Minnesota Physician March 2018 by Minnesota Physician Publishing

MINNESOTA

MARCH 2018

PHYSICIAN

THE INDEPENDENT MEDICAL BUSINESS JOURNAL

Volume XXXI, No. 12

The Annual Wellness Visit Understanding the benefit and preventing denials BY MICHAEL J. DORRIS; CAROLYN S. HENSON, CPC, CAC; AND NATHAN L. KENNEDY, JR., CPC, CHC

oney, does Medicare pay for an annual physical?” asked one Minnesota patient. “I don’t know,” his spouse replies. “Call the doctor’s office.” “Hello, I need to schedule an annual physical and I am on Medicare. Next Tuesday at 9:00 a.m.? Great, see you then!”

Opioid prescribing Managing the risk

What’s wrong with this scenario? Medicare does not cover an annual physical exam. Since the rollout of the new preventive service called the Annual Wellness Visit (AWV) in 2011, the terminology of “yearly physical” and “Annual Wellness Visit” are being used interchangeably by providers, beneficiaries, and medical professionals alike—but they shouldn’t be. These services may be similar, but are altogether different resulting in unnecessary cost to you and the Medicare beneficiary on Original Medicare Fee-for-Service (FFS). AWV can help our seniors stay healthy. The Annual Wellness Visit to page 124

BY ANN FIALA, RN, BSN, CPHRM, CHC

pioid prescribing has become a risky business. According to an analysis of the National Practitioner Data Bank by Tony Yang, an associate professor of health administration and policy at George Mason University, “the number of doctors penalized by the U.S. Drug Enforcement Administration (DEA) has grown more than fivefold in recent years. The agency took action against 88 doctors in 2011 and 479 in 2016.” In addition to DEA penalties, both criminal and civil charges are being filed against physicians for patient deaths related to opioid overdose. And while many of these cases were the result of blatant breaches of the standard of care, well-meaning physicians are also contributing to the crisis by prescribing opioids in an indiscriminate manner. Opioid prescribing to page 104

STAY FOCUSED AMONG THE DISTRACTIONS.

Minimize the things that get in the way of why you’re in healthcare to begin with. A focus on reducing lawsuits is just one way we do this. For more information or your nearest agent, contact us at 800.225.6168 or through coverys.com. M E D I C A L P R O F E S S I O N A L L I A B I L I T Y I N S U R A N C E  A N A LY T I C S  R I S K M A N A G E M E N T  E D U C A T I O N

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MARCH 2018 MINNESOTA PHYSICIAN

TH 49 SESSION MARCH 2018

THE OPIOID EPIDEMIC:

Volume XXXI, Number 12

COVER FEATURES Opioid prescribing Managing the risk

By Ann Fiala, RN, BSN, CPHRM, CHC

Complex problems, complex solutions

The Annual Wellness Visit Understanding the benefit and preventing denials

By Michael J. Dorris; Carolyn S. Henson, CPC, CAC; and Nathan L. Kennedy, Jr., CPC, CHC

Thursday, April 26th, 2018, 1-4 pm The Gallery, Downtown Minneapolis Hilton and Towers BACKGROUND AND FOCUS:

DEPARTMENTS CAPSULES

MEDICUS

INTERVIEW

A robust measurement system

Julie Sonier, MPA MN Community Measurement

OTOLARYNGOLOGY Endoscopic ear surgery

A new frontier By Manuela Fina, MD

WOMEN’S HEALTH Endometriosis

CARDIOLOGY The Watchman device

A new treatment for atrial fibrillation By Ganesh Raveendran, MD, MS, and Quan Pham, MD

RESEARCH 28 Somali Americans’ health Change and “the healthy immigrant effect” By Bjorn Westgard, MD

Improving the path to better patient outcomes By Matthew Palmer, DO

Medicine is a field that changes slowly, but in the case of prescribing opioid-based pain medications, the speed of change was unprecedented. It has produced tragic outcomes. Two examples are the number of Americans now suffering from opioid-related substance abuse disorder (over 2 million) and the number of opioid-related deaths (over 50,000 annually, and growing). We are facing a complex problem, created by conflicting industry incentives and one that will demand unified stakeholder participation to solve.

OBJECTIVES: We will examine how the opioid epidemic began. We will discuss the elements of mistrust, blame, and miscommunication within the health care delivery system that were responsible for the staggering levels of destruction we face today. Meeting every definition of an epidemic, we will look at how this issue reaches into all parts of society. We will lay out a strategy that can address the central problems in bringing the opioid epidemic under control.

Panelists include:

Sponsors include:

Karina A. Forrest-Perkins, MHR, LADC

Center for Diagnostic Imaging

Chief Executive Officer, Wayside Recovery Center

Todd Ginkel, DC

Director of Clinical Affairs, Physicians’ Diagnostics & Rehabilitation Clinics

PROFESSIONAL UPDATE: PAIN MEDICINE

Ashwin George, MD, MBA

CEO, Valley Pain Relief and Wellness Center

Previously addicted patients

The challenge of treating their pain By Anne Pylkas, MD

Beth Gomez, RN, BSN, JD

Laura Palombi, PharmD, MPH Assistant Professor, U of M College of Pharmacy

Physicians’ Diagnostics & Rehabilitation Clinics U of M College of Pharmacy

Chief Medical Officer, UCare

2018 COMMUNITY CAREGIVERS

Minnesota Department of Human Services

UCare

Manager, Risk Management, Coverys

Larry Lee, MD

Recognizing Minnesota’s Volunteer Physicians

Coverys

Valley Pain Relief and Wellness Center Wayside Recovery Center

Jeff Schiff, MD, MBA

By Lisa McGowan

Medical Director, Minnesota Health Care Programs, DHS

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Minnesota Physician is published once a month by Minnesota Physician Publishing, Inc. Our address is 2812 East 26th Street, Minneapolis, MN 55406; email mpp@mppub.com; phone 612.728.8600; fax 612.728.8601. 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

Study Shows Opioids Not Superior for Chronic Pain Relief A year-long study conducted by researchers at the Minneapolis VA has shown strong evidence against using prescription opioids to treat chronic pain. The objective of the study was to compare opioid versus nonopioid medications over 12 months based on three factors—pain-related function, pain intensity, and adverse effects. There were 240 participants recruited from Veterans Affairs primary care clinics from June 2013 through December 2015, and follow-up with these patients was completed December 2016. Eligible patients had moderate to severe chronic back pain or hip or knee osteoarthritis pain despite analgesic use. Each participant was randomly assigned to use either generic versions of opioids or nonopioids for 12 months. Opioids tested included generic Vicodin, oxycodone, and

fentanyl patches, and nonopioids included acetaminophen, ibuprofen, and prescription pills for nerve or muscle pain. The results show that overall, there was no significant difference in mean pain-related function over 12 months between the two groups, and nonopioid patients actually reported a slightly better score. In addition, pain intensity was shown to be significantly better for the nonopioid group and adverse medication-related symptoms were significantly more common in the opioid group. The authors note that the results support federal guidelines implemented in 2016 that say opioids are not the preferred treatment for chronic pain and that non-drug treatment or nonopioid painkillers should be used instead. It states that opioids should only be used if other methods haven’t worked. The full study is published in the March 6, 2018, issue of the Journal of the American Medical Association (JAMA).

Hennepin Healthcare Medical Cannabis Reduces Implements Name Change Pain, Opioid Use for Hennepin Healthcare is the new Minnesota Patients name for the integrated system that includes Hennepin County Medical Center (HCMC); MVNA home care; Hospice of the Twin Cities; the Advantage and Horizon care networks; Upstream Health Innovation; Hennepin Health Foundation; Hennepin EMS; the Minnesota Poison Control System; multiple clinics and pharmacies in the metro area; and a new, 377,000-squarefoot Clinic & Specialty Center that will open in downtown Minneapolis in late March. The parent organization’s name change does not affect the name of HCMC, despite an effort to change the hospital’s name in late 2016. It does include a new website (hennepinhealthcare.org) and an updated logo. The system is operated by Hennepin Healthcare System, Inc., a subsidiary corporation of Hennepin County.

A study from the Minnesota Department of Health has shown that for a significant number of patients, medical cannabis reduces pain levels and use of other pain medications, including opioids. The results show that 42 percent of Minnesota patients taking medical cannabis for intractable pain reported a pain reduction of 30 percent or more. Patients also reported improvements related to sleep and reduced anxiety. This study is the first of its kind in the state and is based on the experiences of the initial 2,245 people enrolled for intractable pain in Minnesota’s medical cannabis program from Aug. 1, 2016, to Dec. 31, 2016. Of that group, 2,174 patients purchased medical cannabis within the study’s observation period and completed a required self-evaluation before each purchase. The self-evaluation includes a screening tool called PEG, which

V PTSD is now an approved condition V

HAVE YOU REGISTERED WITH THE MINNESOTA MEDICAL CANNABIS PROGRAM? Registration can be done online; there is no fee and it takes only a few minutes. Visit the registry website: mn.gov/medicalcannabis Your account will provide access to medical cannabis purchasing information from patients you certify. Once you are registered, you will be able to certify patients with a variety of conditions, including: • Cancer, Glaucoma, Tourette Syndrome, HIV/AIDS, and ALS

• Inflammatory bowel disease, including Crohn’s disease

• Seizures, including those characteristic of Epilepsy

• Terminal illness, with a probable life expectancy of less than one year • Intractable Pain • Post-Traumatic Stress Disorder

• Severe and persistent muscle spasms, including those characteristic of MS

Cannabis Patient Centers are now open to approved patients in Minneapolis, Eagan, Rochester, St. Cloud, Moorhead, Bloomington, Hibbing, and St. Paul.

OFFICE OF MEDICAL CANNABIS

(651) 201-5598: Metro (844) 879-3381: Non-metro P.O. Box 64882, St. Paul, MN 55164-0882 health.cannabis@state.mn.us

MARCH 2018 MINNESOTA PHYSICIAN

Many patients have reported improvement in their health status from medical cannabis — some describing dramatic improvements. Smoking cannabis is not allowed under the program. Visit our website for educational resources about cannabinoids and the endocannabinoid system and for scientific literature on the efficacy of medical cannabis in treating certain conditions.

See our website for a detailed first year report. mn.gov/medicalcannabis

CAPSULES

stands for pain, enjoyment, and general activity. Patients rate their pain level, how the pain interfered with their enjoyment of life, and how pain interfered with their general activity—all on a scale of zero to 10. Using this data, the results showed that 42 percent of the patients who scored moderate to high levels of pain at the beginning of the measurement achieved a reduction in pain score of 30 percent or more. In addition, 22 percent of these patients achieved and maintained a reduction of 30 percent for more than four months. Health care providers who care for these patients also reported similar reductions in pain scores, saying that 41 percent of patients achieved a reduction of 30 percent or more. Reaching a 30 percent reduction threshold is often considered a clinically meaningful improvement in pain studies. “This study helps improve our understanding of the potential of medical cannabis for treating pain,” said Jan Malcolm, Minnesota commissioner of health. “We need additional and more rigorous study, but these results are clinically significant and promising for both pain treatment and reducing opioid dependence.” The results also showed that of the 353 patients who self-reported taking opioids when they began using medical cannabis, 63 percent (221 patients) reduced or eliminated opioid use within six months. The health care practitioner survey also showed that 58 percent of patients who were on other pain medications, including opioids and benzodiazepines, were able to reduce their use when they began using medical cannabis. No serious adverse events (those that are life threatening or require hospitalization) were reported during the observation period. However, about 40 percent of patients reported adverse side effects and of those, about 90 percent said they were mild to moderate. Common adverse effects reported include dry mouth, drowsiness, fatigue, and mental clouding. And 55 patients reported severe adverse side effects, meaning ones that interrupted their usual daily activities.

“These survey results are a good starting point,” said Tom Arneson, research manager for the office of medical cannabis. “We need more research into the potential value of medical cannabis in pain management, especially as our communities grapple with the harmful impacts of opioids and other medications now in use for that purpose. We encourage health care providers to read the full report as they consider whether medical cannabis should be part of their strategies for treating patients’ intractable pain.”

HealthPartners to Use Pharmacists to Improve Chronic Disease Outcomes HealthPartners Institute has received a $3.5 million grant from the National Heart, Lung, and Blood Institute to improve chronic disease outcomes and reduce costs by integrating retail pharmacists as part of the care team. According to the institute, more than 50 percent of adults treated for diabetes, hypertension, or lipid disorders don’t have an ideal track record of taking their medications. This project uses a clinical decision support tool to identify patients with issues taking their medications and applies a team approach to helping them achieve goals for glucose, blood pressure, or lipids. Through the intervention initiative, pharmacists will reach out to patients to review and discuss any questions or problems related to their medications. The pharmacist and provider care will be coordinated through electronic communication, and the pharmacists’ assessments and recommendations will be incorporated into patients’ visits with their primary care provider. “If this project is successful, it will expand the relationship between providers, pharmacists, and patients beyond the current norms of prescription fill/refills,” said JoAnn Sperl-Hillen, MD, principal investigator at HealthPartners Institute. The impact will be evaluated by examining data from eligible patients seen at 20 HealthPartners primary

REQUEST FOR NOMINATION Publication Date: June 2018 NOMINATION CLOSING May 4, 2018

Seeking Exceptionally Designed Health Facilities in Minnesota Minnesota Physician announces our annual Health Care Architecture & Design Honor Roll. We are seeking nominations of exceptionally designed health care facilities in Minnesota. The nominees selected for the honor roll will be featured in the June 2018 edition of Minnesota Physician, the region’s most widely read medical publication. Eligible facilities include any construction designed for patient care: hospitals, individual physician offices, clinics, outpatient centers, etc. Interiors, exteriors, expansions, renovations, and new structures are all eligible. In order to qualify for the nomination, the facility must have been designed, built, or renovated by January 1, 2018. It also must be located within Minnesota (or near the state border within Wisconsin, North Dakota, South Dakota, or Iowa). Color photographs are required at 300 dpi resolution (no more than eight) with a caption for each. If you would like to nominate a facility, please fill out the form below and, a brief project description (150– 250 words) or fill out the form on our website by Friday, May 4, 2018. Online form: www.mppub.com/architecture-and-design-honor-roll.html

Health Care Architecture & Design Honor Roll Nomination Form Facility name Type of facility Location Ownership organization Owner address, phone Architect/interior design firm Architect address, phone Engineer Contractor Completion date Square feet Total cost Brief description

Send to: Minnesota Physician Publishing Honor Roll 2812 East 26th Street, Minneapolis, MN 55406 Fax: 612.728.8601 Email: comments@mppub.com For more information, call 612.728.8600

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MINNESOTA PHYSICIAN MARCH 2018

CAPSULES

care clinics, 10 of which will be randomized. If the intervention is shown to be successful, HealthPartners says it has the potential to become a new model of care that could benefit patients living with chronic diseases.

Kidney Stones Becoming More Prevalent The incidence of kidney stones is on the rise, especially among women, according to results of a study from Mayo Clinic. Researchers used data from the Rochester Epidemiology Project to investigate the increase to determine if it is a new trend, or due to an improvement in the way kidney stones are detected. They examined first-time presenters of kidney stones in residents of Olmsted County between 1984 and 2012, focusing on gender, age, and stone formation. Their findings showed that symptomatic stone formers tended to be female, with the highest increase between women ages 18 to 39.

In addition, they found that bladder stones were less frequent and tended to be more noticeable in men due to prostatic obstructions. Women had a higher frequency of infection stones as a result of recurrent urinary tract infections. “Symptomatic kidney stones are becoming more common in both men and women,” said Andrew Rule, MD, lead investigator of the study. “This is due in part to the increased use of CT scans to diagnose kidney stones.” Advances in imaging technology have allowed researchers to better examine and classify stone formation in patients than they have in the past, according to Rule. “We are now diagnosing symptomatic kidney stones that previously would have gone undiagnosed because they would not have been detected,” he said. Rule notes that further research is needed to clarify the findings. In addition to the advances in diagnostic capabilities having an effect on kidney stone diagnoses, the data studied was from a largely Caucasian

MARCH 2018 MINNESOTA PHYSICIAN

area, and this population has a greater tendency toward kidney stones compared to other racial groups.

Lakewood and Children’s Partner on Virtual Care for Pediatric ER Patients Pediatric patients at Lakewood Health System now have access to virtual health services from Children’s Minnesota through a new agreement between the health care systems. “The bottom line is that this partnership will allow more of our patients to get the care they need without the cost and time of traveling to the Twin Cities,” said Kimberly Bryniarski, quality improvement manager at Lakewood. “In fact, about half the patients who were sent to Children’s Minnesota in 2016 could have stayed in Lakewood if the virtual partnership had been an available resource.” Through the partnership, emergency department physicians at Lakewood’s main campus in Staples have 24/7 access to pediatric specialists at

Children’s using audio/video technology. Lakewood emergency department physicians will place a call to Children’s when they deem it appropriate, and a pediatric emergency medicine physician at Children’s will connect via video conference. Conditions that may require this virtual consultation include an unidentifiable rash, pneumonia-like symptoms, an allergic reaction, or a mild trauma case. “The ability of the Children’s Minnesota physician to see the patient is very important,” said Bryniarski. “It helps determine whether the child should be sent down to Children’s or whether Lakewood should try a course of treatment first. And if the patient ultimately needs to be admitted to Children’s, the registration process will be faster because Lakewood will have shared the required registration information with Children’s.” Lakewood is Children’s first virtual partner in north-central Minnesota. They hope to explore expanding the partnership to other departments in the future.

Charles Lazarus

Osmo Vänskä

Bertha E. Toriz, MD, of Minnesota Gastro enterology, has received the Distinguished Clinician Award from the American Gastroenterological Association for her achievements in the specialty. The award is given to a physician who combines the art of medicine with the skills demanded by the scientific body of knowledge in service of their patients. A recipient is chosen from both private practice and clinical academic practice—Toriz received the private practice award. Her clinical experience has centered on inflammatory bowel disease, celiac disease, hepatology, esophageal disorders, pelvic floor dysfunction, and general gastroenterology. She earned her medical degree at the University of Iowa Carver College of Medicine.

Charles Ryan, MD, will step into the role of director of the hematology, oncology, and transplantation division at the University of Minnesota Medical School, effective April 2018. He will also serve as associate director for clinical research in the Masonic Cancer Center and hold the B.J. Kennedy Chair in Clinical Medical Oncology. Ryan is currently a professor of clinical medicine and urology at the University of California, San Francisco; a Thomas Perkins Distinguished Professor in Cancer Research; and the associate director for clinical science at the Helen Diller Family Comprehensive Cancer Center. He is recognized for his research on prostate cancer, and his studies have revealed information on the roles of androgens and the androgen receptor in castration-resistant prostate cancer. Ryan earned his medical degree from the University of Wisconsin.

Susie Park

Sharon Bezaly

Louis Lortie

The King’s Singers

Cameron Carpenter

Jason Kallestad, MD, has been named the new medical director of Ridgeview Hospice. He also serves as the medical director of Ridgeview’s palliative care program. In addition to practicing inpatient and outpatient palliative medicine since 2011, Kallestad was an assistant professor of medicine at the University of Minnesota from 2011 to 2016 and co-chair of the Fairview Southdale Hospital Ethics Committee from 2013 to 2016. He earned his medical degree at the University of Minnesota School of Medicine. Robert Tuttle, MD, has been named medical director of the Allina Health Orthopedic clinical service line, a role in which he is responsible for the system-wide medical and surgical management of orthopedic disorders. He specializes in hip and knee replacement and complex hip and knee replacement revision and, along with his new responsibilities, Tuttle will continue his surgical practice at Abbott Northwestern Hospital and join the Sports & Orthopaedic Specialists team full-time. He earned his medical degree at Chicago Medical School.

The Steeles

MEDICUS

Our Love is Here to Stay

Charles Lazarus and The Steeles

with the Minnesota Orchestra Apr 6

Sarah Hicks, conductor / Charles Lazarus, trumpet / The Steeles, vocalists

Wagner, Liszt and Schumann Apr 13-14

Markus Stenz, conductor / Louis Lortie, piano

The King’s Singers GOLD Apr 15

Please note: The Minnesota Orchestra does not perform on this program.

Cameron Carpenter Plays Rachmaninoff

Apr 20-21

Klaus Mäkelä, conductor / Cameron Carpenter, organ

American Voices

Copland and Bernstein May 3-5

Osmo Vänskä, conductor / Sharon Bezaly, flute / Susie Park, violin

612-371-5656 / Orchestra Hall minnesotaorchestra.org PHOTOS Anders Krison (Bezaly). Additional credits available online.

Media partner:

MINNESOTA PHYSICIAN MARCH 2018

INTERVIEW

A robust measurement system Julie Sonier, MPA MN Community Measurement MN Community Measurement (MNCM) collects and publishes data on health care quality, cost, and patient experience. Why is this important?

These three areas correspond to the Institute of Medicine’s Triple Aim framework. Quality, cost, and patient experience are interdependent, and there is plenty of room for improvement in our health care system for each dimension. Without measurement, we wouldn’t know where our biggest gaps are or where to focus resources for improvement. MNCM’s goal is to empower the community with data to identify improvement opportunities and assess progress. We publish metrics at the statewide level and the medical group or clinic level. When MNCM first started publishing data, many were surprised by the amount of variation across providers on the measures. While variation and room for improvement overall still exist, increased transparency has focused attention on the gaps and spurred progress.

Can you share your thoughts on the Quality Incentive Payment System (QIPS) and the impact of “pay-for-performance” incentives?

The basic goal of QIPS and other pay-forperformance incentives that explicitly incorporate quality incentives into the way that providers are paid is good. However, there are significant drawbacks to this approach. Financial incentives in QIPS and the

In addition to information publicly available on www.mnhealthscores.org and in the reports we publish, MNCM has a set of tools providers use to analyze their own results over time and see how their results compare to those of other providers. Many provider organizations focus quality improvement efforts on measures that MNCM collects and publishes. Information about these quality improvement projects tends to be anecdotal, but we’re always interested in hearing from provider organizations about how they are using the data and how MNCM can better support these efforts.

MARCH 2018 MINNESOTA PHYSICIAN

“...” measurement, Without we wouldn’t know where our biggest gaps are. “...”

What tools does MNCM offer for providers and how are they used?

What can you tell us about your Patient Reported Outcomes Measures (PROM)?

MNCM is a national leader in developing and implementing quality measures that use PROMs. We currently collect and report PROMs for depression, asthma, spine surgery, and knee replacement surgery. PROMs are important because they tell us about the outcomes of care from the patient’s perspective—not just whether certain tests were done or lab values were in a certain range. At the national level, CMS is prioritizing the use of outcome measures and PROMs in particular, so we expect this type of measurement to grow. How do you respond to concerns about social risk factors that affect measurement but are outside of a physician’s control?

Please tell us about the value of multiple stakeholder participation in health care data collection and analysis.

Multi-stakeholder participation and collaboration are critically important to who we are and everything we do. MNCM’s ability to engage diverse perspectives has always been a key strength. Our board of directors includes representation from clinicians, hospitals, health plans, employers, consumers, and state government; the same is true for committees and workgroups that make recommendations on measure development, public reporting, and risk adjustment.

as a nation, we still have a lot to learn about what works and what doesn’t in payment reform, but it’s clear that good data and measurement are key to success in these types of arrangements.

related Bridges to Excellence (BTE) program were never large enough to make a significant difference; they lacked a “critical mass” of purchasers involved to have a big impact. Also, as long as pay-forperformance initiatives are layered on top of our deeply flawed fee-for-service system, we’re not going to see the kinds of improvements that we want. When QIPS was enacted, it was viewed as a first step toward a system that would be fundamentally different—with accountability for cost and quality. Ten years later, the landscape has certainly changed and we see a lot of payers and providers entering into contracts that involve accountability and financial risk for cost and/or quality. As a state and

We know that many social factors influence patient outcomes independently of what happens at the medical clinic, so it’s important to account for differences in patient populations across providers. MNCM does segmented analysis by risk factor and also calculates risk-adjusted rates that take variations in patient characteristics into account. This year, we are modifying our risk adjustment methodology to account for socioeconomic factors at the ZIP code level.

While there currently is no perfect solution, it’s crucial we keep working on this problem together and directly address variations in outcomes for different patient populations. There are many examples of providers addressing social risk factors in innovative ways—reaching beyond the walls of the clinic to do so. Payers are starting to recognize that patients with high social complexity are more difficult to care for, and are beginning to incorporate social risk factors into their payment methodologies. How is the trend toward consolidation in health care affecting costs and quality? Is it helping or hurting?

The trend toward increased market consolidation that we’ve seen at the provider level for many years now has the potential for both positive and negative effects. Certainly, providers may be more successful

at negotiating higher payment rates after a merger than before. However, operating at a larger scale might also make it easier to invest in the kinds of infrastructure and data systems that support better population health management—and can ultimately improve quality and contain cost. If you look at MNCM data, you’ll see a lot of variation in cost and quality that doesn’t seem to have anything to do with a provider’s size—we see both small and large providers who have achieved high quality and low cost. Consolidation itself isn’t necessarily going to make things better or worse, but it’s one more reason why the transparency MNCM brings to these issues is important. What are some of the most common misperceptions about MNCM?

MNCM is an independent nonprofit organization with governance from stakeholders across the system. Our role as a vendor for the Statewide Quality Reporting and Measurement System (SQRMS) leads to people sometimes confusing us with the state. We aren’t regulators; in fact, we rely very heavily on a multi-stakeholder consensus-based process to make decisions about what we do and how we do it. We use this same process to make recommendations to the state about SQRMS.

“The Hub helped me get back on Social Security so that I could pay my bills while I continue to work on my health.”

Separately, I think the depth and richness of the data MNCM has is underappreciated. When I talk to people in other states, they are always in awe of the measurement and reporting we have in Minnesota. The data we have on variations by race, ethnicity, language, and country of origin are a particularly unique and valuable resource. What are the biggest challenges you face moving forward?

Two of the biggest challenges related to measurement are burden and alignment. It’s important to consider the value of a measure compared to how difficult it is to calculate—some measures are easy to calculate but not very useful, while others have a lot of value but more provider burden. We have an exciting project underway that we hope will ultimately reduce the burden for measures providers currently submit to MNCM. Alignment is also a challenge. This has really come to the forefront with Medicare’s implementation of the Quality Payment Program (QPP). We are making progress toward having MNCM measures included in federal programs, which will benefit Minnesota providers. MNCM can also submit data to QPP on behalf of providers who choose that option.

What would you like physicians to know about MN Community Measurement?

I’d like physicians to know how important and valuable their ongoing commitment to quality improvement is. Minnesota has benefited tremendously from the fact that all of the stakeholders in the health care system have been able to collaborate to build the robust measurement system that we have today. As we look to the future, MNCM is thinking about how we can build on this history to make data and measurement less burdensome, but also more timely and actionable. Input from physicians has always been a priority, and we will be actively consulting with the physician community on future work. Julie Sonier, MPA, is president of Minnesota Community Measurement. She has over 20 years of experience working on initiatives to improve health care cost, quality, and access. Her past experience includes directing health care purchasing for Minnesota state employees, serving as Minnesota’s state health economist, and working with states across the nation on health care reform initiatives.

Resources, tools, solutions. With Disability Hub MN, you can put an essential resource directly in your patients’ hands. From explaining health coverage options to submitting medical benefit applications, Hub experts are uniquely positioned to support people with disabilities.

MINNESOTA PHYSICIAN MARCH 2018 9

3Opioid prescribing from cover

overdoses are continuing to “get worse” in the state. Recognizing that more needed to be done to curb this trend, Minnesota passed Session Law, Chapter 124 in 2016, which increases the availability of naloxone, an opioid reversal agent, throughout the state. Physicians can now work with pharmacists to prescribe naloxone to those who are at risk for opioid overdose, and may do so without being subject to civil liability or criminal prosecution. Additionally, community health boards may designate a prescriber of record for that community to work with local pharmacies to assist family members and civil charges are first responders.

Balancing the duty to care for patients who have legitimate pain and following the “do no harm” creed of the Hippocratic Oath can be challenging for health care providers. In recent years, numerous opioid prescribing recommendations have been published to help physicians and licensed independent practitioners navigate the risks of prescribing opioids. Minnesota now has additional resources. As stated on the Minnesota Department of Health Criminal and (MDH) website, “In 2014, Minnesota was chosen being filed against physicians to be one of six states to participate in the National for patient deaths related Governors Association (NGA) prescription drug to opioid overdose. abuse academy. A Minnesota State Substance Abuse Strategy (SSAS) frame was proposed to develop a robust approach to prevent opioid use disorder and reduce access to prescription pain medications throughout Minnesota.” Minnesota has taken a three-pronged approach to mitigating the risk of pain management and opioid addiction. The components include 1) emergency response; 2) intervention and treatment; and 3) primary prevention and public health.

Emergency response Considered a “tertiary prevention,” emergency response is meant to save lives. According to the MDH Opioid Dashboard, deaths and nonfatal

Consider the following risk mitigation strategies to reduce the likelihood of overdose deaths when prescribing opioids:

• Know your patient’s history. Mental illness, previous overdoses, addiction history, sleep apnea, and chronic medical conditions (kidney failure, respiratory compromise, liver disease) may increase the propensity for overdose.

• Prescribe the lowest effective dose. This recommendation applies to patients who are prescribed opioids for the first time, as well as those who have been treated with opioids in the past. With new patients, the higher the dose, the greater the risk of chronic use. Patients who have taken opioids in the past may not recognize that they do not need a dose as high as they have taken previously and may take too much. • Do not prescribe long-acting opioids. Patients who are prescribed long-acting opioids are at double the risk of overdose than those who are on the short-acting form. • Consider co-prescribing naloxone to patients at an elevated risk of opioid overdose. This can be especially important if the patients are taking high doses, have chronic conditions that affect opiate metabolism, or have a history of past abuse.

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• Educate patients and family members regarding the risks and signs of overdose, as well as the appropriate response. It is crucially important for patients and their family members to be aware of the inherent risks associated with opioids. A sample pain management agreement is available at: http:// pmp.pharmacy.state.mn.us /assets /f iles /PDFs /Sample%20Pain%20 Management%20Contract.pdf.

Intervention and treatment A secondary approach—intervention and treatment—involves caring for those who have already been harmed by opioid addiction. Minnesota has performed a population data assessment regarding substance abuse and opioid addiction. As detailed in Minnesota State Targeted Response to the Opioid Crisis, significant disparities in drug poisoning deaths were found to exist among American Indian/Alaska Natives and African Americans as compared to Whites. Accordingly, state strategies focused on the following targeted populations: American Indians, African Americans, women/pregnant mothers, and infants with neonatal abstinence syndrome. Legislation has been proposed to increase access to treatment, assessment, care coordination, and peer support for high-risk populations in Minnesota.

Consider the following recommendations to identify and treat opioid addiction:

• Screen patients for early identification and intervention. Have patients complete a brief validated survey to evaluate past use and refer high-scoring patients to a specialist. The Substance Abuse and Mental Health Services Administration (SAMHSA) has several tools, available at: https://www. integration.samhsa.gov/clinical-practice/ screening-tools#drugs. • Know your community-based treatment options. By staying aware of the treatment and recovery services in your area, primary care providers can refer substance abuse patients and thereby possibly improve recovery rates.

Minnesota convened the Minnesota Opioid Prescribing Work Group (OPWG) and published a draft set of guidelines in November 2017. The guidelines are a framework for opioid prescribing practices to help prevent chronic use and abuse. A panel of experts developed the guidelines by referencing existing recommendations at both the state and national levels. The guidelines are intended for both primary and specialty outpatient providers. Here are the primary principles from the Minnesota OPWG draft guidelines:

Primary care is on the front line of a battle that has taken many lives.

• Stay up to date with medication-assisted therapy access and information. In some cases, abstinence and therapy alone are not sufficient to successfully treat opioid dependence. Staying up to date regarding medication treatments, and knowing which providers specialize in them, will provide additional options to patients who continue to struggle with addiction.

Primary prevention and public health

1. Prescribe the lowest effective dose and duration of opioid analgesia when an opioid [is] indicated for acute pain. Clinicians should reduce variation in opioid prescribing for acute pain.

2. The post-acute pain period—up to 45 days following an acute event—is the critical timeframe to halt the progression to chronic opioid use. Clinicians should increase assessment of the biopsychosocial factors associated with opioid-related harm and chronic opioid use during this period. 3. Chronic Pain: The evidence to support chronic opioid analgesic therapy for chronic pain is insufficient at this time, but the evidence of harm is clear. Providers should avoid initiating chronic opioid therapy

Primary prevention is focused on understanding the origin of opioid addiction and stopping it before it becomes a public health issue.

Opioid prescribing to page 384

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3The Annual Wellness Visit from cover

• Detection of cognitive impairments • Review of functional ability and level of safety

How the AWV works

• Hearing After your Medicare patients on Original Medicare FFS have been on • Ability to successfully perform activities of daily living (walking, Medicare Part B for longer than 12 months, they eating, etc.) can get an AWV (G0438) to develop or create a prevention plan. Medicare covers one yearly • Fall risk AWV visit every 12 months. There’s no need • Home safety for the Medicare patient to get the “Welcome to Once these services are completed, the Medicare” preventive visit (G0402) before getting Minnesota reimbursement based Medicare patient will also get a brief written plan, a yearly AWV. If your Medicare patients received on the Medicare fee schedule is similar to a checklist, letting them know which the “Welcome to Medicare” preventive visit, rather healthy at $171 per visit. screenings and other preventive services they’ll they’ll have to wait 12 months before they can get need over the next five to 10 years based on 1) the first yearly AWV as outlined in Table 1. personalized health advice; 2) referrals for health Medicare covers the AWV at no cost to your education and preventive counseling to help them Medicare patients, if the Medicare physician stay well; and 3) a written screening schedule. accepts the assignment. The Minnesota reimbursement based on the Subsequent yearly AWVs providing personalized prevention plan services Medicare fee schedule is rather healthy at $171 per visit. The AWV is not a (PPPS) include: routine physical check-up. The initial AWV includes the following for patients:

• Updates to the patient’s medical/family history

• Personalized prevention plan

• Measurements of weight (or waist circumference), blood pressure, and other routine measurements as deemed appropriate, based on medical and family history

• Health risk assessment • Blood pressure, height, and weight measurements • Review of potential risk factors for depression

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• Updates to the list of current medical providers and suppliers that are regularly involved in the patient’s medical care, as developed at the first yearly AWV • Detection of any cognitive impairment updates to the patient’s written screening schedule as developed at the first yearly AWV • Updates to your list of risk factors and conditions for which primary, secondary, or tertiary interventions are recommended or are underway, as developed at the patient’s first yearly AWV • Discussion of personalized health advice and a referral, as appropriate, to health education or preventive counseling services or programs • An updated health risk assessment It’s important to note Medicare pays for only the first AWV per beneficiary per lifetime and pays for one subsequent AWV per year thereafter. There is no Part B deductible or coinsurance.

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Period of eligibility:

Year 1

Year 2

Year 3 and after

Medicare benefit:

“Welcome to Medicare”

Initial Annual Wellness Visit

Subsequent Annual Wellness Visit

Billing code:

(first 12 months)

Initial Preventive Physical Exam (IPPE)

G0402

(first 12 months)

(AWV)

G0438

Table 1. Annual wellness eligibility. Source: National Government Services–A CMS Contractor Agent

MARCH 2018 MINNESOTA PHYSICIAN

(third 12 months and each 12month period following AWV)

G0439

If a patient needs more than AWV coverage: • Other Medicare services can be added during these AWV visits. • Separate evaluation and management services can be provided and billed at the same visit as the Welcome to Medicare or AWV, provided the services are significant, separately identifiable, and medically necessary to treat the beneficiary’s illness or injury. • The Welcome to Medicare and AWV are free; other services that Medicare pays for may be subject to deductible and copay/ coinsurance requirements.

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Nursing Facility

Home

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State or Local Public Clinic

Urgent Care

Preventing denials Now that you understand the AWV benefits, let’s explore what Minnesota physicians can do to prevent AWV denials. National Government Services reviewed claims data from the last several years from Minnesota Original Medicare FFS providers. Minnesota has roughly 1 million people on Medicare with nearly half of that population enrolled in Original Medicare FFS. It was found that 130,271 AWV claims were paid over a three-year period with 14,212 denied as billing errors. Common billing errors Minnesota physicians can easily correct with further education include: • Submitting an AWV before the patient is allowed their next annual visit (frequency). • Submitting an AWV when the patient has not been eligible for Medicare for one year (should bill Welcome to Medicare). • Billing an initial AWV more than once (second and subsequent should be billed as subsequent AWV).

Table 2. Place of service codes. Source: National Government Services–A CMS Contractor Agent

The Annual Wellness Visit to page 364

• Duplicate submission of the AWV on one date of service. • Submission of a modifier with the AWV code (typically modifier 25, not valid). • Submitting AWV to Original Medicare when the patient is covered by a Medicare Advantage Plan (submission to wrong contractor).

Who can perform an AWV? Additionally, National Government Services Jurisdiction 6 has received many questions on who can perform these visits and where an AWV can be performed. The following health professionals can perform the AWV: • A physician who is a doctor of medicine or osteopathy (as defined in section 1861(r)(1) of the Social Security Act [the Act]); or, • A physician assistant, nurse practitioner, or clinical nurse specialist (as defined in section 1861(aa)(5) of the Act); or, • A medical professional (including a health educator, registered dietitian, or nutrition professional, or other licensed practitioner) or a team of such medical professionals, working under the direct supervision (as defined in Code of Federal Register (CFR) 410.32(b)(3)(ii)) of a physician as defined in this section. An AWV can be conducted in the places listed in Table 2. Correct codes are included in the table as well.

AWV awareness! AWV utilization can be challenging to understand, not only in Minnesota but across the country. Out of the 130,000 AWV claims paid, the data suggests that less than 10 percent of Minnesota’s People with Medicare are using the AWV benefits each year. MINNESOTA PHYSICIAN MARCH 2018

OTOLARYNGOLOGY

Endoscopic ear surgery A new frontier BY MANUELA FINA, MD

ver the past five years, a revolution has taken place in the surgical management of chronic ear disease. The traditional surgical technique of operating in the middle ear cavity through a microscope is being replaced by a new surgical approach that utilizes a rigid endoscope that is thinner than a pencil, introduced in the ear canal, and connected through a camera to a high-definition screen. The surgeon, holding the endoscope in one hand and using the other hand to operate, has a highly magnified view of the middle ear without the need for an external incision or to drill through the mastoid to gain access. This new technique, called endoscopic ear surgery, is starting a new era in the field of otology, similar to when laparoscopic surgery radically changed the way surgeons accessed the abdominal cavity. The utilization of endoscopy is not new. It has been used for other surgical procedures such as sinus and vocal cord surgery, but for managing chronic ear disease, the primary tool has been the microscope.

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Figure 1. Dr. Fina performing endoscopic ear surgery. Source: Photo courtesy of HealthPartners (printed with permission)

Surgery by microscope To call this new surgical technique “a revolution in our surgical field,” is not an overstatement. For over 100 years, otolaryngologists have been trained to repair tympanic membrane perforations and other chronic ear conditions by relying solely on the microscope, utilizing a two-hands approach. This allowed the surgeon to dissect and remove adhesive bands and cysts of keratinized epithelium in the tiny space of the middle ear with one hand, while the other non-dominant hand held a tiny suction tip to aspirate any bleeding. Over the past 20 years, endoscopes have been slowly introduced to ear surgery, but only as an occasional, adjunct tool used to inspect areas of the attic, middle ear, and mastoid after surgery with a microscope was completed. In the 1980s, early pioneers of the endoscopic approach for management of ear disease introduced the concept of “primary endoscopic ear surgery” to entirely dissect and remove ear pathologies through a transcanal approach. Jean-Marc Thomassin (Marseille, France) in his landmark book, “Otoendoscopically Guided Surgery” (1994) demonstrated that certain blind areas of the tympanic cavity, such as the sinus tympani, not only were visible under endoscopic visualization but that diseased tissue hidden in these areas could be grasped and removed with a bimanual endoscopic technique thus avoiding the need for mastoidectomy and drilling a recess between the posterior ear canal and the vertical segment of the facial nerve to gain surgical access. Muaaz Tarabichi (Dubai, UAE) is considered the pioneer of contemporary endoscopic ear surgery by publishing the first papers on exclusive endoscopic transcanal approach for attic cholesteatoma.

Are two hands better than one? As often happens when a new concept is introduced, the first pioneers in endoscopic ear surgery were met with resistance and diffidence. Why on earth would a surgeon give away the ability to operate with one hand, when he/she can use two hands? Why would a surgeon renounce the

MARCH 2018 MINNESOTA PHYSICIAN

primary quality of the three-dimensional view of a microscope and work off the field by looking at a two-dimensional image provided on a screen? Despite resistance and skepticism, many surgeons were intrigued by the unparalleled view provided by the endoscopes and started to adopt this new technique. In the past 10 years there has been a growing number of otologists worldwide who have adopted the new transcanal endoscopic approach “not just to take a peek” but to perform surgery through the view obtained transcanal. Following the surge of interest in this new technique, the literature on endoscopic ear surgery has “exploded” in the past five years, with publications reporting on the outcomes of endoscopic repair of tympanic perforations, the equivalent closure rates, and decreased operative time. More study is needed to validate the long-term outcome of endoscopic ear surgery for more complex procedures, but the early publications on minimally invasive transcanal endoscopic management of cholesteatoma have reported improved disease control and decreased recidivism. Interestingly, endoscopic ear surgery is “the hot topic” at national and international otolaryngology meetings and a rapidly increasing number of endoscopic ear surgery training courses are being held worldwide to teach the new generation of surgeons this technique. In the U.S., the number of ear surgeons embracing the endoscopic technique is rising, and awareness is raised among surgeons that endoscopes should at least be used as complementary to the microscope to diagnose disease. Currently, few U.S medical centers and otolaryngology residency training programs have faculty experienced in this technique. The University of Minnesota is one of only a few training programs in endoscopic ear surgery. Other training programs include the Massachusetts Eye and Ear Infirmary, Vanderbilt University, and the University of Texas Southwestern.

The advantages of endoscopic ear surgery Intuitively, one may believe that the main advantage of endoscopic ear surgery is avoiding a painful incision behind the ear, which allows a faster recovery and requires less postoperative pain medications. Most patients that undergo transcanal endoscopic ear surgery report minimal pain and often need only a few tablets of ibuprofen in the first two to three days following the surgery. The main advantage of endoscopic ear surgery is preserving healthy tissue and avoiding a mastoidectomy when disease is not involved. Preservation of the mastoid is essential in maintaining the gas exchange function of the mastoid mucosa, which ultimately plays an important role in maintaining stable middle ear pressures. This is especially true when there is altered eustachian function as it occurs in patients affected by chronic otitis media.

Procedures performed with endoscopic ear surgery Tympanic membrane perforations Up until this revolutionary change, few ear conditions could be treated solely through a transcanal approach. Tympanic membrane perforations of a smaller size can be approached transcanal, but if the perforation is larger or located anteriorly, the view obtained through the microscope does not allow a full view of the tympanic cavity. An open approach through a posterior auricular incision is necessary to better visualize the anterior margins of the perforations and optimize graft placement. The endoscopic approach has allowed transcanal repair of perforations of all sizes—even subtotal and total perforations, which Endoscopic ear surgery to page 324

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WOMEN’S HEALTH

Endometriosis Improving the path to better patient outcomes BY MATTHEW PALMER, DO

“

y endometriosis story began when I was 12 years old. My periods were always heavy and painful. Occasionally, I missed school because of pain and other symptoms. My pediatrician started me on birth control when I was 15 and my period symptoms improved, but I still suffered with monthly pain that was not related to my period. I also began to suffer bowel symptoms and routinely felt bloated and had severe abdominal cramps around the time of my period. My pediatrician sent me to see an ob/gyn and I was told I was doing the right things. My pain would get better in time. I became sexually active in college and began to experience severe pain with intercourse that felt like a knife stabbing me deep in the gut. I went back to my ob/gyn and was told I may have endometriosis. She recommended that I go on the medication Lupron Depot, which I took for about six months. “While I felt awful while I was on it (hot flashes, couldn’t sleep, anxious, and irritable, etc.), my pain did get better. Unfortunately, a few months after coming off the Lupron Depot my pain returned and was worse than before. My doctor told me I needed to have a laparoscopy to treat the pain.

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At the time of my first laparoscopy I learned I had some endometriosis “spots” around my pelvis and during surgery she “ burned” all of the spots that she could. After surgery I felt better for about six months. Following that first surgery, I underwent two more over the course of five years. Each time my doctor assured me that she got all the spots she could but there still may be some spots that were too dangerous to try and treat surgically. At this point, I wasn’t having sex as it was too painful. I had become dependent on Percocet to manage my pain and was depressed nearly every day.”

Definitions Endometriosis is a complicated and insidious disease that bears a significant rate of morbidity among reproductive aged women worldwide. The prevalence of endometriosis in the general population is estimated to be 10 percent. In women with pelvic pain, this prevalence jumps to an astounding 82 percent. The average age at the time of diagnosis is 28, although the mean onset of pelvic pain symptoms is usually much earlier. The estimated annual health care burden in the United States exceeds $20 billion. Endometriosis is characterized by the presence of endometrial tissue outside the endometrial cavity. While the cause of endometriosis is unknown, several theories exist. Most experts would agree that the disease is multifactorial in etiology. Some suggestions have been made, including retrograde menstruation with refluxed menstruum implanting on pelvic structures, coelomic pluripotential mesothelial cells lining the peritoneum undergoing metaplasia into endometrial tissue, and implantation of cells through hematogenous or lymphatic embolization. The fact that the disease develops in some women and not others is the confounding factor that is not clearly understood. Although most women have retrograde menses, those who develop endometriosis may have an inherent immune dysfunction that impairs normal clearance, yet promotes disease progression through factors promoting adherence or invasion; angiogenesis; and sensory, sympathetic, or parasympathetic innervations. The ectopic deposits of endometrium can be found in the ovaries and on the pelvic peritoneum, the uterosacral ligaments, and the posterior cul-de-sac as well as extra-pelvic sites, such as the bowel and diaphragm. Endometriosis is generally a progressive disease that begins as stage 1 with a few small deposits of ectopic endometrium and can progress to stage 4 in which severe adhesions cause the pelvic structures to be adherent to one another or to the small bowel or colon. Generally speaking, the disease may take several years to progress but the time frame for this process is variable and young women in their late teens or early 20’s may present with stage 4 disease.

Risk factors A history of early menarche and the presence of other autoimmune type conditions are associated with a higher prevalence of endometriosis. A woman’s risk for endometriosis increases seven- to ten-fold with family history of the disease in a first-degree relative, such as her mother or sister. Being overweight and smoking are associated with a lower risk of

MARCH 2018 MINNESOTA PHYSICIAN

endometriosis. There are no known measures that a woman may take to prevent endometriosis from developing.

Symptomology The majority of women affected by endometriosis present with a constellation of symptoms, including chronic pelvic pain, dysmenorrhea, deep dyspareunia, dyschezia, and subfertility. Additional comorbid conditions include asthma, fibromyalgia, irritable bowel syndrome, and migraine headaches.

Diagnosis often delayed

endometriosis surgical specialist for consideration of surgery. Medical options such as danazol or GnRH agonists will suppress the proliferation of endometriosis with an anti-estrogen effect, but generally can only temporarily treat the symptoms of endometriosis and are fraught with side effects that include vasomotor symptoms, and ultimately osteopenia or osteoporosis. These medications may be considered in patients who are not surgical candidates but should not be used long term.

Endometriosis is a complicated and insidious disease that bears a significant rate of morbidity.

Both patients and clinicians contribute to the delay in diagnosis of endometriosis. Clinicians often minimize a patient’s report of severe pelvic pain and may neglect to consider the importance of family history. Women are often reluctant to report the severity of their pelvic pain symptoms. Of interest, the reported delay in the diagnosis of endometriosis is much shorter for women who present with infertility than for those who present with pelvic pain. In one study, the delay to diagnosis was 3.13 years for women who present with infertility and 6.35 years for women who present with severe pelvic pain.

When a primary care clinician suspects endometriosis and initial attempts to improve the patient’s symptoms have failed, it is important for the patient to be referred to a specialist skilled in the diagnosis and treatment of this disease. A specialist in endometriosis can offer a patient the most advanced medical and surgical modalities for treatment, and can design a multi-disciplinary approach that includes physical therapy and nutrition for the patient to achieve the highest possible chance of minimizing recurrence. While an ob/gyn surgeon is the best person to manage this complex disease, sadly, most ob/gyn physicians receive only minimal training on the management of endometriosis in residency.

Surgical options: comparing ablation to excision

There are generally two surgical approaches to the management of endometriosis. The first involves superficial ablation via electrocautery or laser vaporization. This can be effective for temporary pain resolution following surgery but usually is superficially oriented and cannot treat deep infiltrative disease. The second involves complete resection beyond the superficial peritoneum and into the deeper pelvic structures. In a recent metaanalysis, dysmenorrhea, dyschezia, and chronic pelvic pain—all important symptoms of endometriosis—have shown significantly greater improvement for excision compared to ablation 12 months after surgery. The surgical complexity of this disease state for many

Endometriosis to page 254

Back and Neck Pain... Results That Matter

The evolved patient Of note, more and more endometriosis resources are available to consumers through online searches and discussion groups. These patients often perform a great deal of personal research about their disease and available and effective treatment options. Clinically moderated sites such as Nancy’s Nook Facebook page have thousands of members who openly discuss their symptoms and clinicians or treatment strategies that have helped them. These patients routinely “do their homework” and come to their appointments well prepared and knowledgeable about endometriosis.

First line treatment Patients who have not had a prior laparoscopy for a definitive diagnosis, especially if they are in their teens or early 20s, should first be prescribed hormonal management in either a cyclic (or, preferably) a continuous dose. If the patient has improved symptoms of dysmenorrhea and there are no overt symptoms of dyspareunia or bladder or bowel complaints, this may be a reasonable approach to management of suspected endometriosis. Oral contraceptives may be used, but other hormonal approaches such as NuvaRing or even a progesterone IUD will avoid first-pass metabolism and can be more effective for patients, with fewer systemic side effects. Patients with deep dyspareunia, urinary urgency with a full bladder, dyschezia, or bowel pain with menses, should be referred to an

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PROFESSIONAL UPDATE: PAIN MEDICINE

Previously addicted patients The challenge of treating their pain BY ANNE PYLKAS, MD

have found to be effective.

n 2016, nearly two people in Minnesota died from a drug overdose every day. More than half of the deaths involved opioids. Fortunately, we are making progress in reversing the opioid epidemic by reducing the number of prescriptions for opioid medications. Organizations that have recently rolled out stricter prescribing guidelines include the U.S. Centers for Disease Control and Prevention, the Minnesota Department of Human Services, and the Institute for Clinical Systems Improvement. Two facts remain that present a challenge for physicians: more than 30 percent of Americans have acute or chronic pain and nearly one in 12 Americans have a substance use disorder (also known as addiction). So chances are relatively high that many physicians will at some point be presented with a patient who has pain and is or has been addicted to opioid pain medications. This presents a dilemma for physicians: for patients who are in recovery, there is a risk of relapse in treating pain with opioids. However, inadequate pain relief is also a significant risk factor for relapse. So far, there is little evidence to guide us in how to manage pain with these patients. But as an addiction medicine specialist, here are some things I

Helping Beautiful Things Emerge From Hard Places

Build a foundation of trust People who have been addicted to opioids or have been on opioids for a long period of time have reduced thresholds to pain. We do not know if or when thresholds return to normal after stopping use of opioids. People in recovery might fear that pain management will be inadequate, and judgmental responses by caregivers can create a difficult environment for successful pain management. Before any treatment can be effective, it’s important to establish a therapeutic relationship. It’s natural to question whether someone with a history of a substance use disorder is seeking relief from pain or if they are about to relapse. In my experience, many patients who have been addicted, may underreport their level of pain. If you believe that they are in pain, they will trust that you will treat them and be more forthcoming in giving you information you need to help them.

Manage risk A mainstay of all pain management is learning how to manage risk in prescribing. This is very important in patients with a history of substance use disorders. Patients who are in stable, long-term recovery are generally self-aware and will bring up their recovery status, but those in early recovery (less than one year) may not. If you have concerns or suspicions about current or past drug use, don’t hesitate to do your homework. Ask the patient, check charts, get collateral information, and get urine drug screens before deciding how to proceed. For patients in recovery, acute pain is ideally treated with non-opioid measures. If opioids are warranted, such as in the case of severe tissue injury or post-operative pain, care should be taken to manage risk and monitor adherence closely. If you do decide to utilize opioid medications, take risk management steps to be vigilant: • Prescribe the lowest dose for the shortest time needed • Monitor the Minnesota and Wisconsin prescription monitoring programs • Prescribe weekly and ask that they come in before prescribing more medication • Use urine drug screens

Understand treatment of acute pain in medication-assisted therapy patients There is the special case of patients receiving medication-assisted therapy for opioid use disorder, which creates complications in acute pain management. Although methadone and buprenorphine are analgesics, they are not effective in treating acute pain. TWO CENTERS.

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Buprenorphine is a prescription medication used to treat opioid use disorders. It has been approved for office-based treatment of opioid use disorders since 2002, but it requires that practitioners receive extra training and federal regulations limit the number of patients they can treat. Buprenorphine is 75 times stronger than morphine and traditionally, physicians have been trained

short-acting opioids, and use the risk management techniques described to stop or reduce buprenorphine before prescribing any opioid medication earlier to ensure adherence. for acute pain. However, there is little evidence or clinical consensus on how to treat this. In my experience, leaving patients on their stable dose Naltrexone is also considered medication-assisted therapy and can be of buprenorphine has been more effective than decreasing the dose. This used for opioid use disorders. While methadone and buprenorphine activate is because when you try to reduce the dose, the the mu opioid receptor, naltrexone blocks the mu patient will experience withdrawal. Then you opioid receptor and therefore blocks the “high” must control the pain and the withdrawal and the of opioids. It can be taken as a once daily oral opioid doses become high very quickly, due to the pill or as a monthly injection. Patients receiving potency of buprenorphine. Because buprenorphine naltrexone will be insensitive to opioid analgesia For patients who are in recovery, has a very high affinity for the mu opioid receptor, and can pose major therapeutic challenges when there is a risk of relapse in treating a more potent short-acting opioid may be needed, they are in acute pain. For this reason, presurgery pain with opioids. such as oxycodone or hydromorphone. The time assessments should routinely ask about the use period and frequency of dosing should be similar of naltrexone. There is research that suggests to someone not on buprenorphine. High frequency that oral naltrexone should be discontinued 48 visits, urine drugs screenings, and PMPs should be to 72 hours before the procedure. At that point, used to monitor adherence. pain can be treated as normal with non-opioid Methadone is a synthetic opioid that was introduced in the 1940s to treat pain. In the 1960s, it became widely used as a maintenance drug for the treatment of opioid use disorders. Methadone, when used to treat opioid use disorders, must be dispensed from a federally regulated opioid treatment program, also known as a methadone clinic. Treating acute pain in patients who are on methadone maintenance is less complex than in those on buprenorphine. There is no need to change the methadone dose and their normal methadone dose will not treat the acute pain. Be sure to confirm the methadone dose with the methadone clinic, treat with

management and opioids as needed. For patients on injectable naltrexone, there is no way to “stop” the medication. Therefore, opioid analgesics may need to be very potent and a patient will likely need to be closely medically monitored while receiving opioids.

Understand treatment of chronic pain for patients in recovery Chronic pain is difficult to manage in any patient, but patients in recovery present a particular dilemma. The bottom line is that chronic opioid therapy Previously addicted patients to page 344

OVER PROCESSING

OVER PRODUCTION

PATIENT MOVEMENT

WORKER MOTION

INVENTORY

8 FORMS OF WASTE IN HEALTHCARE

WAITING

CORRECTION OF DEFECTS

WASTED STAFF SKILLS

ARE YOU READY FOR CHANGE IN YOUR ORGANIZATION? EAPC incorporates LEAN process improvement and evidence-based design principles in the facility planning, design, and project delivery processes to eliminate waste in your current or potential new facilities. Chad Frost, Director of Business Excellence, LEAN Specialist | 701.775.3077 | chad.frost@eapc.net

BUSINESS EXCELLENCE

www.eapc.net MINNESOTA PHYSICIAN MARCH 2018

2018 COMMUNITY CAREGIVERS

Miguel E. Fiol, MD Recognizing Minnesota’s Volunteer Physicians By Lisa McGowan

Each year, Minnesota Physician Publishing recognizes physicians and health care providers who have volunteered their medical services. Whether volunteering at home or overseas, these caregivers help people in need and come away with a revitalized sense of their work. Their compassion, commitment, and generous spirit reflect the deeply held values in Minnesota’s medical community.

University of Minnesota Medical School

ith Hurricane Maria heading toward Puerto Rico, Dr. Miguel Fiol, who was vacationing in San Juan with his wife Marta, decided to tough it out and help with the hurricane relief. When it was safe to venture out, he volunteered his medical services at the largest shelter in San Juan. The devastation was unbelievable, said Fiol: “It looked like after the atomic bomb was dropped.” Hospitals could not offer services so all emergencies had to be handled in the shelter. Fiol had to return sooner than expected to Minnesota, but he, along with the University of Minnesota Foundation and “El Fondo Boricua” of the St. Paul Foundation, put together a medical/nursing team to return. The team consisted of Eileen Crespo, MD, (Hennepin County Medical Center); Ruben Crespo-Diaz, PhD, MD, (U of M Internal Medicine Fellowship Program); Eduardo Medina, MD, (Park Nicollet); Serge PierreCharles, MD; and Carla Vélez Rivera, RN, (Fairview Southdale Hospital) (photo left to right: Medina, PierreCharles, Crespo, Vélez Rivera, and Fiol).

Our most important contribution was psychological support to the embattled people of Puerto Rico. Crespo-Diaz was instrumental in securing and shipping 300 pounds of medical supplies needed for the trip. Fiol, a neurologist at the University of Minnesota Medical School, and the team went at the end of October and spent a week seeing patients and traveling extensively to the mountain towns of Canóvanas, Lajas, Naranjito, and Morovis. They set up pop-up clinics where they provided primary care consultations and did home visits. “The stress and trauma was painful to experience,” said Vélez Rivera. People were physically and emotionally exhausted from the daily tasks of maintaining sanitary conditions with little water, buying groceries every day, or waiting in line for gas or cash. Despite this, people did a remarkable job of caring for bedridden or sick family members. After their return, the team remained involved by working with the “Coalition of Puerto Ricans,” a group providing help to 100 families who are resettling in Minnesota. Aside from primary care, communities in Puerto Rico need mental health support. Fiol’s team is concerned with the rising suicide rate in Puerto Rico, and they are working with island physicians to assist with suicide prevention programs there. According to Fiol, “Our most important contribution was psychological support to the embattled people of Puerto Rico. It meant the world to them that we cared and came to help. The work in Puerto Rico continues to be a challenge, but Minnesotans have shown extraordinary support for all efforts to assist in this terrible disaster.”

MARCH 2018 MINNESOTA PHYSICIAN

Rachel Frazin, APRN

Kendra L. Gram, MD

Locum tenens for Alaska Native tribal organizations

Children’s Minnesota Children’s Respiratory and Critical Care Specialists, P.A.

fter her daughter Daniele’s suicide by overdose in 2009, Rachel Frazin, an advanced practice registered nurse, began a pilgrimage of understanding that took her to Nepal, where she provided cursory care at a week-long health camp sponsored by an American nonprofit. That’s when she decided to create her own organization, Tsum Valley Medical Mission, to provide comprehensive care in the Tsum Valley, a remote area of the Middle Himalaya of Nepal near Tibet. According to Frazin, “My genuine happiness lies in doing for others.” Her fiscal sponsor, the Empower Nepal Foundation, run by St. Paul restaurateur Padam Sharma, sponsors Frazin’s effort to provide culturally sensitive care to the Tsumbas (as they call themselves). In addition to primary care, the Tsum Valley Medical

You will never minister to a more grateful people. Mission provides women’s health care, including the first-ever cervical cancer screening program and family planning; preventive and restorative dentistry; eye care; and public health education. The most common medical problems include chronic musculoskeletal pain, gastritis, and asthma/COPD. A day’s drive and a six-day hike from Kathmandu, Tsum Valley is described by veteran hikers as “Shangri-La” with bridges suspended over rushing rivers and the surrounding towering mountains. The Tsumbas, who farm at altitude without the benefit of machines or roads, cannot access professional medical and dental care because of the absence of practicing professionals. Ninety percent of the people are illiterate with little understanding of health and disease. Most Tsumbas rarely go to Kathmandu for specialty care because of the necessary time spent away from their fields and animals as well as fearfulness rooted in their insular existence. After the earthquakes in 2015, several clinics were built with international donations. The clinics are staffed with health assistants who have modest medical training and very basic knowledge of primary and preventive care. Frazin recruits medical providers, nurses, dentists, and support staff for her yearly forays to Tsum—she purchases supplies and the medications that the clinicians prescribe; fundraises; and arranges follow-up care for patients. Each year her team provides 10 days of care in the Compassion Health Clinic in Upper Tsum and in tents or teahouses in Lower Tsum. Frazin started the first EHR in the valley to ensure continuity of care, but it’s a struggle with no internet. She finds volunteering tremendously rewarding and tells providers, “At times, you will witness suffering that is untreatable, but you will never minister to a more grateful people.

n August 2017, Dr. Kendra Gram traveled to Kolkata, India, as part of a multidisciplinary cardiovascular care team from Children’s Minnesota. Volunteering through Children’s HeartLink, they were on a training visit to Rabindranath Tagore International Institute of Cardiac Sciences (RTIICS), a 550-bed tertiary care hospital that serves West Bengal and eastern India. RTIICS performs more than 1,200 pediatric open-heart surgeries each year, however they have limited resources to provide more complex cardiovascular care. One of the major goals of Children’s HeartLink is to shorten the surgery waiting time for children with congenital heart disease, and to help RTIICS be successful in providing more complex surgical and perioperative care. According to Gram, a cardiac intensive care physician at Children’s Minnesota, “The stress and anxiety of having a sick child is universal for parents.” Ongoing training and mentoring of specialists to strengthen the clinical and organizational capabilities of the hospital will allow more complex surgeries to occur in a timely manner so children have the opportunity for the best possible outcomes.

Volunteering re-energizes my love for what I do. Gram and the team not only actively assisted in the care of children with heart disease at RTIICS, but also taught the local medical staff skills to enable ongoing improvement in patient care. They worked with staff on how to more effectively manage their patients with the limited resources currently available to them, focusing on ventilator strategies, post-operative management, infection prevention, and methods to improve nutrition in critically ill patients to expedite their recovery. They also created a plan for ongoing nursing education and worked to strengthen team dynamics to specifically improve bedside care, developing a structure for multidisciplinary team rounds to allow the nurses, respiratory therapists, and multiple physician specialists to equally participate in the care of the patient. Since Children’s HeartLink’s involvement, RTIICS has demonstrated a significant decrease in hospital-acquired infections in their pediatric cardiac patient population. Gram encourages physicians to volunteer even if the time commitment seems overwhelming. This was her first time volunteering in India and she found it to be rewarding both professionally and personally. The excellent work the physicians do with limited resources was humbling, especially when she is accustomed to working with the latest technology. That served as a reminder of what the basic focus of medicine really is. She is eager to return to Kolkata this fall, “Volunteering re-energizes my love for what I do.” MINNESOTA PHYSICIAN MARCH 2018

2018 COMMUNITY CAREGIVERS often works with residents and students to teach them how to diagnose heart disease, to understand echocardiography, and to perform interventional and surgical procedures safely. Cabalka volunteers through Samaritan’s Purse, a nondenominational evangelical Christian organization whose mission is to “provide spiritual and

I am continually humbled when I have an opportunity to volunteer.

Allison Cabalka, MD Mayo Clinic

s a Christian, Dr. Allison Cabalka believes it is her responsibility to share the gifts and skills she has been given to help others in low resource areas of the world. She has been volunteering since 1999 and travels overseas to volunteer three to four times a year. According to Cabalka, a pediatric cardiologist at Mayo Clinic, “I am continually humbled when I have an opportunity to volunteer.” In 2017, she traveled to Tenwec Hospital in Bomet, Kenya in May and September. Tenwec is a 300-bed hospital that was founded in 1937 by missionaries from World Gospel Mission. It is one of the largest mission hospitals in Africa and is also a teaching hospital that trains Kenyan interns and residents. Cabalka

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physical aid to hurting people around the world.” They send hundreds of volunteer medical teams to impoverished nations for a week to 10 days. At Tenwec, Cabalka used her pediatric cardiology skills to examine patients, assess them clinically for possible congenital or rheumatic heart disease, and make recommendations on their care. This ensured that patients got an accurate diagnosis and she often added them to an upcoming surgery list for when the surgical team arrived. Children received lifesaving care that is not normally available to them. “It is a priceless opportunity to see the look of joy on a parent’s face when a healthy child is returned to them,” said Cabalka. The Children’s Heart Project (CHP), another arm of Samaritan’s Purse, works in countries where open-heart surgery is not available. The children are screened in their country and those with life-threatening heart disease are set up for surgery in a partner hospital in the U.S. like Mayo Clinic. Samaritan’s Purse funds the trip for the child, a parent, and an interpreter. Once in the U.S., a local family or church hosts them for five or six weeks. Cabalka provides care for these children at Mayo and has also hosted several families in her home. A huge team of local volunteers takes these families to appointments, provides meals, and takes them on outings. Cabalka pointed out, “Caring for these kids and their families is a great team effort!”

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Most of the patients that come to the clinic have advanced venous stasis disease, often with ulcers. Nicholson, along with other surgeons and nurses, debride wounds, treat venous insufficiencies, use sclerotherapy, and ablate and close veins. Wound dressing kits and compression hose are given

The satisfaction that accompanies serving others has to be experienced. to the patients, who are very motivated to follow instructions for wound care and who often return for follow-up visits the next year.

Phifer Nicholson, MD Fairview Surgical Consultants, PA

t took nearly six hours for Dr. Phifer Nicholson to reach the town of Olanchito, Honduras, by bus from San Pedro Sula. After Nicholson and the medical team arrived, they set up a clinic in a community center with eight exam rooms, using curtains as dividers where the team treated patients with venous disease. Patients often take 12-hour bus trips to get to the weeklong clinic in Olanchito. According to Nicholson, a vascular surgeon with Fairview Surgical Consultants, “Many of the patients we see live far away from cities and have little access to medical care.” Honduras is a poor country. According to the CDC website, the number of physicians in Honduras is insufficient to cover the population’s primary care needs. People living in rural areas have almost no access to basic health care.

Nicholson has been volunteering for five years; first in Kenya with Marked Men for Christ and for the last two years with the Hackett Hemwall Patterson Foundation (HHPF) which has led trips to Honduras since 1969. He learned about HHPF’s vein sclerotherapy trips to Olanchito at a medical meeting in 2016. Because of his interest in treating venous disease, he jumped at the chance to improve his skills while serving patients in a third-world country. Physician volunteers with HHPF enjoy a day of lectures about venous disease and treatment techniques before opening the clinic. His advice to other physicians who might be thinking about volunteering is to give it a try! “The satisfaction that accompanies serving others has to be experienced,” said Nicholson. “The gifts, mercy, and grace I have been given can never be fully repaid.” Along with his wife Lisa Nicholson, a registered nurse who also volunteers in Olanchito, they feel it is important to serve because their faith tells them it’s important. The joy that Hondurans show despite living in poverty has helped Nicholson to live more simply, focus more on faith and family, and find joy in daily life.

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2018 COMMUNITY CAREGIVERS to four days a month where she performs extractions including those from impacted wisdom teeth, treatment of infections, and alveoloplasty (jawbone reshaping). She is also working with Hope Dental to start a continuing education class in oral surgery for general dentists who want to feel more confident performing routine extractions.

Volunteering makes me a better provider and a more compassionate human.

Rachel Uppgaard, DDS Pacific Dental Services, University of Minnesota

nspired by her father volunteering at the Union Gospel Mission in St. Paul, Rachel Uppgaard began volunteering at the mission’s free dental clinic when she was in dental school, 10 years ago. In January 2018, after providing free dental care in the mission’s basement for 53 years, the newly named Hope Dental Clinic began operating as its own nonprofit organization and moved to a new state-of-the-art facility in Dayton’s Bluff. Uppgaard, an oral and maxillofacial surgeon, began volunteering with church groups and school programs for the underprivileged when she was in eighth grade. She feels fortunate to have received an incredible education and said, “I want to be able to give back to the community I live in.” She volunteers at Hope Dental two

Hope Dental Clinic is the largest free dental clinic in Minnesota and relies on grants, donations, and hundreds of volunteers to operate. Half of the volunteers are dental students from the University of Minnesota School of Dentistry, in addition to dental assisting and dental hygiene students from different institutions and 50 dentists and oral surgeons. Hope Dental’s mission is to provide education and dental services to the underserved. They saw 2,347 patients in 2017 thanks to 11 paid staff members and over 400 to 500 volunteers. The most common services provided are cleanings, fillings, and extractions. The cost of dental care is a barrier to many who don’t have dental insurance and who live below the poverty line. According to Uppgaard, “Many of Hope’s patients have never had a dental exam or cleaning and require significant surgical and restorative care to return their oral cavities to a healthy state.” Community education is an important part of Hope Dental’s mission and they run school education programs about oral health and nutrition in about 1,000 daycares and preschools in the Metro area. They also hold several treatment events each year where people can receive open treatment. Uppgaard feels that it’s important to see firsthand how broken our health care system is by caring for those in need. “Volunteering makes me a better provider and a more compassionate human.”

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3Endometriosis from page 17

likely related to endometriosis. I decided to give surgery one more chance and I am so glad I did. I underwent a robotic-assisted resection of endometriosis women with stage 3 and 4 disease rivals advanced ovarian cancer and the doctor found and removed deep endometriosis disease from the cases, and most ob/gyn surgeons are not prepared to properly operate tissues surrounding my ureters as well as a nodule from my colon. After on these patients. The endometriosis specialist awaking from surgery, I knew immediately that I will be able to navigate the complex spaces of felt different. Sure, I had the surgical incision pain the pelvis, including the retroperitoneum, and but I knew my endometriosis was finally gone. The be able to remove disease that has attached itself recovery was not easy and it took several months for to the bladder, colon, ureters, and deep pelvic me to feel totally normal. I went to physical therapy Women who want to become sidewalls. It is very difficult to make an educated every week and changed my diet. I was able to get off pregnant are encouraged not guess as to the stage of the disease and thus the of prescription pain medication after two weeks and to delay their childbearing. difficulty of the surgery prior to the operation. I feel that I have my life back. I am so grateful that Diagnostic imaging such as pelvic ultrasound and I found my doctor and hope that my story can help MRI can aid in the diagnosis of deep infiltrative other women who suffer with this disease to get the disease, but the understanding of the complexity care that they need sooner than I did.” of the surgery based on symptoms and imaging alone can be elusive. An endometriosis specialist will generally co-manage the most complex cases with other surgical Matthew Palmer, DO, is an ob/gyn physician with Oakdale Obstetrics specialists such as urologists and colorectal surgeons for cases involving and Gynecology in Maple Grove. He completed advanced surgical training ureteral re-implantation and bowel resection respectively. with a fellowship in minimally invasive surgery following his residency, Sadly, many patients undergo several laparoscopic ablation surgeries before being referred to a specialist. Many patients describe a surgical experience where the surgeon saw the complexity of the disease and decided to abandon the surgery for fear of operating near easily injured structures such as bladder, bowels, and ureters.

where he focused on surgical management of endometriosis and advanced laparoscopic and robotic surgical techniques.

A multi-disciplinary approach to the post-surgical management of endometriosis proves to be the most effective. Following surgery where the diagnosis of endometriosis is established, most women should be managed long term with hormonal suppression of ovulation and annual follow-up visits with an endometriosis specialist to assess recurrence. Women who want to become pregnant are encouraged not to delay their childbearing plans if possible as the effect of endometriosis on infertility can be variable and multi-factorial. Most patients with endometriosis have a long-standing history of chronic pelvic pain that needs to be addressed in order to provide effective long-term quality of life. Pelvic floor physical therapy is a very important modality in the treatment of chronic pain associated with endometriosis. Additionally, many patients are referred to a nutritionist who specializes in the disease in order to optimize a low-inflammation diet that can improve chronic pain in many patients. Other non-traditional therapies such as acupuncture may also benefit many patients with chronic pain.

Conclusion Endometriosis is a complex disease that is variable in presentation and severity and is best managed by an endometriosis surgical specialist. Patients that exhibit symptoms of deep infiltrative disease should be referred to a specialist to optimize their management and avoid costly and ineffective therapies. “After researching endometriosis on my own I decided to pursue an appointment with a doctor who was a specialist in the excision of endometriosis. At this appointment, he asked me questions that I hadn’t been asked before and I was amazed to learn that so many of my symptoms were

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CARDIOLOGY

The Watchman device A new treatment for atrial fibrillation BY GANESH RAVEENDRAN, MD, MS, AND QUAN PHAM, MD

or some, a diagnosis of atrial fibrillation (AF) may mean a lifetime of being prescribed blood thinners to reduce an increased risk of stroke. Currently, about 5 million people in the U.S. suffer from AF, but that’s expected to increase to 12–15 million by 2050. Additionally, the severity of a stroke due to AF is worse than a non-AF related stroke. The pathophysiology underlying a stroke in patients with AF centers on clot formation, most often in the left atrial appendage (LAA) and in the brain where clots can dislodge to. AF also increases the risk for heart failure. For some patients, anticoagulants are not an option due to a high risk of bleeding. The Watchman device offers another option for patients who cannot be on oral anticoagulants.

It all takes place in the LAA More than 90 percent of the time when a clot is found in the heart of patients with AF it will be in the LAA. The mechanism for this is not yet fully understood, but it is thought that the reason for clot formation in the LAA of AF patients is related to Virchow’s triad. Appreciation of the unique features of LAA anatomy and physiology is necessary to understand this

relationship. The LAA is a remnant of the embryonic heart. It is a blindended pouch projecting anterolaterally out of the left atrium. Its size ranges from 1 cm to 5 cm in both length and width. While the size of the LAA can be appreciably measured, its shape is difficult to describe but is most often thought to look like a chicken wing or broccoli floret. The LAA is quite thin, 1–3 mm and can be translucent. It contains three tissue layers like the rest of the heart. The inner surface, the endocardium, is lined with connective tissue and the medium and epicardium continue from the left atrium without any distinct transition. The main difference between the LAA and the LA is the presence of “ridges” made of pectinate muscles giving the LAA a heavily trabeculated appearance whereas it is quite smooth for the LA. Like the rest of the atria the LAA can contract, however, the contraction strength is reduced during AF and appears to be proportional directly to its duration. Thus, AF patients have a high potential of stasis of blood in the LAA because the interaction of the reduced “pumping” action of the LAA and its unique anatomy of many ridges increase the total inner surface area. Additionally, there is some evidence of endothelial dysfunction in AF patients causing less production of nitrate oxide leading to a hypercoagulable state. Therefore, Virchow’s triad of hypercoagulability, endothelial dysfunction, and blood stasis appears to be present in patients with AF.

How to treat AF The cornerstone of therapy for AF is to prevent thromboembolic complications such as stroke and to control the heart rate. Anticoagulation with a vitamin K antagonist (warfarin) has long been proven to be an effective tool in reducing the risk of stroke in AF patients. However, the need for required monitoring and the potential for labile INR due to warfarin’s common interactions with food and other drugs has always been its Achilles heel.

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The development and introduction of novel oral anticoagulants over the past several years have proven to be more effective and convenient for patients than warfarin. Unfortunately, like warfarin, all novel oral anticoagulant agents are designed to “thin” the blood, which increases the risk of major bleeding. As a result, there are a sizable number of AF patients who would benefit from taking long-term anticoagulation but who cannot because of their high bleeding risk. The scientific community has been working to find an alternative for a long time.

The Watchman device The mechanism of stroke in patients with AF is related to thrombus formation in the LAA. Patients who cannot tolerate an anticoagulant secondary to either bleeding or who are at higher risk for falls leading to catastrophic complications could be treated with occlusion of the LAA. This procedure, called a left atrial appendage closure, eliminates the longterm need for a blood thinner and uses a relatively new, implantable device called the Watchman. FDA approved the Watchman device in March 2015 based on the results of the PROTECT AF study, which compared warfarin to the Watchman

device to prevent stroke in patients with AF. The study found the device to be non-inferior to warfarin in preventing stroke, systemic embolization, and cardiac death, however it was superior to warfarin in preventing hemorrhagic strokes. The study demonstrated that closure of the LAA with the Watchman device is effective in preventing strokes in patients with AF. Currently, there are more than 375 centers with over a thousand operators performing Watchman in the U.S. More than 40,000 patients have received Watchman worldwide, with nearly 5,000 of those over the last few years. So far, prognosis after the procedure has been excellent.

warfarin in reducing stroke. At best it’s about 90 percent effective, since about 90 percent of the time clots are found in the LAA. Ten percent of clots are found in a non-LAA location, so, for this reason, an oral anticoagulant is always better. Having said that, Watchman is an alternative for patients who cannot be on an anticoagulant agent. Having a Watchman would reduce the risk of CVA compared to doing nothing.

Description The Watchman device is shaped like an umbrella made of a nitinol metal frame and is covered by polyester fabric. It is delivered to the LAA through a 12-French delivery sheath via the transseptal approach. The Watchman device is deployed simply by pulling back the delivery sheath causing the device to open up like a “flower” completely sealing the LAA. The compression of the device against the os and the wall of the LAA is one of the main reasons for an exceedingly low dislodgment rate.

A diagnosis of atrial fibrillation (AF) may mean a lifetime of being prescribed blood thinners.

Who’s a good candidate? The ideal candidates for Watchman are patients with CHADSVASC 3 or higher, with either a history of major bleeding while taking an oral anticoagulant or the inability to maintain a stable therapeutic INR. This, on top of the unavailability of an alternative anticoagulant agent, a medical condition, or the patient’s occupation or lifestyle, could put the patient at high risk of major bleeding due to trauma. Patients with a life expectancy of less than a few years shouldn’t be considered for Watchman. The longer patients live, the more benefits Watchman provides. Primary physicians should refer their patients to receive the Watchman device. Ultimately, it prevents stroke without adding an additional risk of bleeding. This does not mean, however, that Watchman is better than

Placement LAA occlusion is performed in the cardiac catheterization laboratory. The procedure is done under general anesthesia and with transesophageal echocardiography (TEE) guidance. On the day of the procedure, the right femoral vein is accessed with a small needle and a 16 Fr sheath is placed in The Watchman device to page 314

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RESEARCH

Somali Americans’ health Change and “the healthy immigrant effect” BY BJORN WESTGARD, MD

ince civil war broke out in Somalia in the early 1990s, large numbers of Somalis, with their unique cultural and dietary preferences, have been immigrating to more developed countries. They settled in many areas of the U.S., but the largest number (estimated at 31,000) live in Minnesota and are concentrated in the Twin Cities.

The effects of U.S. culture have led other relatively healthy immigrant populations to change their dietary intake, energy expenditure, and other health-risk related behaviors, leading to corresponding increases in the rates of diabetes, obesity, and overall cardiovascular disease (CVD) risk. Whether this “healthy immigrant effect” has occurred among Somali immigrants is not known, and measures of CVD and cardiometabolic risk factors in this community have been scarce. To address this knowledge gap, as well as to answer broader research questions, we obtained funding from the NIH’s National Heart, Lung, and Blood Institute to conduct a study in 2013. We assembled a collaborative, community-representative team of physicians, researchers, and community health workers from the

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HealthPartners Institute, Hennepin County Medical Center, the East Africa Health Project, WellShare International, and Aurora Health Care, and set out to evaluate these health risks in order to inform and prioritize public health measures to prevent metabolic syndrome and CVD among Somali immigrants. Several physician members of this collaborative, including Dr. Doug Pryce of Hennepin County Medical Center; Dr. Ahmed Dalmar of Aurora Health Care; and Dr. Osman “Harare” Ahmed of the East Africa Health Project, conducted one of the first studies to survey CVD health in what was then a relatively new immigrant community in 2001. At the time, their cluster-randomized survey of 253 Somali household members in the Twin Cities was the largest and most systematic study of health in the Somali community. Our current study was designed as a follow-up to the 2001 study in order to answer a broader set of research questions. Our interests included understanding how social networks and social capital might relate to CVDrelated behaviors, risk factors, and outcomes in this community.

Involvement of the Somali community It was clear even in the proposal and design phases of our study that meaningful community input and engagement would be vital. Our community partners shared cultural insights and helped recruit Somali leaders and community members for a series of listening sessions. Session participants recommended that we explain to the community the idea of disease prevention and its importance for health; engage imams, mosques, community health centers, and other community leaders to increase awareness of the study; work with Somali physicians to develop messages about cardiometabolic risk and how social networks influence health; encourage the community through Somali media to participate in the study if given the opportunity; and provide ample opportunities for the community to ask questions. To provide a broader base of opinion and guidance, we developed a community advisory panel with whom we meet semi-annually. The panel includes members of the listening sessions, Somali media, and medical and religious leaders identified by our community partners. The panel has played multiple roles throughout the study: 1) advising on the development of our survey instrument, and anthropometric and blood sampling procedures; 2) providing cultural insights into emerging problems and potential solutions; and 3) providing a direct means of sharing study progress. Our engagement with the panel has been essential in establishing and maintaining trust with the community, cultivating understanding of the study objectives, introducing study staff, and demonstrating the relevance of our efforts to community well-being.

Recruitment based on social network referrals Because of our interest in the potential importance of social networks and social capital as factors influencing CVD, we used a “chain-referral” recruitment technique called respondent-driven sampling (RDS). Following this technique, we began our sample with a small number of adult Somalis varying in age and sex and then asked them to recruit other adult Somalis from their close social contacts into the study. Such techniques are most often used to study “hidden” populations for which there is no reliable sampling frame. We also

adjustments to facilitate valid comparisons between these two surveys. We are therefore restricting the 2015 data to subjects 32 years or older at the time of interview and who indicated arrival in the U.S. in 2001 or earlier. These restrictions provide a sample of individuals who could have been in the Twin Cities during the 2001 study. We are also standardizing the age and sex distributions of both sets of study data to recent U.S. Census data from the American Community Survey for Somalis in the Minneapolis/St. Paul area. Finally, we are weighting our 2015 study data using RDS-based weights to account for the recruitment U.S. culture has led other relatively methodology of our sample. Because our analyses healthy immigrant populations to are preliminary and ongoing, we can offer only a change their dietary intake. brief narrative description of our findings.

chose RDS because of concerns that the existing U.S. Census counts of the local Somali community likely underestimate its true size and, possibly, its composition, making the Somali community a partially “hidden” population for which a satisfactory sampling frame does not exist. The theory behind the RDS method holds that with sufficient “waves” of recruitment (at least five) the study sample will approximate a random sample, representing the larger community.

In 2015, after obtaining IRB (international review board) approval, we surveyed a sample of roughly 1,150 adult Somali immigrants living in the Minneapolis/Saint Paul metropolitan area. Trained and gender-concordant Somali community health workers from WellShare International conducted face-to-face interviews, obtaining consent, taking anthropometric measurements (height, weight, waist-circumference, blood pressure), and drawing blood samples for laboratory testing (for lipids, hemoglobin A1c as a measure of blood glucose, high-sensitivity C-reactive protein as a general marker of inflammation). The interview survey assessed self-reported cardiometabolic disease and risk factors as well as health insurance status, established primary care, duration in the U.S., educational attainment, employment, marital status, household income, English-language fluency, and other demographic variables.

Changes in population and prevalence of CVD risk factors Differences in measurement, sampling, and population dynamics between the current and previous studies required us to be cautious and make appropriate

After the age and sex standardization, the sex composition of the two samples was quite comparable, with females representing 53 percent of the 2001 sample and 56 percent of the 2015 sample. The age composition of the recent sample was somewhat older than the 2001 sample, with nearly half of the 2015 sample aged 45 or older and only about a quarter of the 2001 sample in this age range. It is unclear how to interpret this difference. One possibility is that ongoing immigration since 2001 may have over-weighted the 2015 sample toward older ages, as older family members often “follow” younger immigrants. It is also possible that the RDS method may have led to over-recruitment from older groups in the Somali Americans’ health to page 304

Maureen Nelson Plays The Lark Ascending Friday, April 6, 8:00pm Saturday, April 7, 8:00pm Ordway Concert Hall, Saint Paul Sunday, April 8, 3:00pm St. Andrew’s Lutheran Church, Mahtomedi Thursday, April 12, 6:00pm – HAPPY HOUR CONCERT Ordway Concert Hall, Saint Paul Friday, April 13, 11:00am Wooddale Church, Eden Prairie Friday, April 13, 8:00pm Wayzata Community Church, Wayzata Saturday, April 14, 8:00pm Saint Paul’s United Church of Christ, Saint Paul Sunday, April 15, 2:00pm Benson Great Hall, Arden Hills The Lark

SPCO violinist Maureen Nelson takes center stage for Ralph Vaughan Williams’ iconic Ascending tone poem for violin and orchestra.

MINNESOTA PHYSICIAN MARCH 2018

3Somali Americans’ health from page 29 community. A final possibility is that our age-standardization is not sufficient to allow comparison between the two studies. We therefore offer the following observations tentatively, and subject to future revision. Preliminary univariate descriptive analyses comparing prevalence data between the 2001 and 2015 data suggest differences in the prevalence of CVD risk factors. The 2001 study found that levels of obesity, dyslipidemia, diabetes, hypertension, and smoking were generally all lower in the local Somali sample than in the general U.S. population at that time, with 4 percent of participants reporting living in the U.S. for more than 10 years. In our 2015 study, a majority of participants reported living in the U.S. for more than 10 years, and the prevalence of diabetes (A1c >= 7 percent), hypertension (systolic/diastolic blood pressure >= 140/90 mm Hg), and dyslipidemia (total cholesterol >= 200 mg/DL, high-density lipoprotein:total cholesterol >= 5) have increased. Similarly, the prevalence of overweight (BMI >= 25 kg/m2) and obesity (BMI >=30 kg/m2) are higher in the 2015 data, while the prevalence of current smoking is similar. One encouraging note is that the proportion of participants with health insurance coverage was just over 80 percent in 2001 and is slightly higher in the 2015 data.

Implications and future directions Once completed, our study will provide the most current profile and best longitudinal comparison of cardiovascular health and risk factors among new Somali Americans. If our preliminary results are validated, rising rates of diabetes, hypertension, and dyslipidemia in this population are of concern,

as are steady smoking rates among men and increases in the already high prevalence of overweight and obesity among women. Together, these changes would suggest that interaction with the U.S. environment has had effects upon the Somali population that portend significant downstream consequences from metabolic syndrome and CVD risks. These analyses will help prioritize the modifiable CVD risks to which treating clinicians, health systems, and public health officials should devote their resources. The high rates of insurance and established primary care in this population offer some hope in this regard. Our future work will focus on understanding the role of social networks and social capital in contributing to or protecting against adverse changes in community health. We will also model culturally-appropriate and diseasespecific interventions for modifiable CVD risk factors in order to identify how best to combat the health effects of exposure to the U.S. environment among Somali immigrants. Bjorn Westgard, MD, is an emergency physician at Regions Hospital and an investigator at HealthPartners Institute. In his work in the emergency department (ED) he has sought to balance biomedical and sociological approaches to patient care in urban and rural locales. His training as a medical anthropologist brought him to the ED where everyday care requires a social medicine perspective and attention to the social determinants of health. His teaching and research have focused on ED use for preventable conditions among priority populations, “food deserts” and diet-related ED visits, longitudinal changes in ED use among the homeless, supportive housing, and reducing health disparities in emergency care.

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3The Watchman device from page 27 it. Under TEE guidance, a needle is used to cross the interatrial septum. Once the position is confirmed, a delivery sheath is advanced and positioned in the LAA. Based on the TEE measurement taken, an appropriate size Watchman device is placed in the LAA. Once the position and stability of the device is confirmed by TEE, the fluoroscopy delivery system is removed. Patients are observed overnight and discharged the following morning. Patients are placed on warfarin for 45 days, followed by aspirin, and then a P2Y12 agent for six months.

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randomized trial to compare Watchman to warfarin. The trial followed more than 700 patients for 2.3 years. The second smaller trial, PREVAIL, had about 400 patients with 18 months of follow-up. This trial was published a year later. Both trials show that Watchman was non-inferior to warfarin in terms of ischemic stroke prevention. In light of these trials and data from registries, FDA approved Watchman to be considered for patients with a CHADSVASC score of 3 or greater who could not be on oral anticoagulant because of their bleeding history or being at risk for major bleeding. As more studies are done and data become available, Watchman could be a first line therapy to prevent stroke, whereas right now it is approved only for those who cannot tolerate warfarin.

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3Endoscopic ear surgery from page 15 can be repaired endoscopically with similar success rates and with the advantage of eliminating external incisions. The graft utilized to repair the perforations is made of cartilage harvested from a tiny canal incision in the anterior aspect of the ear canal—the tragus. The incision remains hidden within the ear canal and leaves no visible scar.

traditionally, a mastoidectomy is required to reach certain areas of the middle ear cavity not accessed by the transcanal microscopic approach. Endoscopy is changing the management of cholesteatoma by improving visualization in the portion of the middle ear not fully visible under microscopy and by not breaching the mastoid. This allows the surgeon to achieve better control of the disease and lower the rate of recurrent disease.

The endoscopic approach has drastically changed the need to perform a mastoidectomy. In my Endoscopic ear surgery Cholesteatoma experience, about two-thirds of cholesteatomas can is “the hot topic” at The principal advantage of endoscopic ear surgery national and international be approached transcanal using an endoscope. This applies to the treatment of cholesteatoma. This otolaryngology meetings. represents a major change compared to the traditional destructive and expanding growth consists of approach, which required a mastoidectomy for about keratinizing squamous epithelium that originates 80 percent of the cases. Among those patients still from retraction pockets of the pars flaccida or requiring a mastoidectomy, the endoscopic approach long-standing tympanic membrane perforations. has reduced the need for more radical surgeries such Cholesteatoma has erosive and expansile properties as modified radical mastoidectomy, which results in a non-self cleaning cavity, resulting in erosion of the tympanic membrane, bony ear canal, and ossicles. requires periodic cerumen debridement, and precludes patients from swimming Cholesteatoma typically does not cause pain and these epithelial cysts can grow or water exposure. insidiously with only a few sentinel signs and symptoms such as conductive Other otologic indications for endoscopic ear surgery hearing loss and intermittent ear drainage. Undetected, cholesteatoma can continue its process of erosion and expansion, growing over the tympanic Several procedures that used to be performed through a microscope segment of the facial nerve, or eroding into the bony otic capsule and causing can now be approached endoscopically with improved field of vision and facial nerve palsy, vertigo, and permanent sensorineural hearing loss. Left improved graft or prosthesis placement: ossicular chain reconstruction; untreated, cholesteatoma can continue its spread and erosion through the base stapedectomy surgery for otosclerosis; surgery for canal stenosis; removal of the skull and into the brain. Although cholesteatoma originates in the attic, of canal bony growths including osteomas and exostosis; and resection of glomus tympanicum, a vascular tumor that typically manifests with unilateral pulsatile tinnitus and a reddish mass behind an intact tympanic membrane. Not all ear surgeries can be performed endoscopically. Cochlear implants require a mastoidectomy in order to place the electrode in the round window and keep it tucked in the mastoid to prevent extrusion and is best done with a microscope.

The future

Compassionate, Comprehensive, & Personalized care for adult and pediatric patients with neurological conditions, including:            

Head Injury/Concussion Epilepsy/Seizures Headache/Migraine Neck/Back Pain Sleep Disorders Movement Disorders Parkinson’s Disease Tremors Alzheimer’s Disease Dementia Muscle Weakness Carpal Tunnel Syndrome

        

Sciatica Neuromuscular Disease Muscular Dystrophy Dizziness Numbness Stroke Multiple Sclerosis ALS And other neurological disorders

Because endoscopic ear surgery requires dexterity with handling endoscopes and working off a screen, the new technique has gained support among the younger generation of doctors. For new residents in training, the learning curve is not as steep as for the older generation of ear surgeons who find it difficult to adopt a new surgical technique that requires a different skill set. This new technique will replace the traditional approach gradually, as more and more newly graduating otolaryngologists will be trained in the endoscopic approach. I believe that within the next decade, endoscopic ear surgery will be considered the standard of care. This is an exciting time of change for the field of otology and we are excited, here in Minnesota, to be the front-runners of this new technology. Manuela Fina, MD, is an assistant professor at the University of Minnesota

612.879.1500

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in the Department of Otolaryngology Head and Neck Surgery and practices at HealthPartners Specialty Center–Otolaryngology/ENT in St. Paul. She has pioneered endoscopic ear surgery in Minnesota and presented her results nationally and internationally in Italy, France, and Scotland. Dr. Fina is a passionate proponent of endoscopic ear surgery and has been training the otolaryngology

MARCH 2018 MINNESOTA PHYSICIAN

residents at the University of Minnesota in endoscopic ear surgery since 2013.

St. Health Cloud VA Care System Brainerd | Montevideo | Alexandria

with a Mankato Clinic Career Established in 1916, physician-owned and led Mankato Clinic is 100 years strong and seeking Family Physicians for outpatient-only practices. Over 50% of our physicians are involved in leadership positions and make decisions for our group. Full-time is 32 patient contact hours and 4 hours of administrative time per week. Four-day work week available. Clinic hours are Monday-Friday, 8 a.m.-5 p.m. OB is optional. Call is telephone triage, 1:17, supported by a 24/7 Nurse Health Line. Market-competitive guaranteed starting salary, followed by RVU production pay plan. Benefits include 35 vacation / CME Days annually + six holidays, $6,600 annual CME business allowance and a generous profit-sharing 401(k) plan. We’re just over an hour south of the Mall of America and MSP International Airport. If you would like to learn more about building a Thriving practice, contact:

Dennis Davito Director of Provider Services 1230 East Main Street Mankato, MN 56001 507-389-8654 dennisd@mankatoclinic.com

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

• Physician (Pain Clinic)/Outpatient Primary Care • Psychiatrist (Mental Health)

• Pulmonologist (Primary & Specialty Care) Applicants must be BC/BE.

Apply online at www.mankatoclinic.com

Helping physicians communicate with physicians for over 30 years. Advertising in Minnesota Physician is, by far, the most cost-effective method of getting your message in front of the over 17,000 doctors licensed to practice in Minnesota. Among the many ways we can help your practice: • Recruit a new physician associate • Share new diagnostic and therapeutic advances • Develop and enhance referral networks

US Citizenship required or candidates must have proper authorization to work in the U.S. Physician applicants should be BC/BE. Education Debt Reduction Program funding may be authorized for the health professional education that was required of the position. Possible recruitment bonus. EEO Employer. Competitive salary and benefits with recruitment/ relocation incentive and performance pay possible.

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(612) 728-8600 MINNESOTA PHYSICIAN MARCH 2018

3Previously addicted patients from page 19 should be avoided in patients with a history of substance use disorders. Not only can it create hypersensitivity, but it presents a significant risk of relapse. Alternative methods are highly preferred.

Address physical activity The benefits of exercise for managing noncancerous pain are well documented. Research shows increasing physical activity is effective in treating conditions such as back pain and knee pain. Many people stop moving in response to pain. But they need to know that the best medicine is to keep moving. Even light exercise can be helpful. Interventions that help patients get moving include: • Non opioid medications, such as muscle relaxants, NSAIDs, or acetaminophen • Physical therapy • Occupational therapy • Exercise classes or programs

Address sleep problems Among people who have chronic pain, more than half experience problems with sleep. Pain can make it hard to get enough good sleep. And on the flip side, not getting enough sleep can make you more sensitive to pain. If someone uses opiates for more than a few weeks, it can reduce the kind of sleep that restores your body. So it’s important to get an assessment and treat any sleep problems.

Understand end-of-life care Experiencing pain is one of the most common concerns patients have at the end of life. It’s important to distinguish between the need for opioids to treat pain as a disease progresses and risks for addiction relapse. But in general, compassionate care at the end of life calls for aggressive management of pain regardless of substance use disorder history.

Conclusion While patients with a substance use disorder history can present a challenge, it is possible to pain manage acute and chronic pain in these patients. Building a foundation of trust, but also being vigilant with risk management are the keys for success in this challenging population.

Manage mood disorders Chronic pain is often a mixture of physical pain, emotional pain, and suffering. In fact, as many as three out of four people we see at our pain management clinics have experienced trauma. Emotional pain affects the same area of the brain as physical pain, and it can be very hard for the brain to separate them. Each of these parts, however, requires appropriate treatment and care to maximize healing. Consider psychotherapy to address this root cause.

A Place To Be Your Best. Dr. Julie Benson, MN Academy Family Physician of the Year

Anne Pylkas, MD, is the medical director of Sage Prairie Recovery and manages chronic pain and addiction within the HealthPartners Pain Management Center. She is is board-certified in internal medicine and addiction medicine.

Family Medicine & Emergency Medicine Physicians • • • • •

Great Opportunities

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

POSITIONS AVAILABLE:

OB GYN & FAMILY MEDICINE – Full-scope practice available (ER, OB, C-Section, Hospitalist, Clinic) • Independent/growing system • Located in the heart of lakes country, Staples, MN • Critical access hospital with 5 primary clinics and a senior living facility • 15 family medicine physicians and 16 advanced practice clinicians • Competitive salary, benefits, and sign-on bonus available Contact Michael Paul at 218.894.8633, or michaelpaul@lakewoodhealthsystem.com

MARCH 2018 MINNESOTA PHYSICIAN

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

Urgent Care Physicians HEAL. TEACH. LEAD.

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 positions:

Cardiologist

Orthopedic Surgeon

Psychologist

Endocrinologist

PACT/ Woman Health Director Pulmonologist

Emergency Medicine Physiatrist

Urologist (part-time)

Hospitalist

ENT (part-time)

Psychiatrist

apply online at www.USAJOBS.gov

(605) 333-6852 ·

At HealthPartners, we are focused on health as it could be, affordability as it must be, and relationships built on trust. Recognized once again in Minnesota Physician Publishing’s 100 Influential Health Care Leaders, we are proud of our extraordinary physicians and their contribution to the care and service of the people of the Minneapolis/St. Paul area and beyond. As an Urgent Care Physician with HealthPartners, you’ll enjoy: • Being part of a large, integrated organization that includes many specialties; if you have a question, simply pick up the phone and speak directly with a specialty physician • Flexibility to suit your lifestyle that includes expanded day and evening hours, full day options providing more hours for FTE and less days on service • An updated competitive salary and benefits package, including paid malpractice HealthPartners Medical Group continues to receive nationally recognized clinical performance and quality awards. Find an exciting, rewarding practice to complement all the passions in your life. Apply online at healthpartners.com/careers or contact Diane at 952-883-5453 or diane.m.collins@healthpartners.com. EOE

www.siouxfalls.va.gov

PRACTICE WHERE BEAUTY SURROUNDS YOU

Family Practice Physician Join a provider-driven not-for-profit organization in our Cook, MN location. Work in a well-established, modern facility. Participate in on-call schedule, share in-patient and after-hours care, (no OB). BC/BE and current or eligible for MN license required. National Health Service Corps loan repayment potential.

WORK-LIFE BALANCE: • Competitive salary • Significant starting & residency bonuses • 4-day work weeks • 51 annual paid days off Ski, hike, run, fish, canoe, kayak, camp and more in nearby state parks, Boundary Waters Canoe Area, Voyageurs National Park and Superior National Forest. Please contact: Travis Luedke, Cook Area Health Services, Inc., 20 5th St. SE, Cook, MN 55723 tluedke@scenicrivershealth.org 218-361-3190

THE STRENGTH TO HEAL and get

back to what I love about family medicine.

Do you remember why you became a family physician? When you practice in the Army or Army Reserve, you can focus on caring for our Soldiers and their Families. You’ll practice in an environment without concerns about your patients’ ability to pay or overhead expenses. Moreover, you’ll see your efforts making a difference. To learn more, visit healthcare.goarmy.com/kb60

MINNESOTA PHYSICIAN MARCH 2018

beneficiary, congressional, and provider customer service operations.

3The Annual Wellness Visit from page 13

He reaches out to Congressional Field offices, provider associations, and

To increase Medicare AWV utilization over the next five years, take the following actions with Medicare providers and people with Original Medicare: • Visit ngsmedicare.com for free tools, resources, and webinars to help you and your office staff understand AWV guidelines and what to do if your patient needs additional services during an AWV visit. • Educate Medicare seniors that Medicare AWV is not a yearly physical but a wellness check.

beneficiary advocacy groups to educate them on the biggest impacts that may affect how people with Medicare receive their Medicare benefits. Michael has received numerous national and regional citations for his efforts from the Centers for Medicare & Medicaid Services, Members of Congress, and senior advocate groups.

Time spent finding a mental health professional means delays in receiving treatment.

Carolyn S. Henson, CPC, CAC, is a Part B Provider Outreach & Education Consultant and has over 23 years of experience as a Medicare

• Promote the AWV benefits to your Medicare patients at other patient encounters.

educator, both for internal departments and the provider community. She currently works in the

Conclusion

Provider Outreach and Education Department and

Now that we understand the misconceptions, billing errors, and, most importantly, the benefits of Medicare AVW, the Minnesota Aging community partners are working with physicians to promote AWV benefits to Medicare seniors and to avoid AWV billing errors. For more information about the AWV, go to medicare.gov or ngsmedicare.com.

teaches Medicare billing coverage and policies.

Nathan L. Kennedy, Jr., CPC, CHC, has worked with National Government Services for nearly 30 years obtaining a broad knowledge base of the entire Medicare Part B program. Nathan continually upgrades his knowledge by

Michael J. Dorris, serves as Jurisdiction Affairs Manager for Congressional

working with other areas of the Contractor and assisting with issues that arise

Field Offices, Medicare Providers, and External Medicare Partners for 20

on a company level.

states and five U.S. territories. He has been with National Government Services, Inc., for over 23 years. Michael has served in many roles with

Minneapolis VA Health Care System Opportunities are available in the following specialties:

• Associate Chief of Ambulatory Care • Chief of Internal Medicine • Chief of Nephrology • Director of Primary Care Pain Management • Internal Medicine/Family Practice • Outpatient Clinics: Maplewood, MN (Rover); Chippewa Falls, WI; Superior, WI

US citizenship or proper work authorization required. Candidates should be BE/BC. Must have a valid medical license anywhere in US. Background check required. EEO Employer.

Minneapolis VA Health Care System (MVAHCS)

is a teaching hospital providing a full range of patient care services with state-of-the-art technology, as well as education and research. Comprehensive health care is provided through primary care, tertiary care and longterm care in areas of medicine, surgery, psychiatry, physical medicine and rehabilitation, neurology, oncology, dentistry, geriatrics and extended care.

Possible Recruitment Incentive • Competitive Salary Excellent Benefits • Paid Malpractice Insurance

For more information on current opportunities, contact: Nicole Barthelemy: Nicole.Barthelemy@va.gov • 612-467-4304 or Yolanda Young: Yolanda.Young2@va.gov • 612-467-4964

One Veterans Drive, Minneapolis, MN 55417

MARCH 2018 MINNESOTA PHYSICIAN

•

www.minneapolis.va.gov

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3Opioid prescribing from page 11 and carefully manage any who remain on opioid medication. The full set of the Minnesota OPWG draft guidelines is available at: https://mn.gov/dhs/assets/draft-complete-set-of-recommendations_ tcm1053-319378.pdf Consider the following risk strategies when prescribing opioids: • Know your patient’s history and evaluate their risk of addiction. As stated earlier, it is vital to provide a thorough assessment prior to prescribing opiates to avoid the risk of patient dependence and/or death. • Access the state prescription monitoring program (PMP) database to evaluate a patient’s history of opioid use. By checking the PMP, providers are able to assess if patients are taking or have taken opioids in the past. This should be done prior to any new prescription and periodically for those patients on chronic therapy. • Evaluate non-opioid pain management options. Non-opioid and non-pharmacologic interventions may be sufficient to treat some types of pain. An individual functional assessment should be performed and care planning should be completed in partnership with the patient. • Prescribe the lowest effective opioid dose. As mentioned earlier, starting with the lowest, most effective dose can prevent risks related to opioid exposure.

• Limit prescriptions for acute pain to a three-day supply for an injury and a seven-day supply for post-surgical pain. As part of the normal healing process, pain should begin to decrease within a few days of an injury or surgery. Providers should reassess pain and the overall treatment plan often to avoid issues with chronic opioid use. • Educate patients about the risks of opioids. Patients should be viewed as partners in planning their ongoing care. • Implement evidence-based practices for chronic pain management. The literature does not currently support the longterm use of opioids. Staying current with opioid-related prescribing practices will help providers stay within the standard of care when treating patients for pain.

Conclusion The risks of opioid prescribing to both patients and providers has grown exponentially over the last several years. Primary care is on the front line of a battle that has taken many lives. In order to change the trajectory, health care providers must ensure that they implement a standardized approach to pain management and follow the most up-todate recommendations. Ann Fiala, RN, BSN, CPHRM, CHC, is a senior risk consultant at Coverys. She has more than 30 years of health care experience with extensive experience in medical staff credentialing, regulatory readiness, patientcentered care, utilization and case management, and data analytics.

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is for Cancer Care. University of Minnesota Health Cancer Care brings care innovations close to home. We are proud to bring breakthrough cancer treatment options to your patients, right in their own communities. We partner with renowned research experts at Masonic Cancer Center, the Twin Cities’ only NCI-designated comprehensive cancer center, to provide advanced, multidisciplinary treatment options and clinical trials—many of which are not available anywhere else.

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