Abbott neurologist and clinical neurophysiologist Stanley Skinner, MD.

Federal Medicare Payment Data Released Federal data for 2012 Medicare payments to physicians were released to the general public in April. The numbers are causing some concern, as the data can be potentially misleading when viewed without the News to page 6

Building Bridges to Quality Healthcare

HIE-Bridge™ is the state-wide health information exchange (HIE) service offered by Community Health Information Collaborative (CHIC). HIE-Bridge™ allows health care providers to have real-time access to clinical information from multiple sources. CHIC is the first and only MN state-certified Health Information Organization (HIO) offering full exchange capabilities.

With HIE-Bridge you will TM

• Greatly enhance clinical care coordination • Securely query, receive and exchange data in compliance with HIPAA and MN privacy laws • Access real-time information from multiple sources in a single, unified longitudinal view • Achieve Meaningful Use mandates

• Access the eHealth Exchange • Improve provider collaboration and workflow efficiency

See us at th e MN e -Healt h Summit June 11-1 2 Booth 13 ,

To find out more… Call 218-625-5515 info@medinfosystems.org www.hiebridge.org

Simple. Convenient. Effective.

NOBILITY H E A LT H

Take your Clinical, Operational and Financial performance to the next level with Nobility Health’s comprehensive Home Health Care Software Practice Management Electronic Visit Verification Point-of-Care

News from page 5

proper context. Routine office visits accounted for more payments than any single expenditure. However, the data also showed great disparity in reimbursement to different specialties. For example, ophthalmologists received a higher amount of total payment because of a common eye disorder treatment for the elderly. Minnesota was no exception to this trend. Ten of the 13 top-earning doctors in the state, who earned more than $1 million each through Medicare billings for services and equipment, were ophthalmologists. In a process as complex as Medicare reimbursement, there are many factors to consider. The L.A. Times reports, “Federal officials cautioned against drawing sweeping conclusions about individual doctors from the numbers. High payouts do not necessarily indicate improper billing or fraud, they say. Payments could be driven

higher because providers were treating sicker patients who required more treatment or because their practice was focused more on Medicare patients.” The process of releasing this data has been ongoing since 1979, when the American Medical Association (AMA) was granted a request to prohibit releasing doctor-specific Medicare information. That injunction was vacated in 2013. “What we don’t want to happen here is that patients be misinformed by raw data,” said AMA president Ardis Dee Hoven, MD. “At the end of the day, what we need in this country is data that shows value, and this data isn’t going to show value.”

National Award Given to 17 State Hospitals Seventeen Minnesota hospitals have achieved the Healthgrades 2014 Outstanding Patient Ex-

perience Award for the delivery of positive experiences for patients during hospital stays. Healthgrades assessed 3,582 U.S. hospitals that submitted surveys to the Centers for Medicare & Medicaid Services for admissions between March 2012 and April 2013. Of these, 3,000 met requirements to be considered for the award and the top 15 percent, or 447 hospitals, received the award. The 17 Minnesota hospitals receiving this year’s award are: Bigfork Valley Hospital, Bigfork; Cuyuna Regional Medical Center, Crosby; Essentia Health–St. Joseph’s Medical Center, Brainerd; Fairview Northland Medical Center, Princeton; HealthEast Woodwinds Hospital, Woodbury; Lakeview Hospital, Stillwater; Mayo Clinic Hospital Methodist Campus, Rochester; Mayo Clinic Hospital, Saint Marys Campus, Rochester; Meeker Memorial Hospital, Litchfield; New Ulm Medical Center; Ridgeview Medical Center, Waconia; Ridgeview Healthcare Center, Aitkin; St. Cloud Hospital; St. Francis

Regional Medical Center, Shakopee; St. Joseph’s Hospital, St. Paul; St. Joseph’s Area Health Services, Park Rapids; and Stevens Community Medical Center, Morris. “As consumers are becoming more active participants in their health care, measured performance surrounding the patient experience at a hospital is an increasingly important consideration for patients in choosing where to receive their care,” said Evan Marks, executive vice president for strategy and informatics at Healthgrades. When compared to hospitals performing in the bottom 15 percent for patient experience ratings, award recipients, on average, experienced 38 percent more patients giving their facilities an overall rating of 9 or 10. They also had an average of 42 percent more patients who report that they would definitely recommend the hospital to their family or friends.

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Minnesota Physician May 2014

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Joseph Blonski, MD, board-certified in family medicine and on staff at CentraCare Family Health Center and St. Cloud Hospital, has received the St. Cloud Hospital Physician of Excellence award. Blonski played a key role in developing Project H.E.A.L., an outreach program of the center that seeks to overcome barriers to health care in Central Minnesota by offering free health screenings and basic care to those with little or no insurance. Blonski earned a medical degree from Loyola University of Chicago–Stritch School of Medicine and completed a family medicine residency at Naval Hospital, Charleston, S.C.

Leif Dahleen, MD, board-certified in anesthesiology, has joined Essentia Health–St. Joseph’s Medical Center, Brainerd. He earned a medical degree from the University of Minnesota Medical School, Minneapolis, and completed an anesthesiology residency at the University of Florida, Gainsville.

2014

Minnesota Physician Publishing

This August, Minnesota Physician will publish a feature recognizing physician-directed medical research projects. We invite nominations from our readers. If you or an associate is currently engaged in a medical research project, please contact us, either by phone or through the form below. The research may be from any field and conducted on any level—basic, clinical, community-based, epidemiological, health servicesrelated, etc. The only criterion is that the principal investigator(s) is an MD.

Elise C. Carey, MD, FAAHPM, has received an early-career physician award, one of the 2014 Hastings Center Cunniff-Dixon Physician Awards. Chair of the Section of Palliative Medicine, Division of General Internal Medicine at Mayo Clinic, she was selected for her national leadership in palliative care education and for expanding Mayo’s palliative care services. Subhadra Chereddy, MD, board-certified in family medicine, has joined the family and community medicine department at Hennepin County Medical Center (HCMC), Minneapolis. She earned a medical degree from Guntur Medical College, India, and completed a family medicine residency at the University of Minnesota. Also joining HCMC is Khalil Farah, MD, board-certified in gastroenterology, who has Subhadra Chereddy, joined the gastroenterology department. Farah MD earned a medical degree at American University of Beirut, Lebanon, and completed an internal medicine residency and a gastroenterology fellowship at Saint Louis University, Mo. James Miner, MD, is the new chief of emergency medicine at HCMC. Board-certified in emergency medicine, Miner earned a medical degree from Mayo Medical School, completed an emergency medicine residency at HCMC, and joined HCMC’s emergency department in 1999. He is also a professor of emergency medicine at the University of James Miner, MD Minnesota Medical School, Minneapolis. Veeti Tandon, MD, board-certified in internal medicine, has joined HCMC’s department of internal medicine, where she completed an internal medicine Veeti Tandon, MD residency after graduating from the University of Minnesota Medical School. Tandon previously worked as a hospitalist at Abbott Northwestern Hospital, Minneapolis, for eight years.

ESEARCH REC R N

ON ITI GN

Jasjit Ahluwalia, MD, MPH, has been selected as the 2014 recipient of the Duncan Clark Award from the national Association for Prevention Teaching and Research. This award is presented to a physician with a distinguished record of achievement in the areas of teaching, research, and advocacy in the fields of prevention and public health. Ahluwalia, a professor in the University of Minnesota Department of Internal Jasjit Ahluwalia, MD, MPH Medicine and founding executive director of the university’s Center for Health Equity, has devoted several decades to improving the health of high-risk populations.

PHY SIC

MEDICUS

Whether the research is conducted in an academic institution, a rural or urban clinic or hospital, a managed-care organization, health system foundation, corporation, or state agency, we welcome its nomination. In brief overview, we will feature as many projects as possible, representing a geographically and institutionally diverse sample. Thank you for your participation. We welcome your assistance in recognizing Minnesota’s outstanding medical research community.

Name of project: Research site: Funder: Principal investigator(s): Contact data (Phone and/or email): Comments:

Send to: Minnesota Physician Publishing 2812 East 26th Street, Minneapolis, MN 55406

Tel: 612-728-8600 • Fax: 612-728-8601 • amarlow@mppub.com

Please note: All nominations must be received by June 15, 2014 and will be held in confidence. We will contact you and no information will be published without approval from the PI(s).

Leif Dahleen, MD May 2014 Minnesota Physician

interview

A look inside community health W hat is a community health center (CHC)?

offered under MNsure. Our health centers are working hard to reach existing patients as well as others in their communities, to help them enroll in Medical Assistance or purchase private coverage.

It is a nonprofit primary care clinic serving a community that has been designated as “medically underserved” under federal law. It provides medical, dental, mental health, and supportive The movement toward accountable care proservices, primarily to patients on Medical Asvides community health centers with opportunisistance or who are uninsured. The care model ties to demonstrate the value and quality of their emphasizes care coordination, team-based care, services in new ways. We have always embraced and supportive services the goals of the Triple that work for the patient. Aim: improving the paA patient-majority board Having an insurance card tient experience, improvof directors oversees the ing population health, and does not solve all problems. health center’s operations reducing per capita cost of and ensures its responcare. All of our health censiveness to the communters are either designated, or in the process of beity’s health care needs. coming, patient-centered medical homes through Rhonda Degelau, JD Minnesota Association of Community Health Centers Rhonda Degelau, JD, has served as executive director of the Minnesota Association of Community Health Centers for the past 19 years. During that time, she also served as president of the Greater Midwest Association of Primary Health Care and on the board of directors of the National Association of Community Health Centers. Previously, she held various legal and business positions in the health plan industry.

The community health center model has its roots in South Africa, where Dr. Jack Geiger encountered it in the late 1950s. He brought the idea back to the United States, and established the first two CHCs, one in Boston and one in rural Mississippi. The model was embraced by President Lyndon Johnson in 1965 as part of the War on Poverty. A federal program to regulate and support CHCs—Federally Qualified Health Centers—was established in 1975. Today, there are 1,200 community health centers with 9,000 sites, serving 22 million people in the United States.

P lease tell us about the Minnesota Association of Community Health Centers (MNACHC). We have 17 community health centers in Minnesota, with 70 clinical sites. Together, they serve 183,000 patients. MNACHC was formed in 1980 and serves as a resource to the health centers on federal regulatory and funding issues. We also assist communities interested in establishing a community health center. We do a great deal of health-care policy analysis and government relations work on behalf of the health centers. We seek out partnerships and other resources aimed at increasing access to care and improving quality of care. We provide educational opportunities for health center staff, including our annual “Many Faces of Community Health” conference, which draws more than 350 participants.

H ow is federal health care reform impacting the work you do? The Affordable Care Act provides a great opportunity for many of our uninsured patients to get health insurance coverage, either through the Medicaid expansion or through commercial plans

Minnesota Physician May 2014

the National Committee for Quality Assurance or Minnesota’s health care home initiative. We are also moving into Medicaid delivery system and payment reform demonstrations.

W hat can you tell us about the demographics of your patient base? Our patient base is a very low-income population. More than 70 percent live below federal poverty guidelines (FPG) and another 25 percent live just above FPG. As you might expect, large numbers are either uninsured or covered by Minnesota’s public health care programs. Thirty-seven percent are uninsured and 42 percent are on Medical Assistance or MinnesotaCare. Only 13 percent are privately insured, and another 8 percent are on Medicare. Our patients are also ethnically diverse. One-third are white, with African Americans, Latinos, Asians, and Native Americans making up the remaining two-thirds.

H ow do these patients gain access to your services? Minnesota’s community health centers welcome all patients, whether insured or not. For those who are uninsured, health centers provide services on a sliding fee scale based on income and family size. MNACHC’s website, www.mnachc. org, includes maps with the locations of all of our facilities.

W hat can you share about how your services are funded? Community health centers bill for and collect payments from Medicare, Medicaid, and private plans for patients who have coverage. They also receive annual federal grants to help defray the costs of caring for the uninsured. The grants

cover less than 50 percent of those costs. Patients contribute as they are able. Health centers also pursue local public/private grants to fill the gaps.

containment standpoint, to provide timely and necessary preventive and primary health care services to all who are in need. And it’s simply the right thing to do!

H ow would you say the term “safety net” applies to your work?

W hat types of health concerns do you see the most?

Community health centers care for those who fall outside the mainstream in terms of health insurance coverage and income level. We strive to make health care more accessible by providing interpreter services for non-English speaking patients, transportation support, and other enabling services.

Like any primary care clinic, our health centers see patients of all ages, though for some there may be a higher proportion of seniors and others may have more pediatric patients. We manage a lot of chronic disease (mostly asthma, diabetes, and cardiovascular disease) and provide a lot of preventive services. There is also a great demand for dental services.

Even if the Affordable Care Act makes significant inroads to reducing the numbers of uninsured, we still will need a safety net of health care providers whose stated mission is to care for low-income populations. Having an insurance card does not solve all problems. It certainly doesn’t change one’s income status. The challenges of living in poverty will still exist and impact one’s opportunities to achieve optimal health status. Even with increased insurance coverage, there will still be those who fall through the cracks: the homeless, the undocumented, and those who voluntarily remain uninsured. It is in our best interest, both from a public health standpoint and from a cost

Because we see a high volume of immigrant populations, we may see more hepatitis and HIV than some providers. Many immigrant populations from war-affected countries also have a high level of post-traumatic stress disorder.

H ow do mental health issues factor into the physical health concerns of your patient population? Since the most marked difference in our patient populations may be the high poverty rate, the attendant stresses often present as anxiety and depression, which compound

our efforts to help our patients manage their medical conditions.

P lease tell us about some of the challenges you face recruiting physicians and other medical professionals. Community health centers, as small nonprofits, are at a disadvantage competing with large health systems for a limited pool of primary care physicians, as well as for other medical professionals. One of the advantages that we can offer, however, is the opportunity for school loan repayment in exchange for serving in federally designated Health Professional Shortage Areas (HPSAs). There is a federal program, as well as a state program. The good news is that, once recruited, many providers are committed to the mission and tend to stay at health centers.

W hat do you want doctors to know about MNACHC? I would like doctors to know that their colleagues at community health centers are actively engaged with the goals of the Triple Aim, and are working to bring the best of innovations and best practices to better serve a very challenging and diverse patient population.

University of Minnesota Office of Continuing Professional Development To align with the goal of promoting a lifetime of outstanding professional practice, the University of Minnesota Medical School’s Office of Continuing Medical Education is now the Office of Continuing Professional Development.

2014 CPD Activities

(All courses in the Twin Cities unless noted)

LIVE COURSES Bariatric Education Days: Decade of Bariatric Education May 21-22, 2014

Psychiatry Review September 29-30, 2014 Twin Cities Sports Medicine October 3-4, 2014

Topics & Advances in Pediatrics May 29-30, 2014

Practical Dermatology (Duluth, MN) October 17-18, 2014

Pain Mechanisms: From Molecules to Treatment June 2-6, 2014

Lillehei Symposium: Cardiovascular Care for Primary Care Practitioners October 23-24, 2014

Workshops in Clinical Hypnosis June 5-7, 2014

Internal Medicine Review November 12-14, 2014

Maintenance of Certification in Anesthesiology (MOCA) Training August 23 & October 25, 2014

Emerging Infections November 21, 2014

NPHTI Pediatric Clinical Hypnosis September 11-13, 2014

Geriatric Orthopaedic Fracture Conference December 5-6, 2014

www.cmecourses.umn.edu ONLINE COURSES (CME credit available) www.cme.umn.edu/online • Global Health - 7 Modules to include Travel Medicine, Refugee & Immigrant Health - Family Medicine Specialty - NEW! Global Pediatric Education Series • Nitrous Oxide for Pediatric Procedural Sedation For a full activity listing, go to www.cmecourses.umn.edu

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

may 2014 Minnesota Physician

Fixing Medicare? from cover

quality and efficiency, Minnesota providers historically have been punished for the high-value care they provide, in the form of lower reimbursement rates from Medicare. That doesn’t make any

health care value over volume. Background

First, here is a little history of the way Medicare pays physicians. Congress passed the current Medicare physician payment formula in 1997, as

I will not stop fighting for a long-term solution.

sense. Right now, we have an unprecedented opportunity to help change it by overhauling the Medicare physician payment formula and implementing a system that rewards

part of a larger effort to control costs. The law tied Medicare physician payment rates to the gross domestic product (GDP), a measure of economic growth, using a form-

The Lawyers and Lobbyists that Doctors Trust Medicine is complicated. So are the laws that doctors, hospitals and insurance companies have to manage. Lockridge Grindal Nauen is one of Minnesota’s leading health care law firms. Our health care clients are so satisfied they’ll write us a referral.

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Minnesota Physician May 2014

ula known as the sustainable growth rate (SGR). The purpose of the SGR was to ensure that levels of spending for each Medicare enrollee did not exceed the per capita increase in GDP. This meant that as long as Medicare expenditures for physician services were below this growth rate, physician payments were increased. Starting in 2002, however, expenditures for these services exceeded targets, triggering reductions in physician payments. Each year, Congress has taken action to delay the implementation of these payment reductions; these votes are often described as the “doc fix.” Yet, delaying these cuts—rather than fully replacing the underlying formula—has only made the problem worse, and only increased the price tag of the fix for each successive year. Moreover, the annual threat of payment reductions and short-term fixes is not good for physicians or Medicare beneficiaries. Take, for example, the young physician from Rogers who called my office to discuss how proposed payment cuts would affect his practice and his future. As a father and a new surgeon, this doctor described the challenges of paying off high levels of debt and starting a new practice in a time of financial uncertainty. Other care providers have shared similar frustrations. An oncologist from Rochester wrote to tell me that systematic short-term fixes have made it difficult to make long-term business decisions. A podiatrist from Worthington said that impending cuts could impede his ability to participate in care improvement initiatives. Repealing the SGR

Leaders of the House and Senate committees of jurisdiction introduced legislation earlier this year to get rid of the SGR once and for all, and to replace

it with a series of reforms that rewards value-based care. Under their proposal, the Centers for Medicare & Medicaid Services will stabilize physician payment rates over the next five years. To reward value over volume, the legislation combines three existing quality programs, including the value index that I helped craft, to create a streamlined, value-based performance program. Under this program, providers who meet certain performance thresholds across a range of categories, including care quality, efficient use of resources, meaningful use of electronic health records, and engagement with clinical improvement activities, will receive additional payments from Medicare. To promote further innovation in the health sector, the law provides bonus payments to physicians who adopt alternative payment models, such as accountable care organizations and patient-centered medical homes. I strongly believe that this proposal would benefit from the input of Minnesota physicians, and I look forward to hearing your thoughts on it. In budgetary calculations, the Congressional Budget Office estimated that repealing the SGR would cost the federal government money, because the SGR is a mechanism for lowering federal spending. Because of the recent slowdown in Medicare spending, however, the cost of this proposal is significantly lower than it has been in the past. This is yet another reason that the time is right to replace the SGR formula. Short-term patch

Unfortunately, instead of considering and ultimately passing such a permanent fix, the Senate voted—yet again—to pass a short-term patch to this broken system, which postponed these payment cuts for one more year. After talking

with Medicare providers in my state who strongly opposed this measly temporary fix, I decided to oppose the shortterm patch. It provided only a bandage for a wholly broken system, instead of an enduring

deliver.

the proposal is as strong as possible. Your thoughts and ideas can play a vital role in this process.

there has never been a better moment to do that than now.

My goal is to make sure that Medicare beneficiaries, now and in the future, have access to high-quality, affordable health care services. To achieve this, Medicare must

Seeking provider input

I will not stop fighting for a long-term solution, and I need your help and input. As we

Minnesota has always been at the frontier of innovation and improvement. I am committed to fighting for reforms that reward Minnesota care providers for taking the steps they need to be the leaders they are.

Minnesota providers have historically been punished for the high-value care they provide.

solution. I believe that such a solution is both possible and absolutely necessary, and I will continue to fight for a more sustainable replacement that rewards physicians for the high-quality care they

be on sound financial footing and be prepared to meet the needs of an aging baby boomer generation. Replacing the SGR with a system to promote high-value care is a critical step in this direction, and

Thank you for all that you do to provide world-renowned health care.

Sen. Al Franken (D-Minnesota) was elected to the U.S. Senate in 2008. He sits on the Health, Education, Labor, and Pensions (HELP) Committee; the Judiciary Committee; the Energy and Natural Resources Committee; and the Committee on Indian Affairs. Contact him at www.franken.senate.gov.

work toward comprehensive federal legislation that reflects Minnesota priorities and puts us on a course toward a longterm solution, I want to work with you to make sure that

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Seeing sepsis from cover

develop a tool kit to facilitate the adoption by Minnesota hospitals of severe sepsis early detection tools, and the “Surviving Sepsis Campaign” threeand six-hour care bundles. These bundles have helped St. Cloud Hospital decrease mortality due to severe sepsis and septic shock by 49 percent. Additionally, making early identification of sepsis in the emergency department a priority helped Ridgeview Medical Center decrease mortality due to severe sepsis and septic shock by 60 percent.

infection associated with systemic inflammatory response syndrome (SIRS). Some of the early warning signs of sepsis include a temperature above 100°F, a heart rate above 100, and blood pressure below 100. The phrase “100-100-100” resonates with front-line staff and provides a trigger to screen for possible sepsis. (Figure 1.)

If a patient meets the early screening criteria, nurses in our hospitals are empowered to contact a physician, let him or her know that the patient meets the criteria for sepsis and recommend the patient be assessed for severe sepsis or septic shock (see definitions in sidebar). If What it is the patient is positive for severe Sepsis is defined as a probable sepsis or septic Resources for information about sepsis shock, Surviving Sepsis Campaign then the www.survivingsepsis.org/Pages/default.aspx three- and six-hour Institute for Healthcare Improvement www.ihi.org/topics/Sepsis/Pages/default.aspx bundles are imMinnesota Hospital Association Seeing Sepsis Tool Kit plementwww.mnhospitals.org/seeingsepsis

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Defining sepsis, identifying the condition Systemic inflammatory response syndrome (SIRS) Two or more of the following: • Fever or hypothermia (T >100.4°F or <96.8°F) • Tachycardia (HR >90) • Tachypnea (RR >20 or PaCO2 <32) • Leukocytosis, leukopenia, or left shift (WBC >12,000, <4,000, or >10 percent bands) Sepsis • SIRS as a result of infection Severe sepsis • Sepsis associated with organ dysfunction, hypoperfusion, or hypotension • Hypoperfusion and perfusion abnormalities may include: lactic acidosis, oliguria, or acute alteration in mental status Septic shock • A subset of severe sepsis with hypotension (BP <90 or drop of >40 from baseline), despite adequate fluid resuscitation Source: Society of Critical Care Medicine

ed. These bundles are evidence-based guidelines that, when implemented together, improve outcomes beyond what would be expected implementing the individual elements alone. The three-hour bundle includes: • Lactate level. The most frightening patient is one who is sicker than he or she looks, and a serum lactate level may help you identify that patient. If your organization does not have the ability to perform lactate tests, it is worth exploring. In our view, it is something that should be standard in every hospital today. • Blood cultures before antibiotics. It is important to identify the organism causing sepsis, so that the antibiotic selection can be narrowed from broad spectrum within 72 hours of bundle implementation. This decreases the possibility that a patient will experience antibiotic resistance in the future. • Broad-spectrum antibiotics. The guidelines recommend that antibiotics begin within one hour of recognition of severe sepsis. For every hour delay, the mortality rate for the patient increases 7 percent.

Early delivery of antibiotics is one of the key pieces to decreasing the mortality from severe sepsis. • 30 ml/kg saline bolus. Fluid resuscitation should happen as fast as you can administer it. The six-hour bundle builds upon the elements of the threehour bundle and includes three main elements: 1. Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation) to maintain a mean arterial pressure (MAP) ≥65 mm Hg. 2. In the event of persistent arterial hypotension despite volume resuscitation (septic shock) or initial lactate ≥4 mmol/L (36 mg/ dL):

a. Measure central venous pressure (CVP) with the goal of maintaining a CVP of 8 or greater.

b. Measure central venous oxygen saturation (ScvO2) with the goal of maintaining ScvO2 of greater than 70 percent.

3. Remeasure lactate if initial lactate was elevated. At each hospital, time and

care were given to customize the bundles to fit the operational and cultural needs of the facility. In both instances, however, we found the development of an interdisciplinary team to be a key to our success. The inclusion of emergency department physicians and nurses, intensive care unit, radiology, pharmacy, quality improvement professionals, and others, ensures the right people are available to provide the urgent attention needed to improve outcomes.

If your organization does not have the ability to perform lactate tests, it is worth exploring. Also important was education of nurses and other front-line staff about the early signs of severe sepsis. At each hospital, we spent a significant amount of time increasing awareness and helping staff recognize those early signs. A time-critical emergency As physicians, we need to start seeing sepsis as a time-critical emergency, just like trauma, stroke, or acute myocardial infarction (MI). With trauma there is a “golden hour” within which you need to act with urgency, because the sooner you treat the patient thoroughly and comprehensively, the better the outcome.

ICU resources available. The transfer trigger tool includes four components that signal the patient may need to be transferred to a higher setting of care:

Figure 1. Screening for sepsis

1. Lactate >4 or 2. Persistent hypotension despite fluid resuscitation or 3. Evidence of two or more organ dysfunctions or 4. The progression of symptoms despite treatment If a patient presents to a hospital in a rural setting or a critical access hospital that does not have ICU resources, the hospital should begin the three-hour bundle as soon as possible and make arrangements to transfer the patient within two hours to a hospital with ICU resources. The efficient and appropriate triaging of a patient with severe sepsis to a setting that can begin resuscitation is critical to ensuring a successful outcome. Physician leadership is vital The early detection and treatment of severe sepsis is really a paradigm shift in health care. At each of our hospitals, physician leadership to champion the work was vital. Physicians play an important role in advocating for the need for change and for helping others recognize the need to change the culture.

The same is true for severe sepsis. Hospitals commonly have protocols in place to treat multi-trauma, acute MI, and stroke, yet it is less common for a hospital to have protocols in place to identify and treat severe sepsis. In fact, a survey of Minnesota hospitals found that 75 percent of those surveyed do not have sepsis protocols in place. This must change.

At St. Cloud Hospital, the work began with emergency department and intensive care unit physicians. At Ridgeview, it began with a hospitalist and emergency department physician. The tool kit being developed through this project can serve as a resource to ignite culture change in your organization, so that sepsis is treated with urgency. This is not a project you assign to a handful of people and then it’s done. It’s never done; we must remain constantly vigilant and strive for continuous improvement.

One of the unique aspects of the work taking place in Minnesota is the development of a transfer trigger tool. This helps hospitals without ICU resources clearly identify when to transfer a patient to a hospital that has

Early detection and treating severe sepsis with a sense of urgency truly make a difference. Since 2005, 418 people have walked out of St. Cloud Hospital who would have died, had we continued to practice the way

And does the patient just not look right? Screen for sepsis and notify the physician immediately. Source: Minnesota Hospital Association in collaboration with St. Cloud Hospital and Ridgeview Medical Center

we did in the past. Scott Davis, MD, FCCP, FCCM, is medical director ICU, St. Cloud Hospital. David Larson, MD, FACEP, is emergency department medical director, Ridgeview Medical Center, Waco-

nia. The hospitals are leading the development of a tool kit to facilitate the adoption by Minnesota hospitals of severe sepsis early detection tools and the Surviving Sepsis Campaign three- and six-hour care bundles, funded by the Centers for Medicare & Medicaid Services Leading Edge Advanced Practice Topics.

May 2014 Minnesota Physician

Cardiology

Better care, fewer complications

eart disease is the most common cause of death in the United States. Sudden cardiac death remains the proximal cause of death, accounting for approximately 40 percent of deaths among patients with underlying heart disease. The transvenous implantable defibrillator (T-ICD) has been saving lives for more than three decades. The use of transvenous leadbased systems has led to complications, however, including cardiac perforation, pneumothorax lead dislodgement, lead malfunction, and venous occlusion. Infection of implanted T-ICD systems frequently requires complete removal of the ICD system to eradicate the infection. Removal of leads under these circumstances or due to lead failure may require laser sheath-assisted removal with potential vascular perforationâ&#x20AC;&#x201D;leading, in some cases, to death. The weakest link of these devices has always been the

Subcutaneous implantable defibrillators By Charles C. Gornick, MD, FHRS, FACC leads, which track through the venous system to the heart to detect, pace, and, if necessary, defibrillate the heart. As a result, the development of a commercially available subcutaneous ICD (S-ICD) by Cameron Medical/Boston Scientific is welcomed.

detecting and treating ventricular fibrillation and tachycardia. It offers the advantage of eliminating intravenous leads used by T-ICD devices, and their associated risks and shortcomings. Initially, ICDs were used to treat recurrent events in survivors of life-threatening ventricular arrhythmias. The first im-

The S-ICD system has been demonstrated to be safe and effective. Clinical trials have demonstrated the S-ICD is effective in

When you need it.

plantable defibrillators required surgical placement of sensing electrodes and defibrillating patches directly on the heartâ&#x20AC;&#x2122;s surface via an open thoracotomy. The development of transvenous ICD leads was a quantum leap in the use of ICD devices, by allowing placement of these devices without thoracotomy. With the refinement of the transvenous lead systems, it became feasible to place devices for primary prevention of sudden death in patients believed to be at high risk for future life-threatening arrhythmic events. Today, ICD devices are placed in more than 70 percent of implants for primary prevention criteria. Thus, the S-ICDâ&#x20AC;&#x2122;s appeal is that the systems do not use intravascular leads.

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Minnesota Physician May 2014

Historically useful The initial ICDs placed surgically, and later transvenously, were relatively simple devices. They were designed to detect and successfully terminate serious ventricular arrhythmias, using defibrillation shocks between shocking electrodes. Refinements in these devices have included pacing therapy, able to terminate ventricular tachycar-

dia without delivery of painful shocks, as well as other ancillary features (Figure 1). Pacing features have included dual-chamber ICD devices to not only pace both in the atrium and as needed in the ventricle, but also to better discriminate between supraventricular and ventricular arrhythmias as appropriate therapy targets. Newer devices allow for a second look prior to deciding when to deliver shock therapy, which gives pacing therapy a chance to terminate the ventricular arrhythmia. Second-look performance also helps avoid shock therapy if the arrhythmia spontaneously terminates. The addition of a left ventricular lead via the coronary sinus, to achieve biventricular pacing for patients with heart failure and bundle branch block, has provided an additional mortality benefit and has broadened indications for the ICD to include patients with heart failure. The addition of the left ventricular lead not only results in clinical symptom improvement, but also has been demonstrated to improve survival benefit above that achieved with the ICD alone. Current value Remote monitoring features are now present in all current T-ICD devices. Remote monitoring ability gives doctors the ability to continuously monitor patients and ICD system status daily, or, if symptoms arise, allows the patient to initiate a remote transmission from home. This remote monitoring has allowed data collection from hundreds of thousands of patients in the U.S. and Europe. The latter data have resulted in an enhanced ability by doctors to make decisions regarding the use and utility of the T-ICD in patients. Optimal device programming and longterm follow-up of implanted patients has also resulted from this remote monitoring data collection. Additionally, some ICD devices can assess lung water volume, which translates clinically into heart failure status.

Figure 1. Transvenous implantable defibrillator (T-ICD) • Provides effective defibrillation for ventricular tachyarrhythmias • Provides Brady pacing • Provides ATP for patients with incessant monomorphic VT • Provides atrial diagnostics • Familiar implant technique

Figure 2. Subcutaneous implantable defibrillator (S-ICD) • Provides effective defibrillation for ventricular tachyarrhythmias • No risk of vascular injury • Low risk of systemic infection • Preserves venous access • Avoids risks associated with endovascular lead extraction • Fluoroscopy not required

Current T-ICD devices have proven their worth over the last decades. In the U.S., more than 12,000 ICD devices were

implanted each month during 2010 and 2011. The survival benefit of these devices has been demonstrated in numerous ran-

domized trials, both in patients with prior life-threatening arrhythmic events and in primary prevention trials. In numerous primary prevention trials in both ischemic and nonischemic cardiomyopathy patients, there has been a documented 20 percent to 30 percent reduction in mortality during the one and one-half to two years of observation generally contained in these trials. Improved devices developed The long-term complications associated with transvenous ICD systems were the impetus to develop the S-ICD. Lead failure can be due to conductor problems or insulation breach, with steady lead attrition occurring the longer a lead is implanted. The failure rate is higher among young active patients and in all patients with prolonged longevity, due to greater physical stress placed on the leads over time. The first-generation S-ICD system senses, detects, and

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Older and new implantable defibrillators

treats malignant ventricular arrhythmias from an entirely subcutaneous device and lead location (Figure 2). The S-ICD pulse generator and lead are placed subcutaneously over the thorax, so the system is not exposed to the risks associated with intravascular leads. Avoiding intravascular lead placement has led to the S-ICD’s own limitations, however, including lack of ability to provide anti-tachycardia pacing or other advanced diagnostics. Further, the first-generation S-ICD device does not have remote monitoring capabilities. The S-ICD can provide post-shock pacing if significant bradycardia occurs at 50 ppm for up to 30 seconds. But the S-ICD requires higher energy to convert VF than a T-ICD (<65J vs. <16J). The S-ICD delivers 85J in standard settings. In several feasibility studies, and more recently a larger cohort of patients, the S-ICD has Better care, fewer complications to page 38

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May 2014 Minnesota Physician

otolaryngology

Sleep-disordered breathing

leep disordered breathing—snoring and apnea— is a significant problem that can occur in children, teens, and adults. It affects other family members as well, especially sleep partners. There may be physical-medical problems that reduce life expectancy, as well as behavioral-social issues, including poor school performance. Snoring is a condition of which everyone is aware. The noise generated in the throat and nose varies from a quiet vibration to the very disturbing “sawing logs.” This affects both the snorer and sleep partners, preventing a restful healthy sleep for both. Social consequences are significant, as well. Children are uncomfortable participating in sleepover events, and lack of restful sleep may lessen school performance. Snoring has also affected many adult relationships, even being the reason for break-ups. Sleep apnea occurs when

Snoring and apnea can have serious consequences By Larry A. Zieske, MD, FACS there are airflow stoppages of 10 seconds or longer; stoppages of more than one minute are often present. This condition is associated with significant health problems, such as increased blood pressure, higher risk of heart attack, and even a shorter life expectancy. A great

Causes The anatomy of the nose and throat are key to the problem. The common structures involved in the nose are the

There is a wide range of potential interventions, both non-surgical and surgical. number of children and adults are affected by sleep-disordered breathing. Being overweight

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Minnesota Physician May 2014

septum (separating the two sides—cartilage in the front with bone behind) and the turbinates (ridges of glandular and vascular tissue on the outer sides on the inside of the nose). Traumas to the face can lead to crookedness of the septum, known as a deviated septum. This reduces space for airflow and results in a greater negative pressure needed to get air through the nose. This causes more tissue vibration—snoring, or blockage—apnea. The turbinates react to all types of irritation, such as fumes, chemicals, dust, danders, exhaust, things sprayed in the air, and allergens. This also results in reduced space. If nasal polyps grow, the problem is worse. Individuals with facial-skull growth problems are a special instance. The throat can be affected from the top down by adenoids, soft palate-uvula, tonsils, throat wall muscles, tongue and glands near the back of the tongue, vocal cords, and arytenoids. The most common ones that cause trouble are the tonsils and adenoids followed by the soft palate-uvula.

Pediatric treatment In the pediatric-teen group, the parent’s observation and judgment is important. If snoring is deemed significant and poor sleep quality is present, then a medical evaluation is appropriate, with either the primary care physician or ear, nose, and throat doctors. Sleep-disordered breathing has been associated with reduced school performance and behavioral disorders. If tonsil and adenoid or nasal abnormalities are noted, intervention can be started. This could involve environmental adjustments, various allergy treatments, or surgery. Sleep testing is not a routine first measure for children. It may be recommended, however, if there are associated factors such as obesity, head-facial growth abnormalities or the child is younger than age 3. Tonsillectomy and adenoidectomy results have been very satisfying in solving or significantly reducing the sleep problems, and many times behavioral and school issues improve, due to improved sleep quality. Addressing significant nasal structural or functional abnormalities may also be warranted. Surgical correction of deviated cartilage and bone, with adjustment of turbinates inside the nose, is commonly done. Medical treatment of allergies is also beneficial. If throat and nasal interventions are not adequate, further investigations would be needed. A note of caution for children active in sports regarding surgery: There is always the possibility of re-injury. It’s advised that, if possible, surgery be delayed until athletic activity is done. Diagnosis in adults Sleep-disordered breathing in adults is generally approached with a sleep study. Although patients can do testing at home, sleep lab testing has been favored in Minnesota. Several measurements are done, including breathing stoppages of more than 10 seconds, oxygen

levels, awakenings, leg movements, and snoring. Overall, the severity of apnea is graded normal, mild, moderate, or severe. Though snoring alone can be reason enough for treatment, moderate or worse apnea is harmful to a person’s health and should be treated. Treatment Regarding intervention, there are many over-the-counter (OTC) products, including aromatherapy, pillows/rolls, ramps, and nasal internal and external devices. But these are for snoring reduction, not apnea. When they have been examined for groups, no good regular benefit has been found, though for some individuals they may help. Dental mouthpieces designed to bring the jaw and tongue forward are beneficial. There are OTC mouthpieces that are fairly affordable. Those custom-made by dental professionals can be expensive, but are generally more effective. Stress on the jaw joint and chewing muscles make tolerance a significant problem. Regardless, advice about weight management and proper sleep hygiene-habits should be emphasized. This includes regular and adequate sleep time, a proper bedroom environment to promote quiet and comfort, and appropriate weight management. A mainstay of therapy is a breathing mask (commonly referred to as a cpap—continuous positive airway pressure), where a machine delivers pressure to keep the breathing channel open. These generally give good help, and patients can try various nasal or nasal-mouth masks. It’s important that there is humidity in the tubing, to keep the nose membranes from getting too dry. Again, a major problem is tolerance. Many people find them uncomfortable or claustrophobic. Though they are fairly quiet, the noise can be an issue for some patients. Surgery The spectrum of surgical measures is great, but the ones

mentioned below are the most common. Areas that would be evaluated by a physician are: general jaw-face growth; tonsils and adenoids; palate-uvula; and tongue, nose, and lower throat structures. When mild-to-moderate snoring is present without much apnea, palatal implants can be inserted. These go into the soft palate to stiffen the tissue, reducing vibrations/floppiness. They can be placed in the office under local anesthesia for a patient who is not much of a gagger and tolerates dental work well. Otherwise, general anesthesia can be used. Their benefit varies, but it is usually best when the patient isn’t overweight. The more significant surgical procedures that are commonly done fall into the tonsil-adenoid, palate-uvula, inside nose-septum, and turbinate ridge areas. Just like in children, removal of tonsils and adenoids can be quite beneficial to adults. It is regularly done to improve the breathing space at the back of the mouth and nasopharynx, as well as to reduce tissue vibrations—reducing snoring noise. This typically is combined with removal of the uvula and some soft palate tissue, to achieve an even greater benefit. Although these procedures are generally quite helpful, it’s impossible to predict to what degree. Besides standard surgical risks of post-operative infection, bleeding and poor healing (which all fall in the less-than-5-percent range), there is a possibility of a permanent voice change to one that is more nasal, and a greater possibility of reflux of food and drink to the back of the nose (about a 1 percent to 2 percent chance). Nasal procedures to straighten crooked-deviated nasal septal cartilage and bone, septoplasty, and various adjustments to the inside turbinate ridges allow more free air passage. This results in less negative-pressure breathing effort to get proper airflow, which results in fewer tissue vibrations and more air volume. Exact calculations of the benefit cannot be made.

There are actually three types of sleep apnea, according to the American Sleep Apnea Association (www.sleepapnea.org) •

Obstructive sleep apnea is caused by a blockage of the airway, usually when the tongue collapses against the soft palate, which then collapses against the back of the throat, and the airway is closed.

•

Central sleep apnea is similar, but the airway isn’t blocked— the brain just fails to signal the muscles to breathe.

•

Complex sleep apnea is a combination of the conditions.

There is a less than 1 percent risk of a nose being very dry post-surgery. These two procedures are highly reliable in reducing snoring. The benefit to reduce apnea is not quite as reliable, however, but as a minimum should allow an easier use of the breathing masks. There is a more complex group of patients that will require more investigations and potential treatments. They are best served by board-certified sleep medicine specialists and sleep specialty surgeons. These include people with very abnormal facial-skull-jaw growth

problems, very large tongues, and/or neuromuscular abnormalities. Certain medicines may be tried for these patients, as well as more complex surgeries. Today there is a wide range of potential interventions, both non-surgical and surgical. If you or your patient suspects a problem, you may want to seek advice and evaluations from a specialist. If the first interventions are not adequate in their benefit, then additional steps may be taken. Larry A. Zieske, MD, FACS, is affiliated with Ear, Nose & Throat SpecialtyCare of Minnesota Clinic, with offices in Burnsville, Edina, Minneapolis, and Plymouth.

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Professional Update: Rheumatology

eople with autoimmune diseases, such as rheumatoid arthritis (RA) and systemic lupus erythematosis (SLE), have higher rates of atherosclerotic cardiovascular disease (ASCVD) morbidity and mortality compared to the general population. Other inflammatory rheumatic conditions, including psoriatic arthritis and ankylosing spondylitis, have also been shown to have higher rates of ASCVD, but are less well-studied than RA and SLE.

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Finding the link Heart disease and rheumatoid arthritis By Rekha Mankad, MD, FACC; Eric L. Matteson, MD, MPH; and Sharon L. Mulvagh, MD, FACC, FAHA, FASE, FRCPC

disorders, such as SLE and RA. Inflammation, immunity, and atherosclerosis Before we discuss the specific autoimmune conditions, it’s important to review the roles of inflammation and autoimmu-

Successful management … requires a close collaboration between rheumatologist and cardiologist. nity in atherosclerosis, because they likely play a key role in the increased ASCVD risk in these

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patients. In fact, new understanding of the integral role of inflammation and immune mechanisms underlying the atherosclerotic process has rekindled interest in ASCVD development in rheumatic disease patients.

Minnesota Physician May 2014

In the 1980s, lipid-laden foam cells were identified as being derived from monocyte -derived macrophages, thus revealing the role of immunity in the development of atherosclerosis. T-lymphocytes were detected within atherosclerotic plaque in 1986, establishing a role for cellular immunity in the development of ASCVD. Deposition of immune complexes facilitates cholesterol accumulation in atherosclerotic plaques. Early atherosclerosis formation occurs in vessels with increased pro-inflammatory mediators such as leukocyte adhesion molecules, endothelial growth factors, and cytokines. In fact, many of these same pro-inflammatory factors have been identified in RA-affected joints. Since both RA and SLE are disorders characterized by abnormal immune tolerance—associated with acute and chronic inflammation—we can see how these rheumatic disease mechanisms are tightly associated with the underlying mechanisms for atherosclerosis. Systemic lupus erythematosis SLE, also known simply as lupus, is a disease that affects five to six people per 100,000. It

is nine times more common in women than men. The reported prevalence of SLE is about 75 cases per 100,000, with disease onset at any point in life, but most commonly between the ages of 16 and 55. Premature atherosclerosis in lupus was actually described more than three decades ago by Murray Urowitz, MD, a rheumatologist at the University Health Network, Division of Health Care Outcome Research, at the Toronto Western Research Institute. He described a bimodal mortality pattern in SLE, with early death due to active disease and infection, and late deaths due to myocardial infarctions. Cardiovascular (CV) mortality in SLE is particularly dramatic in young, premenopausal women who, according to the Framingham Heart Study, had 50 times the risk as compared to the non-SLE group. The prevalence of myocardial infarction, angina, and peripheral vascular disease in lupus cohorts has ranged from 6.7 percent to 10 percent. The mean age of the first event in these cohorts was 48 to 49 years, again illustrating the profound effect on premenopausal women. The New England Journal of Medicine (NEJM) in 2003 published two studies illustrating the increased incidence of subclinical ASCVD in SLE. In one, 197 patients with SLE—all without a history of cardiac events—were evaluated, with carotid ultrasound to identify atherosclerotic plaque. They were matched to controls by age, race, and sex. Patients with SLE, no matter their age, had greater amounts of atherosclerotic carotid plaque compared to controls, and its presence was found to be independent of traditional CV risk factors. Atherosclerosis was seen in those with a longer duration of disease, higher damage-index scores, and less aggressive immunosuppressive treatment regimens. Interestingly, unlike carotid plaque presence, carotid intimal medial thickness (CIMT) measurements were not significant-

ly different between the lupus patients and controls. CIMT is considered a surrogate marker of early atherosclerosis, but atherosclerotic plaque is more robustly associated with clinical events of stroke and transient ischemic attacks. In the same 2003 issue of NEJM, another study used electron-beam computed tomography to screen for coronary artery calcification (CAC) in patients with SLE, compared to control subjects. They found that CAC occurred more frequently and at an earlier age in the lupus patients, but its presence was not related to traditional cardiovascular risk factors. Rheumatoid arthritis RA prevalence is estimated at approximately 1 percent in Caucasians and occurs more often than SLE. The annual incidence is around 40 per 100,000. RA affects women two to three times more often than men. It can affect persons of any age, but the mean age at onset is about 56. Forty percent of all deaths in RA patients are due to ASCVD. Although CV mortality incidence is similar to that for the general population, it occurs at an earlier age. The relative risk of ASCVD mortality is highest in women under the age of 55. The absolute risk of ASCVD in RA is equivalent to that in a non-RA patient who is a decade older. A meta-analysis published in 2008 found that more than 50 percent of the excess deaths in RA were due to ASCVD. As in SLE, patients with RA have greater atherosclerotic plaque burden, compared to the general population. Patients with longer durations of RA show greater degrees of coronary artery calcification on computed tomography compared to those early on in their RA course, even after controlling for traditional CV risk factors. Evaluation of traditional risk factors Traditional risk factors (including smoking, older age, hypertension, diabetes mellitus, and hypercholesterolemia) do not

Figure 1. Cardio-Rheumatology clinic risk-assessment factors

Patient with RA referred to Cardiology Assessment of traditional and novel CV risk factors

Asymptomatic Optimal traditional risk factors

Patient with symptoms to suggest heart disease disease Anatomic or functional testing

Abnormal traditional risk factors

Normal Normal arterial studies Abnormal arterial studies

Usual risk reduction

solely account for the elevated ASCVD risk seen in the patient with SLE and RA. They do play a role, but may act synergistically with the underlying inflammation and immune changes in these conditions. Although they’re important in the assessment of ASCVD risk in patients with rheumatic diseases, their impact may be less. In particular, body mass index (BMI) seems to have a paradoxical impact on ASCVD risk in patients with RA, because patients with a lower BMI have a greater risk of cardiovascular death. This low BMI in the RA patient may reflect a greater degree of ongoing systemic inflammation (“rheumatoid cachexia”). The ASCVD-related risk of elevated lipids also appears paradoxical in RA patients, since active or high-grade inflammation actually suppresses total and low density lipoprotein (LDL) cholesterol. Thus, we see that disease-specific factors play a significant role in the assessment of ASCVD risk in patients with autoimmune disorders. In addition, some therapies used routinely in the management of SLE and RA may contribute to ASCVD risk. In particular, long duration corticosteroid treatment may be an independent

Normal arterial studies Abnormal arterial studies

Abnormal

Possible coronary angiography

Aggressive risk reduction therapy

risk of CV events. In contrast, disease-modifying agents, especially methotrexate and biologic agents, appear to reduce ASCVD risk in patients with RA.

It is not surprising that traditional scoring tools, such as the Framingham risk score, underestimate ASCVD risk in RA Finding the link to page 36

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May 2014 Minnesota Physician

Special Focus: Community Health

hen a 75-year-old man in the early stages of Alzheimer’s disease proclaims, “Don’t isolate me, don’t place a D[ementia] on my forehead, do walk this journey with me, and do focus on my strengths,” imagine a supportive, collective response by Minnesotans from all community sectors. That’s the vision and the work of the statewide volunteer-driven collaborative, ACT on Alzheimer’s. The collaboration prepares Minnesota communities to address the care and support needs associated with the increasing prevalence of Alzheimer’s disease and related dementias. Community capacity can be enhanced in all community sectors, including clinical, business, government, local planning and emergency preparedness, faith, social services, and long-term care. Right now, 100,000 Minnesotans are living with the

Preparing Minnesota for Alzheimer’s A community-based, collective impact approach By Olivia Mastry, JD, MPH

disease, supported by 250,000 family members or friends who are informal care partners. These numbers will skyrocket by 2025. Minnesota physicians will see many more patients with dementia, along with their care partners. Being prepared, sector-by-sector and community-by-community, will take many forms. The collective impact can transform Alzheimer’s as we know it.

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Minnesota Physician May 2014

Background The genesis for ACT on Alzheimer’s began in 2009, when the Minnesota Legislature called on the Minnesota Board on Aging to establish the Alzheimer’s Disease Working Group (ADWG), to study and make recommendations for needed policy changes related to Alzheimer’s disease. The ADWG delivered recommendations to the Legislature in January 2011. A subgroup of ADWG participants committed to ensuring that the recommendations were implemented, and ACT on Alzheimer’s was established in June 2011. With more than 60 public and private organizational partners (about 20 within the health care industry) and more than 300 individuals, ACT on Alzheimer’s seeks to change systems at multiple levels by using evidence-based and emerging practices and tools to effect change locally and statewide. The focus of the work has five interconnected goals: • Identify and invest in promising approaches that reduce costs and improve care • Increase detection of Alzheimer’s disease, and improve ongoing care and support • Sustain caregivers by offering them information, resources, and in-person support • Equip communities to be “dementia friendly” to support those touched by the disease

• Raise awareness and reduce stigma by engaging communities Resource tools These goals suggest that community readiness for dementia is a community health priority. To that end, ACT on Alzheimer’s has developed consensus-based, best-practice resource tools and materials for physicians and other health care professionals. The tools have been embedded in some health care systems and were adopted as part of the Minnesota Department of Health’s initiative with health care homes. The ACT on Alzheimer’s resource tools include a step-by-step road map for detecting, treating, and managing dementia throughout the continuum of the disease, including managing other concurrent comorbid conditions. The tools are available online for download, and can be embedded in electronic medical records using a template and guide developed by ACT on Alzheimer’s in conjunction with medical record vendor consultants and systems already using the tools. A Clinical Provider Practice (CPP) tool provides physicians a streamlined protocol for managing cognitive impairment and guiding decisions for Alzheimer’s screening, diagnosis, and disease management. Michael Rosenbloom, MD, clinical director of the HealthPartners Center for Memory & Aging, St. Paul, uses the CPP tool to communicate best practice approaches for Alzheimer’s disease. “The CPP tool is a great handout when I am talking with primary care clinicians about treating a person with dementia. It eliminates variability among clinicians and allows patients to receive the highest standard of care for memory loss,” he says. Electronic Medical Record (EMR) Decision Support tools assist clinicians in implementing a standardized approach to dementia care within the health record, including screening, diagnosis and treatment, and disease management. A com-

plementary “Guide to Implementation” of the EMR tool provides tips, steps, and case studies to aid effective implementation. Essentia Health developed an EMR decision support tool based on the ACT on Alzheimer’s template and incorporated it in Epic, the EMR system in Essentia facilities. Essentia Health is beginning a two-year dementia diagnosis and care pilot project, and the new tool will be integrated into the project. The goal is to implement and evaluate a standardized approach to early dementia diagnosis and care, designed to reduce cost and improve outcomes for persons with dementia and their families. The project will involve two certified health-care home clinics in Ely and West Duluth, as well as community partners Senior LinkAge Line, Alzheimer’s Association, and Northwoods Hospice Respite Partners. The project will create training,

staffing, and workflow models for implementing the standardized approach and will evaluate the effectiveness of the models, clinical outcomes, and community connections. ACT on Alzheimer’s goal in developing

the service system • Earlier diagnosis and more appropriate follow-up • Prevention of avoidable hospitalizations An “After a Diagnosis” guide

Right now, 100,000 Minnesotans are living with the disease. the tools is for those with dementia to receive optimal care that reduces the severity of the disease, prevents unnecessary hospital admissions and premature long-term care placements, and improves overall quality of life. The tools include: A Care Coordination Practice tool for health care settings fosters support of the person with dementia and their care partners or caregivers, which can mean: • Less crisis-driven care • Assurance in navigating

with action steps, tips, and resources that physicians can share with a patient and family members when Alzheimer’s or dementia is diagnosed. The information in the guide aligns with the ACT on Alzheimer’s provider practice tools. For example, the guide prompts patients and caregivers to access supportive resources in the community and take steps to plan for future health care, legal, and financial needs. A 10-module Dementia Curriculum for graduate and

undergraduate education programs prepares health care professionals for detecting, treating, and managing dementia. The curriculum was foundational to developing the best-practice content for the resource tools and materials. The Mayo Clinic Medical School includes the Dementia Curriculum in its educational program. Erika Tung, MD, assistant professor of medicine, says, “With third-year medical students, the Dementia Curriculum is a wonderful tool for introducing students to basic approaches in caring for an older adult with cognitive impairment. The curriculum is also useful for faculty working with residents in the subacute or long-term care setting.” Physicians and other health care professionals are critical to the success of a community prepared for the impacts of Alzheimer’s. Their role in Preparing Minnesota for Alzheimer’s to page 34

alz.org/mnnd

24/7 Helpline 800.272.3900

Memory loss that disrupts daily life

New problems with words in speaking or writing

Challenges in planning or solving problems

Misplacing things and losing the ability to retrace steps

Difficulty completing familiar tasks

Decreased or poor judgment

Confusion with time or place

Withdrawal from work or social activities

Trouble understanding visual images and spatial relationships

Difficulty completing familiar tasks

Recognizing the symptoms is the first step toward doing something about it. Early detection matters. The Alzheimer’s Association can help your patients develop a plan for the future.

May 2014 Minnesota Physician

Special Focus: Community Health

wo innovative initiatives in rural Ely, Minn., a mental health clubhouse (Northern Lights Clubhouse) and a community care team, have led to improved health outcomes for patients with complex chronic conditions. The Ely Clinic’s Community Care Team (CCT), an interagency group working to meet patient’s health and wellness needs through coordination of services with multiple access points, builds on the medical home model implemented at Essentia Health’s Ely Clinic. This article describes the development and purpose of the two programs, their relationship with inter-professional health care teams, and the impact of collaboration on health outcomes. Mental illnesses or mental disorders such as depression, anxiety, schizophrenia, and post-traumatic stress disorder create dilemmas for individuals, families, and communities. Isolation and lack of resources

Collaborating on mental health Patient outcomes improved by creative partnership By Pat Conway, PhD, MSW; Heidi Favet, CHW; and Molly Johnston in a remote, rural area add tremendous stress to an already overwhelming experience. Nationally, mental disorders are

In Ely, 17 percent of Essentia Health patients have a diagnosis of anxiety, bipolar disorder, depression, dysthymic disorder, PTSD, and/or schizophrenia. the most common reason for disability (www.nami.org/fact sheets/mentalillness_fact

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sheet.pdf). In Ely, 17 percent of Essentia Health patients have a diagnosis of anxiety, bipolar disorder, depression, dysthymic

Minnesota Physician May 2014

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disorder, PTSD, and/or schizophrenia; the most common diagnosis is depression. The Ely Community Care Team The CCT was established to ensure that there is no wrong door to meeting health and wellness needs of individuals in the Ely area. The CCT is affiliated with 21 agencies, which focus on evaluating the whole needs of individuals—not just the needs served by the particular agency—and makes appropriate referrals and follow-up to ensure that all health needs are met. The CCT provides a framework that strengthens limited resources into a solid network of support. The team meets monthly to network, offer case management, and develop tools and systems for collaboration. Agencies include medical providers, mental health care providers, educators, social service agencies, housing agencies, and community members. CCT care ranges from providing referral information to an individual, to providing care coordination that addresses physical and mental health and psychosocial needs. The care coordinator, a certified community health

worker (CHW), is the point person, connecting individuals and families with programs and serving as the communication conduit between providers and patients. The majority of individuals participating in care coordination have one or more mental health diagnoses and/or psychosocial needs. CHWs come from the communities they serve, building trust and vital relationships. This trusting relationship enables them to be effective links between their own communities and systems of care. This crucial relationship significantly lowers health disparities in Minnesota because CHWs provide access to services, improve the quality and cultural competency of care, create an effective system of chronic disease management, and increase the health knowledge and self sufficiency of an underserved population (www.mnchwalliance.org). Prior to the formation of the CCT, service providers recognized that no clear process existed to meet the complex psychosocial needs of some patients. This lack of a process led to patient needs going unmet. CHWs were identified as a key component of the solution. CHWs are now housed at Northern Lights Clubhouse (NLC) and the Essentia Health–Ely Clinic, providing care coordination at all levels. Referrals come from all CCT agencies, with most of them coming from Ely Clinic. Northern Lights Clubhouse The NLC (www.elynlc.org) is a local initiative that is part of the global Clubhouse International (www.iccd.org) movement, which is included in the U.S. National Registry of Evidenced-Based Practices and Programs. Clubhouse International believes that working is rehabilitative, with a focus on work opportunities within the clubhouse and in the community. The local members and staff work alongside each other to accomplish the work of the clubhouse and learn new skills. NLC goals include decreased social isolation, increased com-

Another NLC member said, “The clubhouse gives me new skills, such as menu planning,

Family nurse practitioner Peggy York-Jesme, CNP, a longtime patient advocate, participated in grant writing that led to the formation of the CCT and is an active member. She is also the NLC board chair. “These projects are important because

Figure 1. Results of Fall 2013 survey on success of the Ely CCT

5 4.5 4 3.5 3 2.5

The Essentia Health–Ely Clinic is the fiscal agent for the CCT and houses its leadership. Providers now have a referral source for patients with unmet needs. “It makes sense for our clinic to be a core part of the solution,” stated Laurie Hall, clinic and integrated behavioral

Effective and efficient service delivery

Health needs are met

Coordinate services

Provide access to care

2 Community education

One member explained, “I am doing a lot better. My mood and cutting are better. I have support I never had before. The clubhouse is my safe haven. It gives me a purpose, something to do during the day. I feel safe and I don’t feel judged here.”

Roles for health care providers Ely primary care providers have played a crucial role in the development of the CCT and NLC through planning, participation, financial contributions, and referrals. Clinic providers and administration joined early conversations about increasing mental health resources for youth and families in the community. Monthly meetings identified problems and explored solutions to create a safety net for individuals who were slipping between the cracks.

there are not enough options for patients with behavioral health concerns,” said York-Jesme. “Helping create solutions is very rewarding to me as a professional, especially in situations that previously left me feeling frustrated and unhelpful.”

Build infrastructure for collaboration between services

The key to success is an environment of support, acceptance, and commitment to the potential and contributions of each individual regardless of the severity of his or her illness. The clubhouse philosophy values people living with mental illness as contributing members, rather than as patients. Members participate in daytime programming, employment and education support, housing support, psychosocial resource management, and holistic wellness programs.

shopping, cooking, and American Sign Language, and social opportunities like the weekly coffee club. We also explore holistic wellness opportunities such as yoga, art, and hiking.”

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munity connectedness, and supported employment and education goals.

health administrator. “Our providers see first-hand the challenges created by the limited services for people with mental illness. Because we are on the front line with patients, we Collaborating on mental health to page 32

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May 2014 Minnesota Physician

Special Focus: Community Health

he University of Minnesota (U of M) is committed to approaching research in a way that improves the health of its communities. It sharpened this focus in 2009, when it established the Clinical and Translational Science Institute (CTSI).

The power of partnerships Strong partnerships are the foundation of any community-engaged research project. That’s why CTSI helps physicians, clinics, nonprofits, and other community groups build mutually beneficial relationships with university researchers, and vice versa. The idea is to create community-university research teams that collaborate throughout the research life cycle, by first developing an understanding of the needs of a community, and then designing a mutually agreeable and appropriate study to address those needs, which ultimately leads to the dissemination and implementation of its findings.

A team approach to research Improving health in Minnesota communities By Kathleen Call, PhD; Sheila Riggs, DDS, DMSc; Deborah Hendricks, MPH, RN, APHN-BC; and Bernard L. Harlow, PhD

For example, suppose a physician who predominantly serves a particular ethnic group notices and has parents voicing concerns about an increase in childhood obesity, and wants to determine whether a behavioral change approach could be an effective form of prevention. CTSI could connect the physician with university researchers who a) focus on childhood obesity; b) have expertise in health disparities facing that particular ethnic group; and c) are proficient in designing,

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Minnesota Physician May 2014

conducting, and analyzing studies. CTSI will also connect this team with community advocates and leaders within that ethnic community, to ensure the research design is culturally appropriate and that the results are being relayed back to the community. These collaborations take a variety of shapes and forms. Perhaps the physician and university researcher have a discussion that opens up for the researcher new issues not previously considered, steering the study in a promising direction. The physician’s clinic could serve as the venue where research is conducted, in close partnership with the university researcher, and/or draw on the expertise of a community member or local organization from that ethnic group, to better understand the issues, engage in the study design, recruit research volunteers, contribute to the interpretation of the results, and develop solutions. Start to finish In addition to forging partnerships, another critical early step in the research process is actively listening to the needs of the community and to physicians who will ultimately provide care. Research must address what the community needs, and not simply what researchers think the community needs. This seemingly small—but important—distinction can affect the success of the research and its impact on the community later. Even with insights from people closest to the issue, a research partnership may strug-

gle to get a study off the ground due to a lack of financial support. This is one of the biggest challenges that research teams face. CTSI addresses it through programs that award funds to community-university teams. Grants have enabled these teams to explore a wide range of issues in four areas: the health of children, rural populations, health disparities, and systems for improving health. Since 2010, CTSI has awarded $1.5 million to community-engaged research projects. Once research gets off the ground, the team can tap into a variety of tools, resources, and experts. For example, CTSI can connect teams with statistical experts who can help with study design and analysis; resources such as partnership checklists to help get the team off to a strong start; and specialists who can provide free consultations about engaging other community members, attracting study volunteers, working with specific populations, overcoming regulatory hurdles, and more. After a study is conducted, the final step is to disseminate the study’s findings to the community. However, this is not happening at a level we would like to see, as the research results often don’t reach the people who benefit most from this knowledge. When researchers involve key stakeholders such as physicians, patients, community members, leaders, and advocates throughout the research process, disseminating knowledge becomes a more natural, seamless part of the process. This helps expand communication beyond traditional academic channels, to reach the individuals that a study impacts most. To support this crucial step, CTSI is launching a dissemination-focused grant program this spring. The program encourages researchers, providers, and the community to work together to publicize research findings to patients, families, clinics, advocacy groups, and policy makers. The goal is to apply best prac-

tices to health care delivery and translate study results into actions needed to improve health. Collaboration in action In 2010, CTSI awarded a Community Collaborative Grant to a university-community physician team to explore the potential of using exenatide to help pediatricians treat extreme obesity in children. Exenatide is a glucagon-like peptide-1 (GLP1) receptor agonist that’s taken by adults with type 2 diabetes. Childhood obesity expert Aaron Kelly, PhD, an associate professor of pediatrics and medicine at the University of Minnesota Medical School, teamed up with Jennifer Abuzzahab, MD, a physician at Children’s Hospitals and Clinics of Minnesota. The doctors and their collaborators conducted a threemonth, placebo-controlled trial, followed by a three-month open-label extension where exenatide was offered to all participants. Nearly two dozen individuals between ages 12 and 19 volunteered for the trial, which was conducted at multiple locations. To streamline multisite information-sharing, the research team used secure software-sharing technology so they could collect, input, and access the data from anywhere. After completing the trial, the research team brought in CTSI’s Biostatistical Design and Analysis Center to analyze and interpret the data. Ultimately, preliminary results showed the feasibility, safety, and efficacy of using this particular drug to treat severe obesity in children. Participants who received exenatide experienced a greater reduction in body mass index (BMI) compared with placebo (-2.7 percent), and a further reduction in BMI during the open-label period (cumulative reduction of 4 percent). After the study, they published their findings in JAMA Pediatrics (Feb. 2013) and created the Minnesota Pediatric Obesity Consortium (MN-POC). The consortium provides a platform to efficiently conduct scientifically rigorous and

clinically relevant multicenter research studies in the field of clinical pediatric obesity. In addition, MN-POC educates health care providers on best practices for helping overweight and obese youths. Training community groups To encourage and position

clinical studies to surveys, often fail because not enough people volunteer for them. CTSI can connect physicians with relevant researchers who need people to participate in their studies, and physicians can direct patients interested in volunteering to online resources. For example, StudyFinder

Research results often don’t reach the people who benefit most from this knowledge. community groups to conduct research, CTSI offers training and educational programs. For the past two years, CTSI cosponsored the Community Research Institute (CRI) with the two other U of M organizations, the Program in Health Disparities Research and the Center for Health Equity. The CRI is a six-week workshop for community leaders and staff that provides training in health-related research methodology to develop and conduct potentially grant-fundable research projects. Rather than relying solely on university experts to provide the training, CTSI also brings in community experts as co-leaders. For example, representatives from the Somali, Latino, and Hmong Partnership for Health and Wellness joined with the U of M Center for Bioethics to educate attendees about ethical considerations in community-based research.

(studyfinder.umn.edu) makes it easy for people to find U of M studies that need volunteers, while ResearchMatch.org acts as a national registry to connect people who are interested in volunteering for studies with researchers who are looking for participants. CTSI is committed to helping physicians discover highimpact ways to get involved with research and get the support they need to be successful. There are many ways physicians

can get involved, whether they co-lead a study with a university researcher, offer their clinic as a study locale, seek guidance connecting to members of the communities they serve, or simply connect with a researcher in their area to share their insights. Kathleen Call, PhD, is faculty liaison for community-engaged research at CTSI, and professor in the Division of Health Policy and Management, School of Public Health, University of Minnesota. Sheila Riggs, DDS, DMSc, is director of the Office of Community Engagement for Health at CTSI, and chair of the Department of Primary Dental Care, School of Dentistry, University of Minnesota. Deborah Hendricks, MPH, RN, APHN-BC, is assistant director of community-engaged research programs, Office of Community Engagement for Health at CTSI. Bernard L. Harlow, PhD, is associate director of Populations and Community Engagement at CTSI, and professor and division head, Division of Epidemiology & Community Health, School of Public Health, University of Minnesota.

Read us online Wherever you are!

Making a difference Strong relationships among university researchers, physicians, and community members can have a significant effect on community health through collaboration, education, and training. Our health systems and its physicians have a tremendous opportunity to advance knowledge about what works and what doesn’t among their patient populations. In addition, physicians are uniquely situated to address one of the biggest challenges facing all researchers: recruiting research subjects. Research projects, which range from

www.mppub.com May 2014 Minnesota Physician

Special Focus: Community Health

Improving care transitions

hile many health care organizations and physicians have worked to make care transitions smoother and more coordinated for their patients, the efforts often remain within those organizations’ walls. A community-based approach with collaboration among the local health care organizations, however, can have a much bigger impact on patient care coordination— and on rates for readmission to the hospital.

Collaboration by organizations cuts readmissions By Janelle Shearer, RN, MA, and Kim McCoy, MPH, MS the initiative, her organization partnered with directors of nursing at three area nursing homes. Leaders from area hospice and home care programs were invited to be a part of the

After receiving funding from the Centers for Medicare & Medicaid Services, Stratis Health invited Minnesota health care organizations to participate in an initiative on improving care transitions in a variety of care settings. Below are the results for three communities.

group studying better care transition options. Additional group members included assisted living, retail pharmacy, and the local Area Agency on Aging. The focus was on reducing readmissions for heart failure patients,

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The nursing home representatives shared several obstacles. For instance, when patients arrived in the nursing homes with accompanying discharge summary paperwork, medications were listed without a diagnosis—a requirement for the nursing home.

“We asked our information technology staff members to look at a way to tie medications with diagnoses within our electronic medical record, so that the information is included in the discharge paperwork,” said Miller.

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ate-level certification. “We started by asking the group: ‘What do you see on your end that could be improved when patients are discharged from our hospital and into your care?’ ”

This started a cumbersome process: The list would need to be faxed back to the hospital with a request to add the diagnosis. Hospitalists would fill in the information and fax it back, a time-consuming step that also delayed care.

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“It was a great learning opportunity for us,” said Miller, who is a nurse with gradu-

Physicians hold a key to making a difference.

Talking to each other Kathy Miller is the director of quality and safety for Essentia Health–St. Joseph’s Medical Center in Brainerd. As part of

in Minnesota Physician

an area that Essentia had targeted for improvement.

nce

No .7

2007

The change was a timesaving, simple fix. It also led to an even better solution: giving the nursing homes the ability to access patients’ medical records. “With EpicCare Link now a part of our electronic medical record, nursing homes can access portions of our patients’ medical records

through a web-based tool,” said Miller. “The portal is secure and HIPAA-compliant, so that information is not accessed inappropriately.” As a result of the initiative, cardiac patients receive a call from a nurse within two days of hospital discharge. Nurses answer any questions patients or family members may have and ask if medications are being taken as prescribed. If a patient needs transportation to a follow-up appointment or can’t afford medication co-pays, a referral is made to the Brainerd area’s Senior LinkAge Line. “At the follow-up appointment, our clinic’s care coordinators closely monitor cardiac patients to make sure physician orders are followed,” said Miller. “Patients appreciate having a care coordinator to call for questions or concerns.” If a cardiac patient lives in another area or will not be seen in the Essentia Health clinic, Miller said that the discharging physician sends all the appropriate information to the receiving physician. Has the project made a difference? The readmission rate for cardiac patients at St. Joseph’s at the start of the initiative was 18 percent. That number is now consistently below 10 percent—and was only 6 percent in December 2013. It starts with physicians Mark Boyce, MD, a family practice physician with expertise in geriatrics, is part of the team created when three hospitals and several nursing homes came together in Duluth to talk about providing better care for patients as they transition from one medical setting to another. “We invited home care agencies to participate, since we know that home care services are underutilized in our part of the state,” said Dr. Boyce. “Fewer than 5 percent of patients use home care, and we believe that may be a missed opportunity. By meeting together, we could learn in a collective fashion what the other facilities and organizations are doing to provide better care.”

While the hospitals instituted new protocols to avoid readmissions—like assuring patients have appointments to see their physicians in the clinic before being discharged from the hospitals—Dr. Boyce believes that physicians hold a key to making a difference. “Good, old-fashioned internal medicine care is at the heart of making transitions more effective,” he said. “As physicians, we’re doing what we’re trained to do.” With the representatives from hospitals, nursing homes and home care agencies working together, lots of questions were raised: Is the medication list correct? Does it make sense? Are the patients complying with medication instructions? “Post-hospitalization care that occurs in skilled nursing facilities is often difficult and complex, because of such maladies as dementia, heart failure, COPD, bowel issues, and depression,” said Dr. Boyce, who sees patients in area nursing homes. “These issues require frequent visits to patients, and coordinated care efforts with skilled nursing facilities and families.” Checklists were among the many ideas discussed as a way to ensure coordinated and standardized care during transitions. “Nursing homes often use checklists of evidence-based protocols for smoother transitions,” said Dr. Boyce. “And our hospitalists are also working on a discharge process checklist that may eventually be a part of our electronic medical record. We’ll have a stronger culture of safety when we can ensure that certain activities have taken place—similar to what an airline pilot uses before take-off.” Together in one room In the north metro, Allina Health’s Unity and Mercy hospitals are in communities with residents who have called the area home for many decades. Kim Schalo, RN, has been with Allina Health for 30 years. Her role as senior clinical business analyst was beneficial to helping the hospitals work with area nursing homes to

improve transitions—starting with improvements in discharge information. “Representatives from our two hospitals met with managers from six nearby nursing homes,” said Schalo. “Many of the participants hadn’t ever met face-to-face before.” “We also consulted with our senior care transition physician providers and the Mercy and Unity hospitalists. We are fortunate to have physicians who are eager to be involved in initiatives that improve care for patients,” explained Schalo. “They do the majority of discharges and were the ones taking calls from nursing home staff who were confused about the information that transferred with the patients from our hospitals.” The after-discharge orders were transcribed using patient-friendly language—and included too much information for the nursing home medical staff. Their request: Just give us the information we need in the discharge orders to care for the patient and give patients or families a separate version.

Initiative expands The Centers for Medicare & Medicaid Services (CMS) plans to expand work with additional communities throughout the country to create successful strategies that improve care transitions, such as those used by the Minnesota communities working with Stratis Health. These community coalitions will seek to improve the quality of care for Medicare beneficiaries. The goal is to engage practitioners, long-term services and support providers, and other community stakeholders in better coordinating patient care. Organizations similar to Stratis Health will coordinate this work, as community members identify and target interventions for special and vulnerable populations, such as people with multiple chronic conditions—for example, dialysis and/or diabetic patients—who take multiple medications, with behavioral health or socioeconomic issues, or are dually enrolled in Medicare and Medicaid. To participate in a team to improve care transitions in your community, contact Janelle Shearer at Stratis Health, (952) 853-8553 or jshearer@stratishealth.org

a group, our hospitals and nursing home partners have created tools to complete tasks more efficiently and effectively.” Best of all, patients receive better and more timely care.

patients. The current national readmission rate for nursing homes is 19.92 percent and the state rate is 17.12 percent (third quarter 2013). Physicians can spend more time in direct patient care and less time tracking down necessary discharge information. “Physicians have so many demands on their time,” stated Schalo. “By working together as

Janelle Shearer, RN, MA, and Kim McCoy, MPH, MS, are program managers at Stratis Health, a Minnesota Medicare quality improvement organization based in Bloomington.

“It was an excellent request and one that led to more adjustments of our skilled nursing order sets—like making dietary restrictions for multiple medical issues easier to access,” said Schalo. “Most of the nursing homes that participated now have access to our electronic medical records, which has greatly reduced calls and confusion.” Better care, increased satisfaction Reviews of health organizations addressing care transition issues in partnership with other provider organizations have proven successful in multiple ways. Readmissions have been reduced—as have hassles. For example, the readmission rate for discharges from the Mercy and Unity Hospitals to the six nursing homes in the project went from 14.7 percent in fourth quarter 2012 to 4.5 percent in third quarter 2013 for Medicare Fee-For-Service

THE STRENGTH TO HEAL

and stand by those who stand up for me. Learn the latest treatments and play an important role in the care of Soldiers and their Families. As a physician on the U.S. Army Reserve Health Care Team, you’ll continue to practice in your community and serve when needed. You’ll work with the most advanced technology and distinguish yourself while working with dedicated professionals. You’ll make a difference. To learn more, call 1-855-276-9579 or visit www.healthcare.goarmy.com/q955. © 2010. Paid for by the United States Army. All rights reserved.

May 2014 Minnesota Physician

Neurology

Back pain

Figure 1. Spinal care program, designed to help people get the back pain care they need, when they need it

Landing on best treatment

Medical Spine Care Model

By Bret Haake, MD, MBA

Patients with Non-Specific Back Pain

Primary Care Physician

ack pain affects most people at some point in their life; one-quarter of adults in the United States have experienced back pain lasting longer than a day during the

total costs associated with low back pain in the U.S. exceed $100 billion per year, two-thirds of which results from lost wages and reduced productivity.

• Standardized tools • Standardized message • Standardized metrics (i.e. imaging, narcotics)

Patient Improves

Active Physical Therapy Patient DOES NOT Improve Patient Improves

Primary Care seeks consultation on appropriate next step for patient with back pain.

Care of patients with back pain is no longer a mystery. past three months. In fact, low back pain is the most common type of pain listed by respondents to a National Institute of Health Statistics survey, and is the fifth most common reason for all physician visits. And, according to a 2006 review, the

In the beginning When I started practicing neurology in 1994, it wasn’t always clear to me how best to treat patients with back pain. For some patients, surgery was needed. But for the vast majority of patients, the degree of pain

BC/BE Family Practice Mankato Clinic is seeking a Family Practice provider to work at Madelia Hospital & Clinic in an inpatient/ outpatient/ Emergency Department practice. Madelia Hospital is a 25-bed, acute care, Critical Access Hospital that has received the JCAHO Gold Seal of Approval. Primary health services available include medical/surgical, Level 4 Trauma, 24/7 Emergency Room, 24-hour Lab, Physical Therapy, diagnostic imaging with a 16 slice CT, digital mammography and more. Madelia Hospital & Clinic offers a sign-on bonus of $75,000 and an additional $50,000 bonus to live in the community. Mankato Clinic employment features: • Excellent first year guarantee and production bonus opportunity • Competitive Benefit Package with 401(k) and profit sharing • Shareholder opportunity in your second year • Generous CME allowance

Contact Dennis Davito for more information at (507) 389-8654 or by email at dennisd@mankato-clinic.com Apply online at www.mankatoclinic.com

Minnesota Physician May 2014

Conservative Management (Medical Spine Specialist)

Patient Improves

Surgical/Interventional Management

Patient Improves

Conservative Management

Patient Improves

(physician directed rehabilitation)

Non-Responders

Hyper-vigilant and/or Hypersensitized

Non-invested

Psychiatric Diagnosis

Interdisciplinary Pain Management

No additional spine care needed

Behavioral Health/ Addiction Program

and disability they experienced didn’t seem to correlate with the type of injury they had or the degree of change in their spine as seen on MRI or CT scans. During most of those early years I was practicing in Fargo, N.D. In North Dakota at that time, there were few neurologists and even fewer spine surgeons. As a result, I saw a lot of patients with back pain and needed to help them decide whether or not they should see a surgeon. The surgeons were just down the hall from me, so, over time, I was able to observe which patients benefited from surgery and which ones did not. Because this was a smaller community, I also was able to note the long-term outcomes of patients who didn’t have surgery. Developing a new strategy After a decade of evaluating thousands of patients with back

pain and watching how they did with different treatments, it became much clearer to me how physicians should care for patients with back pain. Other physicians were observing the same outcomes, and science was catching up with what we were observing (Annals of Internal Medicine 2007; Institute for Clinical Systems Improvement 2012). What became clear was that: • Back pain is common and a normal part of life. • Back pain doesn’t always imply severe injury. • Most people with back pain get better over time. • It is important to stay active and exercise even if pain is present. • Medications can inhibit getting better and can even make pain worse over time.

Figure 2. Five-year results of various treatment regimens

Spine model results

% Patients without narcotic presciption

% Patients without imaging referral

% Patients without surgical referral

% Patients without injection referral

% Patients received optimal care

 2009

71.4%

79.8%

97.2%

97.3%

57.2%

 2010

72.4%

80.2%

97.3%

97.4%

58.0%

 2011

73.8%

81.2%

97.2%

97.4%

59.2%

 2012

76.7%

84.2%

98.5%

97.9%

64.5%

 2013

77.8%

84.9%

98.4%

98.3%

65.7%

These observations suggested a new strategy for helping patients with back pain. Case in point Many patients through the years have reaffirmed for me that this strategy is correct. One patient in particular illustrates this point strongly. He was a man in his 70s who had been injured in a parachute jump during World War II. Because his parachute didn’t open completely, he broke his legs, pelvis, and several vertebrae in his spine. His back X-ray was among the worst I had ever seen. Yet, he had lived a full life as a farmer, raised five children, and had no back pain. When I asked him how he could have no back pain when others had chronic back pain from only minimal injuries, he said, “Yeah, I had pain when I returned from the service. I spent a year in the hospital. But when I got home, I was so happy to be alive that I quit going to doctors, quit my meds, and went on with my life. After a year or two, my pain went away.” This shows how well many patients can do by having a positive attitude, staying active,

and avoiding medications. The brain and nervous system are quite adaptive and, given time, remodel themselves in a way that often leads to less pain. For many people who have a back injury, the best outcome may come from positive thinking, exercise, and allowing the body time to repair itself. New approach In 2007, I started working with the spine program at HealthPartners/Regions Hospital. The medical spine care model that we introduced in our clinics in 2009 is shown in Figure 1. The goals of this program are designed to help patients with back pain get the care they need, when they need it. The first goal is to get people with back pain better faster and with less fear that something bad is wrong. Secondly, our goal is to prevent chronic pain, and lastly, we aim to direct patients to physical therapists and specialists when necessary. When this is done correctly, most patients improve, return to normal activities, and do not need more invasive treatments like injections or surgery. Here are the steps that patients in our program take.

1. First, patients are thoroughly evaluated when they first seek help for

back pain. Evaluation occurs wherever the person obtains care: a primary care doctor’s office, specialty care office, chiropractic office, or physical therapy office. Most people are found to not have any clear or dangerous pathology, i.e., the diagnosis is “nonspecific back pain.” These patients are reassured that they do not have a disease, that it is normal to have back pain at times, that it is important to stay active and exercise, and that avoiding medication is often best in the long run. 2. Second, if patients need advice on exercise or if patients are not improving quickly, they are referred to physical therapy. There, they again are reassured that they are going to be OK, that exercise is good, and that medication is not Back pain to page 30

Physician Sleep Medicine/Tele-medicine The Minneapolis VA Health Care System is recruiting a physician for a combined Sleep Medicine (50%) and Tele-ICU position (50%) within the Section of Pulmonary, Critical Care and Sleep. Board certified in: Internal Medicine, Pulmonary, Critical Care, and Sleep Medicine. A demonstrated track record in research as evidenced by peer review publications and academic status at an Assistant Professor level or higher is required. Experience in ICU Telemedicine, in addition prior experience in directing both Intensive Care Units and Sleep Laboratories. Substantial experience in supervising trainees including fellows, residents and medical students. Be a part of this dynamic and rapidly growing clinic in a great location. Must have a valid medical license anywhere in the US. VA physicians enjoy an excellent benefits package, paid malpractice insurance, and a state-of-the-art electronic medical record. Competitive salary and benefits with recruitment/relocation incentive and performance pay.

For more information: Visit www.usajobs.gov or email Alisha.Crane@va.gov EEO employer

May 2014 Minnesota Physician

Back pain from page 29

the answer. 3. For patients who continue to struggle with back pain despite good intentions, we have them further evaluated by a medical spine specialist, not only to assess whether any X-rays or other consultations are needed, but also to reinforce the message that they can improve with time, that exercise is important, and that medications are not the answer. At that juncture, we also partner with Physicians Neck & Back Clinics to enroll patients in that organization’s active rehabilitation program. This program focuses, again, on a message of returning to normal activities while putting the patients through a rigorous exercise program that has been shown to greatly improve success.

Results Since our program began, there has been a decrease in

reduces overall health expenditures. In fact, in one year, approximately $2 million in

There has been a decrease in the number of patients needing medications for back pain, in the number of patients needing procedures, and in the number of patients needing the more aggressive active rehabilitation program. the number of patients needing medications for back pain, in the number of patients needing procedures, and in the number of patients needing the more aggressive active rehabilitation program (Figure 2, page 29). We believe this means that patients are getting better earlier and that fewer people are having persistently troublesome back pain. In addition to these advantages of rethinking how to treat back pain, this approach

cost savings were realized through less use of medication and imaging, fewer visits to the emergency room, and fewer hospitalizations. Getting better Care of patients with back pain is no longer a mystery. At first, due to lack of a clear treatment path, patients were told to be careful, were told that they had a degenerative condition, and were told to take medication. This benign-sounding advice inadvertently led to more chron-

ic back pain and interventions down the road. Now we know that with appropriate evaluation, reassurance that pain is normal and that it gets better with time, an emphasis on activity and exercise, and minimizing medication, the vast majority of patients get better sooner and with less residual disability. Bret Haake, MD, MBA, is the assistant medical director of neurosciences and the head of neurology at HealthPartners and Regions Hospital, St. Paul. He is also an associate professor of neurology at the University of Minnesota. The treatment model described here would not have been possible without the contributions of Denis P. McCarren, MS, PT, MBA, original Regions spine project manager and now director of neurosciences at HealthPartners and Regions; medical spine specialist Michael Goertz, MD; the spine specialists at Physicians Neck and Back Clinics; and the surgeons at HealthPartners and Regions.

Psychiatrist Unique Practice – Unique Psychiatrist Needed! HealthPartners Medical Group is a top Upper Midwest multispecialty group practice based in Minneapolis/St. Paul, Minnesota. We have a unique metropolitan-based outpatient position available for a talented, bilingual BC/BE psychiatrist interested in a non-conventional practice. This full-time position combines cross-cultural psychiatric medicine with community mental health. Receiving practice support from both HealthPartners Center for International Health and from the Ramsey County Mental Health Center, 0.5 FTE of the position will provide psychiatric care to an international refugee patient population utilizing an integrated holistic/ primary care model. The other 0.5 FTE of the position will work as part of a multidisciplinary team to provide care to individuals with serious mental illness, chemical health difficulties and/or co-occurring medical problems. This exciting practice is full-time, but qualified candidates interested in part-time outpatient opportunities in Cross-Cultural Psychiatric Medicine or Community Mental Health are encouraged to apply. In addition to a competitive salary and benefits package, there are opportunities for an academic faculty appointment at the University of Minnesota, teaching involvement in the Global Health Pathway (globalhealth.umn.edu) and further development of best practice programming at Ramsey County Mental Health Center. For consideration, please forward your CV and cover letter to lori.m.fake@healthpartners.com, apply online at healthpartners.com/careers, or call Lori at (800) 472-4695 x1. EOE

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

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

• Psychiatry • Pediatrics • Pulmonary/ Critical Care • Rheumatology

F o r m o r e i n F o r m aT i o n :

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May 2014

www.acmc.com |

Pediatric Orthopaedic Hospital & Clinic Ranked among the top 10% of hospitals nationwide in patient satisfaction, according to our families! Conditions Treated: (muscle, bone, and joint related)

I am so incredibly grateful for the care we've received at Shriners Hospital for Children. And by "care" I mean far more than just medical care, which in and of itself has been excellent. They also take care of our entire family on a social and emotional level.

Arthrogryposis (stiff joints) Cerebral palsy Cleft lip and palate Clubfoot and congenital deformities of lower extremities Congenital deformities of the hand and upper extremities

– Cheryl, Sophie’s mom

Hip disorders (congenital and acquired) Juvenile rheumatoid arthritis Limb deficiency and prosthetics Limb length discrepancies Metabolic bone disease (rickets, osteogenesis imperfecta) Neuromuscular bisorders (muscular dystrophy, SMA, CMT) Scoliosis and spine deformities Specialized plastic surgery (otoplasty, scar revision) Spina bifida/myelodysplasia All care is provided regardless of the families’ insurance coverage or ability to pay. Referral Line: 612.596.6105 2025 East River Pkwy. | Minneapolis, MN 55414 intaketc@shrinenet.org www.shrinershospitalsforchildren.org/twincities Sophie, age 5

May 2014 Minnesota Physician

Collaborating on mental health from page 23

are in an excellent position to identify individuals’ needs and connect them to services.” When the CCT identified the need for increased care coordination, the clinic committed to pilot the CHW role. “As we transition to the world of accountable care and meeting goals of the Triple Aim, it greatly benefits the patient and the clinic to address the social determinants of health,” said Joseph Bianco, MD, division chief of primary care, Essentia Health East Region. “We will never be successful unless we find and build models to address these needs in our patients. The CCT essentially takes us from the model of the health care home to the health care neighborhood.” Impact of the CCT and NLC The story of a 27-year-old female, diagnosed with bipolar disorder and anxiety, describes

the process and impact of the CCT and the collaboration with CHWs and NLC. The young woman, who moved to Ely from out of state, was referred for care coordination to access insurance and other benefits. The strength-based assessment revealed additional needs. Together, the CHW and young woman established a full range of supports and services to meet her needs and goals. Social phobia was a large barrier in helping her access services of the CCT. The CHW personally introduced the woman to the NLC, where a strong rapport and increased level of support quickly developed. This “warm hand-off” helped reduce her anxiety of meeting new people. The young woman attributes participation in the clubhouse as a significant part of her recovery. NLC connected her to an ARMHS (Adult Rehabilitative Mental Health Services) worker, who assisted in skill building in the individual’s home setting. In five months, she experienced

significant change, becoming a pleasant, smiling individual who has created a plan to stop self-harm. Evaluation of the Community Care Team In 2013, CCT organizations participated in an evaluation to identify community needs, make recommendations, and describe interactions between organizations. In response, Essentia Health–Ely Clinic now makes reciprocal referrals with hospice, the nursing and rehabilitation center, the hospital, the free clinic, Head Start, and the community college. Member feedback also informed development of the CCT Strategic Plan. As part of the Fall 2013 CCT survey, organizations rated their opinion of CCT successes. Connecting organizations to each other, building infrastructure for collaboration between services, providing access to care, coordinating services, and meeting health needs were rat-

Family Medicine

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. 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. 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

Acknowledgments: Funding for these programs is provided by the Essentia Health Foundation, St. Louis County Family Service Collaborative, United Way of Northeast Minnesota, Medica Foundation, Minnesota Department of Health-Health Care Homes Division. Research reported in this publication was supported by the National Center for Advancing Translational Sciences of the National Institutes of Health Award #UL1TR000114. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

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

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Pat Conway, PhD, MSW, is a senior research scientist with Essentia Institute of Rural Health. Heidi Favet, CHW, is the Ely Community Care Team leader. Molly Johnston is the former executive director of the Northern Lights Clubhouse.

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.

allinahealth.org/careers

healthpartners.com

Members commented on the value of the CCT to their clients: “As my contact with new clients increases and I find needs that can be met by this group, I can increase services to my client and improve their issues with the proper sources.”

Here to care

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.

ed highly (Figure 1 on page 23).

May 2014 3.5x4.75_AD_MN_Medicine.indd 1

EOE/AA

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

Pulmonologist

Join the top ranked clinic in the Twin Cities 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:

Oncologist

• Family Practice

Cardiologist (part time)

• Urgent Care

Endocrinology

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

Applicants can apply online at www.USAJOBS.gov

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.

Please contact or fax CV to:

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

763-504-6600 Fax 763-504-6622

www.NWFPC.com

Family Medicine Physician with C-section An ideal balance between your professional and personal life. Provide comprehensive care in a clinical and hospital practice. ER coverage and obstetrics 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 May 2014 Minnesota Physician

Preparing Minnesota for Alzheimer’s from page 21

identifying and diagnosing dementia, educating the patient and caregiver about the disease, understanding community resources available, and providing ongoing medical management, helps people with dementia be informed and supported along their journey. In addition to ensuring that communities are prepared to support the clinical needs of people with Alzheimer’s, ACT on Alzheimer’s is partnering with communities to strengthen the goal to become dementia friendly. “Dementia friendly” means that a community is informed, safe, and respectful of persons with Alzheimer’s and their families, and has supportive options in place that foster quality of life. ACT on Alzheimer’s also offers communities a comprehensive Dementia Capable Community Toolkit, developed in partnership with Stratis

Health. It is web-based, and guides communities in developing action teams, assessing dementia capability, analyzing the assessment results, and planning and implementing

The work of ACT on Alzheimer’s has reached all regions of Minnesota, as well as nationally

Communities are working to raise awareness about the need for early detection and support. changes using best-practice resources. Both urban and rural communities are implementing the tool kit and engaging people and organizations, including the local health care sector. Communities have an option of sharing the provider tools and related education with local clinics and hospitals. Currently, communities are working to raise awareness about the disease and the need for early detection and support. They are also training businesses and faith communities about how to interact with and support people with dementia so that they can continue to maintain

• Keynoting in Glasgow, Scotland, at a knowledge exchange event hosted by Scottish Universities Insights Institute (June, 2014)

independence and carry out day-to-day tasks.

and abroad, including: • Providing counsel to Oregon, Maryland, Pennsylvania, and Washington to support their Alzheimer’s planning or initiatives • Presenting at National Alzheimer’s Project Act and the AARP National Policy Forum • Showcasing ACT on Alzheimer’s tools and work at the Alzheimer’s Association International Conference and at Alzheimer’s Europe

Minnesota is becoming a national model of how a state prepares for the impacts of Alzheimer’s disease and creates a supportive environment for everyone touched by the disease. The health care sector can lead in this effort by incorporating ACT on Alzheimer’s tools and resources in all health care settings, by working within local communities to foster dementia friendliness, and by supporting future policies associated with this disease. Olivia Mastry, JD, MPH, is executive lead for ACT on Alzheimer’s. She has both a master’s degree in public health administration and a law degree from the University of Minnesota. Mastry previously served as vice president of the Center for Healthy Aging at Medica/Allina, and practiced health care law in private practice.

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. Currently we are seeking to add the following specialists: • General Surgery

• Obstetrics/Gynecology

• Radiation Oncology

• Family Practice

• Internal Medicine

• Ophthalmology

• Pediatrics 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

Avera Marshall Regional • Medical Center 300 S. Bruce St. • Marshall, MN 56258

www.averamarshall.org 34

Minnesota Physician May 2014

Opportunities for full-time and part-time staff are available in the following positions: • Dermatologist • Geriatrician/ Hospice/ Palliative Care • Internal Medicine/ Family Practice

• Medical DirectorExtended Care & Rehab (Geriatrics) • Psychiatrist

Applicants must be BE/BC.

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.

Competitive salary and benefits with recruitment/ relocation incentive and performance pay possible. For more information: Visit www.USAJobs.gov or contact Nola Mattson, STC.HR@VA.GOV Human Resources 4801 Veterans Drive, St. Cloud, MN 56303

(320) 255-6301

May 2014 Minnesota Physician

Finding the link from page 19

patients, and likely all patients with inflammatory autoimmune diseases. Measures of the inflammatory disease burden have not been fully incorporated into any ASCVD risk assessment tool, and likely are more complex than simply including a high-sensitivity C-reactive protein measurement, as is utilized in alternative ASCVD risk scoring methods (Reynold’s Risk Score). Based upon this understanding of the relationship between inflammation and rheumatic diseases activity, and the incomplete picture of ASCVD risk painted by traditional risk factors, an important goal for prevention and management of ASCVD risk is to control traditional risk factors aggressively, while actively treating the systemic inflammation of the rheumatologic condition. Due to a paucity of evidence-based data, however, it remains unclear how aggressively or by

which specific therapy patients with these systemic rheumatic diseases should be managed to best reduce these ASCVD risks. Cardio-rheumatology clinic Successful management of inflammatory rheumatic conditions requires a close collaboration between rheumatologist and cardiologist, given the interplay between the underlying rheumatic inflammatory condition and the burden/effect of traditional risk factors for ASCVD. Because this interplay is complex and not totally understood, the identification of this increased risk population and its prospective evaluation is critical. More systematic experience is needed to translate the basic immunologic science to the clinical decision-making in these patients. Directing these patients to a focused clinic will allow for more rigorous and uniform long-term follow-up and treatment.

Minnesota Physician May 2014

To this end, we have devel-

oped a Cardio-Rheumatology clinic as a subclinic of the Women’s Heart Clinic at the Mayo Clinic, with patients being referred primarily from rheumatologists. A compete risk assessment is performed that incorporates both traditional risk factors and more novel ones. Brachial artery reactivity, arterial tonometry, and carotid ultrasound are performed to address subclinical ASCVD. Medical therapy is used in those who are assessed to be at increased risk, since they would obtain the greatest benefit. In addition, there is a lower threshold for additional anatomic and functional cardiovascular testing (see Figure 1 on page 19). There is no disputing the fact that patients with rheumatologic diseases are at significantly increased risk of ASCVD. Inflammation and altered immunity are shared mechanistic features of both ASCVD and autoimmune disorders. Close collaboration across specialties

is vital to reduce the increased rates of morbidity and mortality in this unique patient population. Rekha Mankad, MD, FACC, is instructor of medicine, Division of Cardiovascular Disease at Mayo Clinic. She has recently established the Cardio-Rheumatology Clinic within the Women’s Heart Clinic to address the cardiovascular risks related to autoimmune diseases. Eric L. Matteson, MD, MPH, is professor of medicine and chair, Division of Rheumatology at Mayo Clinic. He has a joint appointment in the Division of Epidemiology in the Department of Health Sciences Research. Dr. Matteson’s clinical and research interests are in the fields of vasculitis and inflammatory arthritis. Sharon L. Mulvagh, MD, FACC, FAHA, FASE, FRCPC, is professor of medicine, Division of Cardiology at Mayo Clinic. She is the director of the Women’s Heart Clinic, and associate director of Preventive Cardiology. Her clinical and research interests are in novel noninvasive imaging techniques, with a focus on women and sex-based differences in cardiovascular disease.

Urgent Care We have part-time and on-call positions available at a variety of Twin Cities’ 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

Olmsted Medical Center, a 160-clincian multi-specialty clinic with 10 outlying branch clinics and a 61 bed hospital, continues to experience significant growth.

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Better care, fewer complications from page 15

demonstrated the effectiveness and safety required for both the European and U.S. markets. It can be implanted without fluoroscopy, using anatomical landmarks, unlike the T-ICD. In the largest clinical trial to date, the S-ICD performed very well. It achieved the primary safety (99 percent) and effectiveness end point for acute conversion of VF (100 percent if full testing protocol was used). Among spontaneous episodes of VT/VF seen subsequently in follow-up of 21 patients, 38 episodes were discrete episodes, and all were converted by the S-ICD system. In two additional patients, VT/VF storms were associated with 81 device episodes. All of the triggering arrhythmias were treated successfully, except one in which the ER team shocked the patient externally while the S-ICD was charging. There were no known arrhythmic deaths in

this study. A chronic conversion substudy demonstrated very high success rates with the 65J shock, with all patients successfully converted by the device with the 80J shock. The S-ICD uses a proprietary algorithm to detect changes in ventricular rate, using a modified sub-surface ECG via one of three vectors recorded between the device generator and two lead coils. The optimal sensing uses an R to T wave ratio that avoids double QRS or T wave over-sensing. A rolling average of four consecutive intervals is used to recognize VT/VF. When 18 of 24 consecutive sensed ventricular events exceed a predetermined detection zone limit, the device charges, delivering a biphasic waveform defibrillating pulse to a maximum of 80J. Early on, with the larger size of the S-ICD generator, there were several infections requiring explantation of the system, but with improved technique and experience, the rate

of device infections dropped substantially. In that large S-ICD trial, the rate of inappropriate shocks was 13.1 percent. If arrhythmias discrimination was used—in other words, rate plus discriminators—inappropriate shocks were significantly reduced. The overall rate of inappropriate shocks seen to date with the S-ICD is comparable to that seen with T-ICDs. The mean time to therapy, or the delivery of converting shocks with the S-ICD system, ranged from 9.6 to 29.7 seconds. This is certainly longer than that achieved with T-ICD systems. However, recent studies point out that delaying therapy can actually reduce the frequency of required therapy, because patients may convert them on their own. Current T-ICD therapy algorithms include longer therapy delay times, to avoid delivery of shocks to arrhythmias that would terminate spontaneously. Notably, in

the S-ICD study, no reports of syncope were associated with the detection and treatment algorithms used. The S-ICD system has been demonstrated to be a safe and effective ICD system in the treatment of patients at risk for serious life-threatening ventricular arrhythmias. The lack of venous access requirement makes this device very attractive in patients with venous occlusions, as well as circumstances in which a high device lead infection rate might be anticipated, such as patients on hemodialysis. Notably, this is the first-generation S-ICD device, and further improvements are anticipated. This includes the ability to remotely interrogate these devices, similar to that which has been done with T-ICD devices. Charles C. Gornick, MD, FHRS, FACC, is director of the Cardiac Arrhythmia Service at the Minneapolis Heart Institute at Abbott Northwestern Hospital, part of Allina Health.

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Minnesota Physician May 2014

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