Minnesota Physician December 2011 by Minnesota Physician Publishing

Volume XXV, No. 9

December 2011

The Independent Medical Business Newspaper

Handoff communication

Creating a new process to improve care By Sommer Alexander, MS, and Michael Aylward, MD

onsider the following two scenarios:

The physicians’ reflections on 2011’s top stories run the gamut from new medications and treatments for specific diseases to how new of 2011, technology and payment models are affecting their for 2012 practices. Some see sweeping changes ahead due to health care and payment reforms; others envision progress in improving patient care and reducing morbidity and mortality from chronic, relentless diseases. We thank all the physicians who participated in this feature for sharing their perspectives with our readers.

the page

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s we approach the end of year, we’ll soon be seeing the inevitable end-of-the-year “Best of 2011” lists—from the frivolous to the proTop stories found. In health care, highpredictions impact medical news in 2011 ranged from foodborne illness to the aftermath of natural disasters; and from political concerns and new models of care to breakthrough drugs for various medical conditions. For a Minnesota perspective on the past year in medical news, we asked physicians to answer two questions for this feature: 1. What was the “big story” or major trend for your medical specialty/practice in 2011? 2. What predictions do you have for your medical specialty/practice in 2012?

• A 52-year-old woman with COPD comes to the emergency department (ED) with cough and fever. She is diagnosed with pneumonia, and ceftriaxone and azithromycin are ordered. The ED physician calls the inpatient physician. The ED nurse calls the inpatient nurse. The patient arrives on the floor, and it is not clear whether she ever received the antibiotics. The inpatient nurse pages the resident admitting for that night. The resident says, “I've never heard of that patient, are you sure she’s coming to us?” And so on. • The same patient comes into the ED, a diagnosis of pneumonia is made, and the patient is given antibiotics. The physicians and nurses who were caring for her in HANDOFF to page 22

IN THIS ISSUE:

Senior and long-term care Page 20

CONTENTS

DECEMBER 2011 Volume XXV, No. 9

FEATURES Turning the page Top stories of 2011, predictions for 2012

Handoff communication Creating a new process to improve care

MINNESOTA HEALTH CARE ROUNDTABLE

T H I R T Y- S E V E N T H

SESSION

By Sommer Alexander, MS, and Michael Aylward, MD

DEPARTMENTS CAPSULES

MEDICUS

INTERVIEW

8 Jennifer Sorensen Minnesota HomeCare Association

PROFESSIONAL UPDATE: DIABETES Bending the curve on diabetes 30 By Maggie Powers, PhD, RD, CDE; Teresa Pearson, MS, RN, CDE, FAADE; and Rita Mays, MS, RD, LN

ANESTHESIOLOGY Pain control

Specialty pharmacy 32

By John R. Mrachek, MD

Controlling the cost of care Thursday, April 19, 2012 1:00 – 4:00 PM • Duluth Room Downtown Mpls. Hilton and Towers

SPECIAL FOCUS: SENIOR AND LONG-TERM CARE Age-old injury, updated treatment

Awakenings 24

By Edward G. Hames III, MD, PhD, and Charles R. Watts, MD, PhD

By Laurel Baxter, MA, RN

Home care

By Amy Nelson

The Independent Medical Business Newspaper

Background and focus: Medications treating chronic and/or life-threatening diseases are frequently new products, which are often more expensive than generic or older, branded products that treat similar conditions. The term specialty pharmacy has come to be associated with these medications. Exponents claim the new technology improves quality of life and lowers the cost of care by reducing hospitalizations. Opponents claim the higher per-dose cost spread over larger populations does not justify the expense.

The cost of research, both failed and successful, is reflected in product pricing. Current federal guidelines allow generic equivalents marketplace access based on the patent date, not the release date, of a product. This considerably narrows the window in which costs of advances may be recovered. A further complicating dynamic involves the payers. Physician reimbursement policies sometimes reward utilizing lower-cost “proven” products and cast those prescribing highercost products as “over-utilizers,” placing them in lower-tiered categories of reimbursement and patient access. Objectives: We will discuss the issues that guide the early adoption of new pharmaceutical therapies and how they relate to medical devices. We will examine the role of pharmacy benefit management in dealing with the costs of specialty pharmacy. We will explore whether it is penny-wise but pound-foolish to restrict access to new therapies and what level of communication within the industry is necessary to address these problems. With the baby boomers reaching retirement age, more people than ever will be taking prescription medications. As new products come down the development pipeline, costs and benefits will continue to escalate. We will provide specific examples of how specialty pharmacy is at the forefront of the battle to control the cost of care.

www.mppub.com PUBLISHER Mike Starnes mstarnes@mppub.com EDITOR Donna Ahrens dahrens@mppub.com ASSOCIATE EDITOR Janet Cass jcass@mppub.com

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DECEMBER 2011 MINNESOTA PHYSICIAN

CAPSULES

State, Hennepin County to Create ACO Project Hennepin County and the Minnesota Department of Human Services (DHS) are partnering on a pilot accountable care organization (ACO) project to serve Medicaid enrollees in Hennepin County. “Hennepin Health” will be a demonstration project serving adults without children who earn less than $8,172 annually for an individual or $11,040 for a married couple. The project will seek to improve outcomes by providing integrated medical and behavioral health care, and social services, while reducing overall costs. “DHS is looking at newer, smarter ways of serving Minnesotans,” says DHS Commissioner Lucinda Jesson. “We are excited to partner with Hennepin County on this project [that] we think will deliver better results for people with higher needs.” County officials say they hope to develop an ACO model

that could be replicated in other parts of the county. ACOs have been in the spotlight recently as part of the federal Accountable Care Act, which proposes using ACOs throughout the country as a way to better coordinate care and bring down costs. The Medicaid population targeted by the pilot project is considered a good test population because it includes many individuals with higherthan-average needs or complex issues that require coordination of care. The county is in a unique position to develop the ACO concept, Hennepin County officials say, since county organizations are already coordinating care. “The county has a cooperative network, which includes a hospital, a health care center, a system of social workers and behavioral health experts, and a managed care organization,” says Jennifer DeCubellis, the county’s area director for Human Services and Public Health Department and director of the project. “By blending medical, behavioral health,

MINNESOTA PHYSICIAN DECEMBER 2011

and social services in a patientcentered care model—and managing the dollars—we should reduce costs and the impact on other systems such as law enforcement, corrections, the courts, and community agencies.”

Questions Raised About Best Age for Cancer Screenings A new finding by University of Minnesota surgeons is raising questions about the most appropriate age for screening for rectal cancer. The American Cancer Society currently recommends that Americans age 50 or older be screened for colorectal cancer. But the U of M study, published in the journal Cancer, found a rise in rectal cancer in people age 40 and younger. The U of M researchers, using the largest cancer database in the United States, found that signet cell histology, a unique type of cancer cell, was almost five times more preva-

lent in those under age 40 with rectal cancer than in older patients. “The prevalence of signet cell histology in patients under age 40 was statistically significant at 4.63 percent versus 0.78 percent in patients over 40,” says lead investigator Patrick Tawadros, MD, PhD. “While rectal cancer remains fairly uncommon in patients under 40, the rising trend, combined with our novel finding that signet cell histology is found at a rate of almost one in 20 in this population, is cause for attention,” Tawadros says. “Clinicians need to be aware of this condition and carefully assess patients who present with any symptoms or signs that may be suggestive of rectal cancer.” Tawadros adds that his team will do further research to see if a combination of genetic testing and other screenings might help in more effectively assessing a patient’s risk for rectal cancer.

Dayton Creates Two Task Forces for Health Care Issues Gov. Mark Dayton has created two new task forces to lead health care reform efforts in Minnesota. The governor says his Vision for Health Care Reform task force will develop an action plan for reforming how the state delivers and pays for health care in Minnesota. He is also establishing a task force to help set up health insurance exchanges in the state. â&#x20AC;&#x153;Minnesota historically has led the nation and the world in the quality of our health care systems and the healthiness of our residents,â&#x20AC;? Dayton says. â&#x20AC;&#x153;Minnesota also has been a leader in reforms that have expanded access to quality health care for all Minnesotans. We must continue to innovate, and there is real urgency to our mission. Health care costs are rising at an unsustainable rate, undermining the budgets of Minnesota families, businesses, and our state and federal government budgets. The status quo is not good enough; we need to find new ways to delivering better quality health care at a lower price. The mission of this task force is to provide recommendations about how we can best accomplish this.â&#x20AC;?

Costs Reduced by Allina/HealthPartners Collaboration A collaborative effort between Allina Hospitals and Clinics and HealthPartners resulted in more than $6 million in reduced medical costs in its first year, according to the two organizations. The Northwest Metro Alliance attempted to make health care delivery more efficient by enhancing connections between health care providers, integrating the electronic medical records used by both organizations, and providing better data to providers about performance in comparison to their peers.

Some specific strategies used by the two groups included increasing the use of generic drugs; reducing the rate of induced labor at Mercy Hospital; expanding urgent care services so that emergency department use was reduced; providing expanded support for high risk and complex patients; and improving patient satisfaction. Officials say that as a result of the collaboration, the medical cost growth rate for the facilities involved dropped from 8 percent to 3 percent. â&#x20AC;&#x153;These results show the value of collaboration between health care organizations to create innovative models that can serve as an Accountable Care Organization, which are models of federal and state health care reform,â&#x20AC;? says Penny Wheeler, chief clinical officer for Allina Hospitals and Clinics.

Nursing Homes Join Program to Reduce Rehospitalizations Nearly 50 Minnesota nursing homes are joining an effort to reduce rehospitalizations. The facilities are working with the Minnesota Department of Human Services (DHS) to implement a program called â&#x20AC;&#x153;Interventions to Reduce Acute Care Transfersâ&#x20AC;? (INTERACT). The program has been adopted by 49 of the 384 nursing homes in Minnesota, and is based on a national model developed by geriatric care experts in Georgia and Florida. The INTERACT program provides a set of tools and practices that help nursing home staff make better observations about residents and changes in their health status. The program helps nursing home staff communicate more clearly and accurately with physicians and hospital personnel. â&#x20AC;&#x153;The overall goal is to reduce the inappropriate use of hospitals and also to create a work environment for staff in which they feel more empowered and more committed to doing a good job,â&#x20AC;? says Robert Kane, MD, who leads the UnivCAPSULES to page 6

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MINNESOTA PHYSICIAN

CAPSULES

Capsules from page 5 ersity of Minnesota’s Center on Aging and is the director of the Minnesota Area Geriatric Education Center (MAGEC). MAGEC is leading the education efforts with nursing homes who implement the INTERACT program in Minnesota. Staff members from participating facilities will undergo a one-year training program, and a mentor from MAGEC will also work with participating nursing homes to carry out the program.

Smoking Ban Cuts Cardiac Deaths, Study Finds A new report by Mayo Clinic researchers shows that the incidence of heart attacks and sudden cardiac deaths was cut by as much as 50 percent in Olmsted County after a smokefree ordinance took effect. The new report, presented at an American Heart Association conference in Orlando, shows that during the 18

months before Olmsted County’s first smoke-free law for restaurants was passed in 2002, the regional incidence of heart attack was 212 cases per 100,000 residents. In the 18 months following a comprehensive smoke-free ordinance in 2007, the report says the rate dropped to 103 cases per 100,000 residents—a decrease of about 45 percent. Additionally, the report found a 50 percent decrease in sudden cardiac arrest cases during that period. “This study adds to the observation that smoke-free workplace laws help reduce the chances of having a heart attack, but for the first time we report these laws also reduce the chances of sudden cardiac death,” says Richard Hurt, MD, director of Mayo Clinic’s Nicotine Dependence Center. “The study shows that everyone, especially people with known coronary artery disease, should avoid contact with secondhand smoke.” The study, supported by a grant from anti-tobacco group ClearWay Minnesota, also

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found that the adult smoking rate dropped 23 percent after the smoking ban began.

MAPS Expands Scope, Hires New Director The Minnesota Alliance for Patient Safety (MAPS) has launched a reorganization that will see the St. Paul-based group expand its scope of patient-safety efforts after hiring a full-time director. The group announced in November that it had hired Nancy Kielhofner, RN, most recently executive director of quality, safety, and accreditation at Allina Hospitals and Clinics. Kielhofner, who served as MAPS culture workgroup co-chair during the past year, will now be executive director of MAPS. Kielhofner notes that Minnesota has been a leader in patient safety and that the MAPS reorganization will allow the group to expand on its earlier work. “The time has come to really re-evaluate and raise the

bar even more for patient safety in Minnesota,” she says. “The mission is to do a thorough analysis and assessment of the organization’s current state, and talk to key safety and quality leaders in health care across the state, including not only hospitals but also nursing homes, long term care, assisted living, ambulatory clinics, and hospice.” The expansion of patient safety efforts is part of a movement in the industry to recognize the interconnectedness of care, Kielhofner says. “This is a recognition that patient safety is not just focused on hospitals,” she says. “We’re really expanding safety efforts across the state in all areas of health care because the transitions of health care are so important.” As part of the restructuring, MAPS will be incorporated as a not-for-profit organization, Kielhofner says, and will be able to expand its membership base to a wider range of health care facilities and groups.

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MEDICUS

Ronald Petersen, MD, has been named chairman of the U.S. Department of Health and Human Services’ new Advisory Council on Alzheimer’s Research, Care and Services. Petersen currently directs the Alzheimer’s Disease Research Center at the Mayo Clinic in Rochester. He also is director of the Mayo Clinic’s Study of Aging. As chairman of the advisory council, Petersen will lead a group of more than 20 members from the public and private sectors who will meet quarterly to discuss the effectiveness of government programs that target individuals who have Alzheimer’s and related dementias as well as their caregivers. Vanessa Knoedler, MD, has joined Metro OBGYN, where she sees patients of all ages at clinic locations in St. Paul, Maplewood, and Woodbury. Board-eligible in obstetrics and gynecology, Knoedler earned her medical degree at New York Medical College in Valhalla, and completed her residency at Mercy Hospital and Vanessa Knoedler, MD Medical Center in Chicago. Her special medical interests include well-woman care, reproductive medicine, and minimally invasive and robotic surgeries for conditions such as uterine fibroids. She is on the medical staff of St. John’s Hospital in Maplewood, St. Joseph’s and United Hospitals in St. Paul, and Woodwinds Health Campus in Woodbury. Charles Fazio, MD, has been appointed chief medical officer of Gestalt Health, a Minneapolis-based deliverer of real-time health care information to partners within the health care community. Fazio most recently served as the chief medical officer and senior vice president at Medica Health Plans in Minneapolis. Prior to working at Medica, Fazio practiced at a succession of clinics and medical centers as a medical director, staff physician, and emergency room physician. Four physicians have recently joined Duluth-based Essentia Health. Erik Wendland, DO, has joined the Nephrology Department Erik Wendland, DO at Essentia Health-Duluth Clinic. Wendland completed a residency at Hennepin County Medical Center in Minneapolis and a fellowship in nephrology at the University of Connecticut in Farmington. He attended Lake Erie College of Osteopathic in Erie, Pa. Paul Tonkin, Paul Tonkin, MD MD, has joined the Urology Department at Essentia Health-Duluth Clinic. Tonkin attended medical school at the University of Minnesota Duluth (UMD), and completed his residency in urologic surgery at the Medical College of Wisconsin in Milwaukee. He received his medical degree from the University of Minnesota and was in UMD’s David Jorde, MD Rural Physician Associate Program. David Jorde, MD, has joined Essentia Health’s Lakewalk Clinic as a family medicine physician. Jorde received his medical degree from the University of Minnesota Medical School and completed his residency at the Duluth Family Practice Center. Before joining Essentia, Jorde practiced in Grand Marais and on the Fond du Lac Reservation. Joseph Levine, MD, has joined Essentia Health’s Cancer Center in Duluth as a hematologist/oncologist. Levine received his medical degree from Joseph Levine, MD the University of Minnesota Medical School and is board-certified in internal medicine. He completed his internal medicine residency at HCMC in Minneapolis and his fellowship in hematology/oncology at the U of M.

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MINNESOTA PHYSICIAN

INTERVIEW

Home care part of total package of health care ■ What can you tell us about the mission and his-

tory of the Minnesota HomeCare Association? The mission of MHCA is to be the voice of home care through advocacy, education, and networking. The association has been around for 41 years. It was founded by a group of home care providers and has really grown in regard to the needs of home care, making sure that there are standards, and that providers have the resources they need to be able to provide good quality care. ■ Tell us a little bit about the different kinds of

licenses your members hold. Jennifer Sorensen Minnesota HomeCare Association Jennifer Sorensen is the executive director of the Minnesota HomeCare Association (MHCA). The St. Paul-based organization represents 250 members, including 90 percent of all Medicare-certified agencies in Minnesota. Sorensen co-chairs the Strategic Communications Committee for the Minnesota Council on Aging, is a member of the Reducing Avoidable Readmissions Effectively (RARE) Advisory Committee, and serves on the Preparing Committees Leadership Group of the Prepare Minnesota for Alzheimer’s 2020 initiative.

■ If a physician determines that a patient would

benefit from home care, then how is the home care provider chosen? It can be done by direct referral. Most of our agencies try to have a working relationship with physician groups, offices, things like that, in regard to referrals. They will actually go out and let the physicians’ offices know who they are and what services they provide. Some of the physicians’ offices are set up differently. They may have a medical social worker who is available to assist with the referral process, or a discharge planner may assist with patients coming out of the hospital. A lot of times it’s based off a list, or the client could be directed to call the health plan to find out who is in your network.

In Minnesota, we have four different classes of license. There is a class A, what is called a professional home health license. The provider may provide all home care services, such as nursing, physical therapy, speech therapy, occupational therapy, nutrition services, social services, home health aide tasks, or the provision of medical supplies and equipment. These services ■ Tell us about the “facemay be provided in a place of to-face” Medicare requireresidence, including a resiments and their impact on dential center, and housingAs an association, home care. with-services establishments. we would like to partner Face-to-face is a CMS federal The class B, or pararequirement for physicians to professional agency license, better with physicians have seen the patient and allows the provider to peron education and signed off on home care 30 form home care tasks and days prior to implementation home management tasks in collaboration. of services or within 60 days a place of residence. of services starting. If the The class C licenses the physician does not sign off individual paraprofessional caregiver. We skip D on that plan of care for the home health agency, and E, and go to F. Under this license, a provider Medicare will not reimburse the home health can provide home care services solely for a resiagency for any services rendered. dence of one or more registered housing-withIt’s one of those things that is very frustrating services establishments. The class F is the assisted because the physicians really don’t understand, living component; services provided under this because it doesn’t affect them, other than they have licensure include nursing services, delegated nursto schedule an extra appointment that a patient ing services, or other services performed by unlimay or may not necessarily need, and then they’re censed personnel. filling out another piece of paper. Minnesota is very complex in regard to the The ramifications of the physician not signing number of licenses. There is discussion and work that piece of paper don’t impact the physician at being done at the state level to revise the current all, but they impact the home care agency 100 perregulations to collapse all of these into maybe two cent. Home health agencies are relying on an different types of state licensures. action of the physicians, but it’s out of their con■ What are the kinds of health care services trol, so they spend a lot of time, resources, and provided by home care? back office staff getting that paperwork filled out and making sure that they’re seeing these patients. Skilled care is care for those who are in need of medical attention. Skilled services may include RN oversight; medication management; physical, occupational, and speech-language therapy; cardiac and pulmonary care; wound care; home health aide; social services support; and infusion therapy. There is also hospice and palliative care for those with terminal illnesses. All of these require a physician’s order. There are also other unskilled or companionlevel-care services. These services may include companionship, certified nurses aides assisting

with activities of daily living, or even respite care and medication management, and do not require a physician’s order.

MINNESOTA PHYSICIAN DECEMBER 2011

■ This sounds like it’s an administrative burden for

the physicians, and there’s some resistance there. How do you deal with that? A lot of our members have worked together to put together a template so that it’s easier for the physician to read, see, and sign off. The home care agencies do a lot of hand-holding and calling and faxing. I think one agency faxed a form 14 times before they could finally get it signed. Other states are having bigger issues than we

are. We have a little better track record in Minnesota. What’s happening in other states is then they have to write off the service because they can’t get paid, and they end up having to discharge the patient. And that directly impacts the patient. As an association, we would like to partner better with physicians on education and collaboration so that they fully understand the scope of home care, and what home care agencies can do for them to keep rehospitalizations from mounting. Home care is where they’re going to be able to find that impact. If we can give the right amount of services at the right time, we can eliminate some of those rehospitalizations. ■ Are there areas where that collaboration

is better? I think you’ll see more of that maybe in rural areas—there are only a couple of home health providers, and there are only a handful of physicians, so you see better collaboration. When you get into the larger metro areas, you see a lot of disconnect because there are so many people, it kind of gets lost in the shuffle. ■ What’s an example of how home health

agencies communicate with physicians? There are a few threads that relate back to the rehospitalization issue. Medication management is the number one rehospitalization

issue. Home health agencies will go into a home, they’ll be monitoring the main medications and then look over to the nightstand and see a bottle of aspirin, a bottle of Tylenol, and of Advil. And as harmless as they may seem, all these things impact the other regimen of medications. If the patient says, “I’m still gonna take it because I’ve been taking baby aspirin for years,” at least we can be a vehicle to let the physician know that, hey, this is happening, you may just want to be aware of this. ■ What needs to be done to improve access

to home care? Reduce the amount of back office administrative components. Even physicians suffer from this; this is truly an industry-wide issue. You have to have double the staff in the office just to get paid so you can be out surveying your patients and your clients in their homes or in their medical office. It’s really kind of gotten out of control in terms of trying to put in safeguards for fraud and abuse and those types of things. We just did a cosponsored event with a group from the Netherlands that has made some innovations in home care. One of the things said at the table was, we keep piling regulation upon regulation to try to fix an issue within the system. But what we don’t do is go back and take the other regulations off to really realign it. So it’s almost like we

need to wipe the slate clean and start over. The other issue is the cost of care. As the cost rises and people live longer, we have issues with how to continue services as reimbursement gets cut. We keep getting more and more people needing more complex services, but the reimbursement rates for those services keep plummeting. It makes it very difficult for home health agencies and other specialties to stay alive. I’ve heard some say, well, people just get into home care because there’s a lot of money to be made. I really find that to be untrue. ■ What is the most important thing you

want doctors to know? I want them to know that home health care augments total care. It needs to be in play in a whole plan of care. If there are ever questions about it, do not be afraid to call the home health agency and ask, because they are more than willing to educate and share with physicians. Especially if you’re dealing with chronically ill folks that need care, it’s definitely a positive option for patients because a lot of that monitoring and day-today care can be taken care of, and the physicians can know that they’re receiving good care at home. At the end of the day, it’s about the patient; it’s not about the physician or the home health agency. It’s about, did we provide the best care for this individual?

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ACEI, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; BP, blood pressure; CO, cardiac output; PVR, peripheral vascular resistance; RAAS, renin-angiotensin-aldosterone system.

Not an actual health care professional.

For additional hypertension control,

– Renin triggers RAAS activation1 – Many untreated hypertensive patients, including those with diabetes, have an overactive RAAS4 – ACE inhibitors and ARBs only partially block the RAAS1

References: 1. Jackson EK. Renin and angiotensin. In: Brunton LL, Lazo JS, Parker KL, eds. Goodman & Gilman’s The Pharmacological Basis of Therapeutics. 11th ed. New York, NY: McGraw-Hill Companies, Inc; 2006:789-822. 2. Data on file. Clinical study report 2327. Novartis Pharmaceuticals Corp. 3. Chrysant SG, Melino M, Karki S, Lee J, Heyrman R. The combination of olmesartan medoxomil and amlodipine besylate in controlling high blood pressure: COACH, a randomized, double-blind, placebo-controlled, 8-week factorial efficacy and safety study. Clin Ther. 2008;30(4):587-604. 4. Alderman MH, Cohen HW, Sealey JE, Laragh JH. Plasma renin activity levels in hypertensive persons: their wide range and lack of suppression in diabetic and in most elderly patients. Am J Hypertens. 2004;17(1):1-7.

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Ann Dillon, MD

Turn from cover Charles Horowitz, MD Minneapolis Clinic of Neurology Specialty: Neurology 2011 has been a major year of transition for the neurologists at the Minneapolis Clinic of Neurology, as we make the transition from paper charts to electronic health records (EHR). The change to EHR has affected us and our patients in ways that are significant. Neurology is a cognitive specialty. We are grounded in getting the full story from our patients, doing a thorough neurologic exam, and spending time to discuss our thoughts and plans. In the past, the orders, prescriptions, and letters to our referring doctors were all paper-based and took a relatively short time to complete, and the majority of our visit was spent in direct care. We now find ourselves spending a good portion of our time with patients reconciling their electronic medication list and waiting for e-prescribed medications to be accepted on our computer screen, scrolling through to click on appropriate orders, and being sure to complete the mandatory screens to achieve “meaningful use.” Patients are learning to be patient with this process. In our effort to maintain the same quality of care and communication with our patients, the visits are longer and the after-clinic hours are much longer. The transition to e-medicine is also changing how we physically see patients. In 2012 and beyond, we will see more examples of telemedicine, and telestroke care is going to become increasingly prevalent in Minnesota and the five-state area. This will potentially allow state-of-the-art stroke care to outstate areas. Neurologic research continues to make amazing genetic discoveries, but for the first time the editorials are focusing on cost-effectiveness of science discoveries and of clinical practices. We can look forward to increasing dialogue and debate in these areas.

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Sharpe, Dillon, Cockson & Associates, PA, Edina Specialty: Internal medicine One of the roles of a primary care internist is to consult with patients about their health care questions. With a patient population that is generally well educated and computer savvy, this means spending a lot of time reviewing issues; possibly correcting advice from trainers, neighbors, hairdressers, and Dr. Phil; and coordinating care with herbalists, chiropractors, and healers. 2011 seemed particularly prone to these discussions, as many previous “givens” have been undergoing re-evaluation. For example: Then: Pap smears yearly Now: Pap smears every three years Then: PSA for prostate screening Now: Don’t use PSA Then: Take your vitamins Now: Possible excess mortality with vitamins Then: Take your calcium Now: Possible excess coronary artery disease with calcium Then: Vitamin D—“Huh?” Now: Does Vitamin D cure heart disease, depression, and arthritis? As we are one of the few remaining small, independent internal medicine practices in the area, 2012 will hold many challenges. Electronic health records (EHR) will finally arrive in our practice, a major change that the doctors and staff both dread and anticipate. The financing of said EHR for a small group necessitates some loss of independence and a realignment of our business arrangements after 30 years. Consolidation of medical care into “coordinated care systems” should become more of a reality and change how we practice medicine. This may ultimately eliminate fee-for-service and introduce bundling of charges that will unite doctors, hospitals, and social services in a new network to deliver health care. Who says you can’t teach old dogs new tricks? Doctors in the next few years will prove that adage wrong!

Paul Waytz, MD Arthritis and Rheumatology Consultants, Edina Specialty: Rheumatology Things occur slowly in rheumatology. Rather than experiencing highlights, rheumatologists get excited more by encouragements or tendencies. Blockbusterism is foreign to rheumatology. Given those caveats, 2011 wasn’t too bad. Though several medications have been used off-label to treat systemic lupus, Benlysta (belumimab), a monoclonal antibody that inhibits certain B-cell activities, became the first lupus drug to gain FDA approval in more than 50 years. It is not precisely clear who will most benefit from the use of Benlysta, which is given intravenously. Patients with severe renal or CNS disease were not included in clinical trials; an endpoint was that people generally “did better.” Studies have been cited for various shortcomings, but the idea of a new drug for a disease with potentially serious morbidity and mortality does offer promise. 2011 provided several studies showing very encouraging safety data regarding anti-TNF (tumor necrosis factor) medications and risk of malignancy. These medications have become a mainstay in treating rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis. Since their introduction 13 years ago, a major concern has been higher cancer rates, given TNF suppression—especially in adult RA, where the risk of cancer, especially lymphoma, is already elevated. The studies found that aside from certain skin cancers, rates of cancer were not increased.

In 2012, another biologic—the first one to be administered orally—will become available for treating rheumatoid arthritis. More interestingly, perhaps, the extremely effective Enbrel, which generated sales of over $3 billion in 2010, will be the first biologic to lose its patent. The FDA will likely determine the issue of “biosimilars” for biologics before this year ends. The pharmaceutical industry will need to address issues related to how similar something generic needs to be, the potential need for comparative clinical trials, the prolonged necessity to assess certain side effects, and what to require for a biosimilar that might be more effective. And then there are the cost and coverage issues …

Nicholas J. Meyer, MD St. Croix Orthopaedics, Stillwater Specialty: Orthopedics The latest development in my specialty of hand surgery has been the introduction of the longawaited collagenase injection (Xiaflex) for Dupuytren’s disease. This enzymatic injectable breaks down the contracted fascia to relieve contracture in appropriate patients with Dupuytren’s. It has taken more than 10 years to get the product to market and into the hands of doctors, and the $3,000 cost per injection reflects that expensive and time-consuming process. So, is this high-tech, high-cost alternative “worth it,” when (a) surgery for Dupuytren’s costs about the same (and is slightly more effective; and (b) needle aponeurotomy—a low-tech, low-cost, and essentially equally effective alternative—are also available? That’s a question we have to ask. It’s imperative that our health care community continue to rein in health care costs while providing effective care. Another big development in orthopedic surgery over 2010–2011 has been in hip replacement surgery. Less invasive, more bone-sparing techniques have been developed and proven to be very effective. However, some of these prostheses showed early wear and loosening characteristics and had to be recalled. Fortunately, most of these patients do fine and don’t have any symptoms or need for further surgery. Looking to 2012, the health care storm brewing on the horizon threatens to become a deluge. Our unsustainable state of health— whether it’s Medicare, costs in general, obesity, or drug abuse— needs to be corrected proactively or it will consume our nation’s resources. Orthopedic surgery has been a target for those trying to decrease costs. Whether this is related to a perceived unfair reimbursement policy for procedures, the cost of implants, or baby boomers needing total joint replacements, it seems that orthopedic surgeons are coming under increasing attack from the public and others in health care, and that orthopedic surgery in general will remain under scrutiny. Regardless, our goal in orthopedics remains the same: to improve our patients’ lives by restoring function and reducing pain.

is no doubt, however, that there will still be a role for the traditional model of care delivery for many, if not most, seriously ill patients. A new effort by the National Institute of Mental Health, known as the Research Domain Criteria (RDoC), has set an ambitious and exciting goal of reconceptualizing psychiatric diagnosis on a foundation of neural systems that underlie different domains of behavior, such as fear circuitry, working memory, or reward learning, for example. There was a premature attempt to align the fifth version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), due to be published in 2013, with the findings of this effort, but this was significantly dialed back after justified accusations of over-reaching. However, this commitment of federal research dollars should start to make our diagnostic system gradually more reliable and valid for the future, and enhance our ability to develop and choose better treatments for our patients.

Colleen Casey, MD Center for Reproductive Medicine, Minneapolis Specialty: Obstetrics and gynecology, reproductive endocrinology It was the beginning of 2011, and I was sitting for my reproductive endocrinology oral boards. There I sat, trying to recall all of the enzymes necessary to convert cholesterol to estrogen, the work-up for Cushing’s disease, and ambiguous genitalia. On the shuttle back to my hotel, it dawned on me how quickly the field of reproductive endocrinology has changed. Very rarely will I diagnose and manage classic endocrine disorders or abnormalities of pubertal development, as my mentors (and board examiners) once did. Granted, I still see these patients, but more

Get ready for more shelf space. Eric Brown, MD Minneapolis VA Medical Center Specialty: Psychiatry Integration of psychiatric consultation into primary care has been seen as a potential solution to the difficulty of accessing care for many patients with psychiatric illness. This idea is becoming a reality, facilitated in part by the medical home movement. The change in role from direct provider to consultant for certain cases will feel strange to some psychiatrists, and will require developing a new comfort level and skill set. I believe it is likely that this will become an area of specialization for a certain cadre of psychiatrists. There

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often than not they come seeking pregnancy. Increasingly, patients want to store their eggs or sperm for future use for various reasons. Some are facing cancer therapy; others want to delay childbearing. For patients undergoing in vitro fertilization, there is an opportunity to cryopreserve excess embryos. For those ethically against freezing embryos, the choice to freeze oocytes prior to fertilization is an alternative option. Fertility preservation is an emerging field that offers both males and females an opportunity to delay childbearing for various reasons. The technology of preserving cells in the frozen state (embryos, sperm, oocytes, ovarian and testicular tissue) continues to improve, offering options for both male and female patients at risk for loss of reproductive function. The problem for cells cooled below freezing is that intracellular water crystallizes to form ice and salt concentrations rise, thus making cell survival impossible. The oocyte is particularly sensitive to freezing due to its large size and membrane composition. Advances in cryoprotectant composition and improved freezing techniques, such as vitrification, offer protection for embryos and oocytes from freezing injury. Although the American Society of Reproductive Medicine considers oocyte freezing for delayed childbearing experimental, small randomized trials have shown that oocyte vitrification is an efficient method to preserve oocytes. The field of reproductive endocrinology is revolutionizing our lives, and these advances hold great promise for the future.

Luke Benedict, MD Allina Medical Clinic, Hastings Specialty: Endocrinology The big story in diabetes is the current assault on established diabetes medications, so that the variety of effective treatments seems to be increasing and decreasing at the same time. Take Avandia, for example. In the public mind, this drug is now as reviled as Vioxx. What was once thought to be a wonder drug has been pulled from the market due a suspected (although never fully proven) increased risk of cardiovascular events. Avandia isn’t the only diabetes drug under scrutiny. Its cousin Actos, another thiazolidinedione drug, was linked in a recent European study to an increased risk of bladder cancer. And drugs in the GLP-1 analogue and DPP-IV inhibitor category (Byetta, Victoza, Januvia, Onglyza, Tradjenta) appear to increase the risk of pancreatitis and, possibly, some malignancies. Of course, what has really changed is patients’ knowledge of the benefits and risks of the medications they are taking. A simple Google search of “Avandia and heart attack” yields 1.5 million results; the top two direct you to law firms. People are much less willing to continue to take a medication that has the faintest whiff of negative publicity (has anyone else had a patient stop taking alendronate in the last year because she thought her jaw would become necrotic?). What is missing from all this is good science—a true risk/benefit analysis of treatment. When patients voice concerns regarding their medications at clinic appointments, I simply review with them the known benefits of the medication, and the known risks. Letting patients with osteoporosis know that the likelihood their alendronate will prevent a hip fracture is substantially higher than their risk of developing jaw osteonecrosis is usually reassurance enough. The future of endocrinology, and of diabetes management in particular, seems to be a circling back to the past. Time-proven medications—sulfonylureas, metformin, and insulin—may again be the preferred mainstays of therapy.

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MINCEP Epilepsy Care, Minneapolis Specialty: Neurology (epilepsy) Most contemporary epilepsy treatment attempts to continuously prevent seizures from starting up because it is usually impossible to predict when seizures will occur. The ideal epilepsy treatment would be activated only when a seizure starts and before the seizure causes impairment. Such a treatment would prevent clinical manifestation of the seizure without continuously subjecting patient to side effects of the treatment. Class I trials of two novel therapies aiming to achieve this goal were reported in the last year (Epilepsia(51), 2010; Neurology(77), 2011). Both involved a new approach to treating seizures: direct stimulation of brain. The SANTE (Superior Anterior Nucleus of the Thalamus in Epilepsy) trial examined results of continuous stimulation of both anterior nuclei of the thalamus via depth electrodes in a group of patients with very severe epilepsy. In approximately 40 percent of patients, the number of seizures was reduced by more than 50 percent during the blinded portion of the trial. Perhaps more interesting was a trial of the Responsive Neurostimulator (RNS). This device is a small processing unit implanted in the skull and attached to two or more electrodes placed directly on the area of cerebral cortex known to cause seizures in that particular patient. The RNS device is programmed to detect seizures and deliver current to the seizure onset area immediately after seizure is detected.

Unfortunately, bottom-line results were somewhat disappointing; approximately 35 percent of patients had seizures reduced by more than 50 percent during the blinded portion of the trial. While these results are no different than those achieved with medications, I think the approach underlying both trials is likely to lead to significant breakthroughs in the next decade if not in 2012. It is increasingly reasonable to imagine a world in which implanted devices play an important role in controlling seizures when medications don’t work. But a lot more work needs to be done.

Timothy D. Henry, MD Minneapolis Heart Institute Specialty: Cardiology The major advance in cardiology in 2011 has to be the tremendous progress made in the availability of percutaneous valve replacement, for both aortic stenosis and mitral regurgitation. This effort has just culminated with the FDA approving the first percutaneous valve for aortic stenosis in the United States. This continues the shift towards less invasive therapy for cardiovascular disease, which also includes the advantages of drug-eluting stenting for patients with left main coronary artery disease, compared to CABG (coronary artery bypass graft) surgery. Over the last decade we have experienced a major reduction in the mortality for cardiovascular patients. For example, in Minnesota cardiac disease is no longer the No. 1 cause of death; and in particular, deaths from heart attacks have decreased by more than 60 percent over the past 10 years. A consequence of this success is an older population with more complex disease. So the issue of percutaneous valves is extremely important because we have an increasing population of patients 85 to 95 years old with severe aortic stenosis, living at home. For these patients, open-heart surgery is frequently too high-risk, so the availability of a percutaneous valve procedure is a major advance. Since we have made such major progress in the mortality problem, we are now working on quality-of-life issues. We are seeing increasing complexity in patients who are living longer. I think the next major advance will be stem-cell therapy for cardiovascular disease. We’ve already made significant progress this year in cell therapy for patients with heart attack, refractory angina, heart failure, and peripheral arterial disease. In particular, we have strong evidence that stem-cell therapy works for patients who need to grow new blood vessels. Growing new heart muscle is a much greater challenge that will take more than a few years, but we’re moving in that direction.

Cancer rehabilitation also has changed in the past year in response to evidence that early exercise, including weightlifting, and reduction of obesity reduce the risk of lymphedema. Since many breast cancer survivors have chest and arm pain, the Cancer Rehabilitation Clinic is the first step toward fixing the problems that prevent patients from taking advantage of these important lifestyle changes. Physical medicine and rehabilitation (PM&R) has always focused on function and on developing techniques to improve quality of life and restore function. We’re now applying that focus on function to serve the need in cancer survivors. We expect PM&R cancer rehabilitation to grow, and growth means more physiatrists will be needed to enter this area of specialty. Recommendations for optimal screening and early detection of cancer-related morbidity will help oncology providers direct their patients to early rehabilitation care. The weakness and medical frailty induced by cancer treatment will not be viewed as “normal” anymore. Measuring and tracking outcomes from cancer rehabilitation will make the public aware of the cost-effectiveness and importance of cancer rehabilitation as an integral part of cancer recovery.

Richard C. Lussky, MD, MPH, FAAP Hennepin County Medical Center, Newborn Intensive Care Unit/Infant Apnea and Pulmonary Program Specialty: Neonatal medicine Newborn screening has evolved greatly since the introduction of the Guthrie test for PKU testing in 1962. In 2011, the field of newborn screening incorporated, for the first time, point-of-care testing with the recommendation to screen each newborn infant with pulse oximetry in the first 24 to 48 hours of life for critical con-

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Nancy Hutchison, MD Sister Kenny Rehabilitation Institute/Virginia Piper Cancer Institute, Minneapolis Specialty: Physical medicine and rehabilitation The big story in my practice is the growth of cancer rehabilitation as the key to cancer survivorship. Research on cancer rehabilitation has exploded in the last few years, and cancer survivors are availing themselves of resources that can minimize the impact of the morbidity from cancer treatment as well as improve and enhance recovery. Patients are better informed about treatment options now. Once they have a treatment plan for the cancer, they want to know how to maintain function and minimize the side effects of treatment. For example, I now see patients before they start radiation for head and neck cancers, to get them started on throat, neck, and arm exercises that will help stave off the stiffness and weakness that can lead to aspiration and muscle contractures.

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genital heart disease (CCHD). Each year, 4,800 infants (11.6/10,000 births) are born with CCHD and are at significant risk for disability or death if not diagnosed soon after birth. The most recent recommendations are at www.cdc.gov/ncbddd/pediatricgenetics/CCHD screening.html and in the October issue of Pediatrics. Additionally, the Minnesota Department of Health’s Newborn Screening Advisory Committee will soon provide a recommendation regarding a newborn pulse-oximetry screening algorithm. In 2012, care of neonates will continue to improve, based on the awareness that in high-risk newborns there is the potential for lifelong sequelae of multisystem organ injury, neurodevelopmental delays, and even death related to care provided in the first minutes to hour of life. The delivery room is becoming an extension of the newborn ICU with the incorporation of sophisticated ICU technology and the ability to provide real-time audiovisual feedback to optimize collaboration and communication among multiple health disciplines that are present for high-risk deliveries. We also are seeing a shift from a focus primarily on survival and life support-based interventions (as mortality rates have greatly diminished) to a more prevention-oriented approach to support. This is based on an improved understanding of the multidimensional nature of premature birth and the subsequent disease processes affecting very immature organ systems and the interplay among organ systems. An example is the multimodal approach to preventing neurological sequelae in high-risk populations of prematurely born infants using prenatal betamethasone, inhaled nitric oxide, surfactant, indomethacin, and caffeine—all working on different pathways of the pathogenesis of brain injury in the prematurely born neonate.

Ronnell Hansen, MD Minneapolis VA Medical Center Specialty: Radiology For radiology, issues of dose reduction and reimbursement have been significant in 2011 and will continue to take center stage in 2012. The primary focus has been on health/safety, as concerns over imaging radiation are driving innovative efforts at dose reduction and accurate reporting/tracking exposures over a patient’s lifetime. Various models estimate relative risks of single/lifetime radiation exposure; however, extrapolation to individual patient risk is challenging at best, with indeterminate predictive accuracy. The American College of Radiology has coordinated with several professional organizations, simplifying the individual-patient approach by using ALARA (“as low as reasonably achievable”) and diagnostic appropriateness principles: 1) protocols maximally lowering exposure while maintaining diagnostic accuracy and 2) evidence-based computer-ordering support gauging relevance to the clinical question. New software, variable x-ray energies, and super-fast scanning all contribute to significantly lower dose, often by 40 percent to 60 percent. Lower volume of IV contrast is also often possible, reducing patient renal stress and risk of reactions. While attention particularly focuses on the most vulnerable (pediatric and chronic disease patients), global efforts are directed to every patient. As in all of medicine, reimbursement reduction is complex and onerous to sustainability of practice and access for patients. Medicare funding for imaging has been cut seven times in six years, $5 billion since 2007 (spending is now at 2004 levels). Imaging growth is now low, at 2 percent. The Obama Administration has recommended an additional $1.3 billion in imaging cuts; many in policy agree this may damage patient access to care and threaten

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the sustainability of private practice. Radiology is in consensus with all of medicine that we must reduce costs and that imaging is vital to that solution. Of great concern, however, is that proposed new reductions will disproportionately affect multiple trauma, stroke, and cancer patients, who often require multiple scans interpreted by different subspecialty radiologists to survive serious illness/injury. As patient advocates, we must all stay tuned to unintended consequences of reform.

Richard L. Lindstrom, MD Minnesota Eye Consultants, Minneapolis Specialty: Ophthalmology While we live in a period of transformation and turmoil in American medicine, the future is bright for the ophthalmologist who positions the practice properly. The 78 million baby boomers will demand access to the best care available and choice of who delivers it. Ophthalmologists can provide primary eye-care services through the most complex tertiary surgical care, although the overall number of ophthalmologists in the U.S. is shrinking. The successful practice in the future will use an integrated eyecare delivery model. Ophthalmic surgeons will practice collegially and provide well-coordinated care along with medical ophthalmologist and optometry business partners. Each of these practitioners will be supported by technicians and assistants, all of whom should be focused on providing easy access for patients and synchronizing services among all care-team members. The practice will function most effectively when focused on a single line of business: eye-care services. The magic is in the integrated eye-care delivery system model, not the scale.

The big story in ophthalmology in 2011 was the introduction of Femtosecond laser-assisted cataract surgery. Today’s cataract patients are generally able to choose their refractive outcome with a variety of intraocular lenses now available. Some of these lenses can correct astigmatism and provide for reading or multifocal capabilities. Although the Femtosecond laser-assisted cataract surgery is very new technology, the hope is that it will provide more precision and predictability to meet patients’ desired refractive outcomes when used in conjunction with certain types of intraocular lenses. As cataract and refractive surgery are becoming more integrated, the future thriving ophthalmologist will need to successfully acquire and blend both surgical skills.

Anne M. Murray, MD, MSc Hennepin County Medical Center, Geriatrics Division Specialty: Geriatrics This summer, after 10 years of preliminary work and publications, I was very fortunate to receive a five-year grant from the National Institute on Aging for a study that will measure stroke and cognitive impairment in chronic kidney disease (CKD) patients: the BRain IN Kidney disease (BRINK) Study. The grant has transformed my career. It has enabled me to form an outstanding interdisciplinary team of collaborators from the University of Minnesota Medical School, Veterans Administration Medical Center (VAMC), and Mayo Clinic. We will explore why patients with moderate CKD (GFR <45) have four times the risk of stroke and twice the risk of dementia compared to patients without CKD. We will obtain brain MRIs and laboratory tests to measure the roles of stroke, white matter disease, inflammation, and dialysis initiation on cognitive decline.

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My goal is to use this study as a springboard for ancillary studies and to give Hennepin County Medical Center (HCMC) and the University of Minnesota Medical School trainees an opportunity to develop their own research careers. The study will be conducted at the Berman Center and the Chronic Disease Research Group at HCMC, the VAMC, and the Mayo Clinic in Rochester. The view to the future in geriatrics is less promising. There is a remarkable lack of “story” for academic geriatrics at the U of M Medical School, from the meager geriatrics and dementia medical school curriculum, to the absence of a geriatrics research institute, to unwillingness to support a division of geriatrics. As the health economics of the aging population confronts every health sector and the need for clinicians and researchers with geriatrics training explodes, the university persists instead in making investments in stem cell research, regenerative medicine, and medical devices. It is hurting us all. An endowed chair in geriatrics and a division of geriatrics could begin to build what has been sorely missing for the past 10 years.

Robert Ganz, MD Minnesota Gastroenterology, PA, Bloomington Specialty: Gastroenterology The field of GI continues to evolve quickly. The American Gastroenterological Association (AGA) recently published a new guideline on the diagnosis and treatment of Barrett’s esophagus, with several notable changes. The new guideline (Gastroenterology, March 2011) calls for screening for Barrett’s esophagus in patients with multiple risk factors, including the general population of white males over age 50, and patients with chronic GERD, hiatal hernia, elevated BMI, or intraabdominal distribution of fat. Also importantly, the guideline includes new recommendations for Barrett’s patients with high-

grade dysplasia; for Barrett’s patients with confirmed low-grade dysplasia; and for patients with nondysplastic Barrett’s esophagus (metaplasia only). The guideline notes limitations of scientific knowledge and uncertainty in several areas of Barrett’s, and emphasizes that in areas of uncertainty, decision-making should be shared between physicians and patients depending on the net health benefit. In the area of hepatology, there have been significant recent advances in the treatment of hepatitis C viral infection (HCV). The standard therapy for hepatitis C until very recently was a combination of pegylated interferon-alpha and ribavirin. However, this regimen was suboptimal, with a sustained virologic response (SVR) of only approximately 40 percent for HCV genotype 1, even after 48 weeks of therapy. The responses are even lower for black patients or and those for high viral loads or advanced fibrosis. This year has seen a major advance in HBV therapy with the approval of telaprevir (Incivek) and boceprevir (Victrelis), two new, direct-acting antiviral agents specifically targeted to inhibit proteases necessary for viral survival. Addition of these drugs to standard interferon therapy has resulted in dramatic improvements in SVR in both those naïve to treatment and nonresponders to prior treatment. Several additional direct-acting anti-HCV agents, as well as novel therapies directed at different HCV targets, are under development. These new therapies are revolutionizing the therapy of type C viral hepatitis.

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DECEMBER 2011

MINNESOTA PHYSICIAN

Victoza® (liraglutide [rDNA origin] injection) Rx Only BRIEF SUMMARY. Please consult package insert for full prescribing information. WARNING: RISK OF THYROID C-CELL TUMORS: Liraglutide causes dose-dependent and treatment-duration-dependent thyroid C-cell tumors at clinically relevant exposures in both genders of rats and mice. It is unknown whether Victoza® causes thyroid C-cell tumors, including medullary thyroid carcinoma (MTC), in humans, as human relevance could not be ruled out by clinical or nonclinical studies. Victoza® is contraindicated in patients with a personal or family history of MTC and in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). Based on the findings in rodents, monitoring with serum calcitonin or thyroid ultrasound was performed during clinical trials, but this may have increased the number of unnecessary thyroid surgeries. It is unknown whether monitoring with serum calcitonin or thyroid ultrasound will mitigate human risk of thyroid C-cell tumors. Patients should be counseled regarding the risk and symptoms of thyroid tumors [see Contraindications and Warnings and Precautions]. INDICATIONS AND USAGE: Victoza® is indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus. Important Limitations of Use: Because of the uncertain relevance of the rodent thyroid C-cell tumor findings to humans, prescribe Victoza® only to patients for whom the potential benefits are considered to outweigh the potential risk. Victoza® is not recommended as first-line therapy for patients who have inadequate glycemic control on diet and exercise. In clinical trials of Victoza®, there were more cases of pancreatitis with Victoza® than with comparators. Victoza® has not been studied sufficiently in patients with a history of pancreatitis to determine whether these patients are at increased risk for pancreatitis while using Victoza®. Use with caution in patients with a history of pancreatitis. Victoza® is not a substitute for insulin. Victoza® should not be used in patients with type 1 diabetes mellitus or for the treatment of diabetic ketoacidosis, as it would not be effective in these settings. The concurrent use of Victoza® and insulin has not been studied. CONTRAINDICATIONS: Victoza® is contraindicated in patients with a personal or family history of medullary thyroid carcinoma (MTC) or in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). WARNINGS AND PRECAUTIONS: Risk of Thyroid C-cell Tumors: Liraglutide causes dosedependent and treatment-duration-dependent thyroid C-cell tumors (adenomas and/or carcinomas) at clinically relevant exposures in both genders of rats and mice. Malignant thyroid C-cell carcinomas were detected in rats and mice. A statistically significant increase in cancer was observed in rats receiving liraglutide at 8-times clinical exposure compared to controls. It is unknown whether Victoza® will cause thyroid C-cell tumors, including medullary thyroid carcinoma (MTC), in humans, as the human relevance of liraglutide-induced rodent thyroid C-cell tumors could not be determined by clinical or nonclinical studies [see Boxed Warning, Contraindications]. In the clinical trials, there have been 4 reported cases of thyroid C-cell hyperplasia among Victoza®-treated patients and 1 case in a comparator-treated patient (1.3 vs. 0.6 cases per 1000 patient-years). One additional case of thyroid C-cell hyperplasia in a Victoza®-treated patient and 1 case of MTC in a comparator-treated patient have subsequently been reported. This comparator-treated patient with MTC had pre-treatment serum calcitonin concentrations >1000 ng/L suggesting pre-existing disease. All of these cases were diagnosed after thyroidectomy, which was prompted by abnormal results on routine, protocol-specified measurements of serum calcitonin. Four of the five liraglutide-treated patients had elevated calcitonin concentrations at baseline and throughout the trial. One liraglutide and one non-liraglutide-treated patient developed elevated calcitonin concentrations while on treatment. Calcitonin, a biological marker of MTC, was measured throughout the clinical development program. The serum calcitonin assay used in the Victoza® clinical trials had a lower limit of quantification (LLOQ) of 0.7 ng/L and the upper limit of the reference range was 5.0 ng/L for women and 8.4 ng/L for men. At Weeks 26 and 52 in the clinical trials, adjusted mean serum calcitonin concentrations were higher in Victoza®-treated patients compared to placebo-treated patients but not compared to patients receiving active comparator. At these timepoints, the adjusted mean serum calcitonin values (~ 1.0 ng/L) were just above the LLOQ with between-group differences in adjusted mean serum calcitonin values of approximately 0.1 ng/L or less. Among patients with pre-treatment serum calcitonin below the upper limit of the reference range, shifts to above the upper limit of the reference range which persisted in subsequent measurements occurred most frequently among patients treated with Victoza® 1.8 mg/day. In trials with on-treatment serum calcitonin measurements out to 5-6 months, 1.9% of patients treated with Victoza® 1.8 mg/day developed new and persistent calcitonin elevations above the upper limit of the reference range compared to 0.8-1.1% of patients treated with control medication or the 0.6 and 1.2 mg doses of Victoza®. In trials with ontreatment serum calcitonin measurements out to 12 months, 1.3% of patients treated with Victoza® 1.8 mg/day had new and persistent elevations of calcitonin from below or within the reference range to above the upper limit of the reference range, compared to 0.6%, 0% and 1.0% of patients treated with Victoza® 1.2 mg, placebo and active control, respectively. Otherwise, Victoza® did not produce consistent dose-dependent or time-dependent increases in serum calcitonin. Patients with MTC usually have calcitonin values >50 ng/L. In Victoza® clinical trials, among patients with pre-treatment serum calcitonin <50 ng/L, one Victoza®-treated patient and no comparator-treated patients developed serum calcitonin >50 ng/L. The Victoza®-treated patient who developed serum calcitonin >50 ng/L had an elevated pre-treatment serum calcitonin of 10.7 ng/L that increased to 30.7 ng/L at Week 12 and 53.5 ng/L at the end of the 6-month trial. Follow-up serum calcitonin was 22.3 ng/L more than 2.5 years after the last dose of Victoza®. The largest increase in serum calcitonin in a comparator-treated patient was seen with glimepiride in a patient whose serum calcitonin increased from 19.3 ng/L at baseline to 44.8 ng/L at Week 65 and 38.1 ng/L at Week 104. Among patients who began with serum calcitonin <20 ng/L, calcitonin elevations to >20 ng/L occurred in 0.7% of Victoza®-treated patients, 0.3% of placebotreated patients, and 0.5% of active-comparator-treated patients, with an incidence of 1.1% among patients treated with 1.8 mg/day of Victoza®. The clinical significance of these findings is unknown. Counsel patients regarding the risk for MTC and the symptoms of thyroid tumors (e.g. a mass in the neck, dysphagia, dyspnea or persistent hoarseness). It is unknown whether monitoring with serum calcitonin or thyroid ultrasound will mitigate the potential risk of MTC, and such monitoring may increase the risk of unnecessary procedures, due to low test specificity for serum calcitonin and a high background incidence of thyroid disease. Patients with thyroid nodules noted on physical examination or neck imaging obtained for other reasons should be referred to an endocrinologist for further evaluation. Although routine monitoring of serum calcitonin is of uncertain value in patients treated with Victoza®, if serum calcitonin is measured and found to be elevated, the patient should be referred to an endocrinologist for further evaluation. Pancreatitis: In clinical trials of Victoza®, there were 7 cases of pancreatitis among Victoza®-treated patients and 1 case among comparator-treated patients (2.2 vs. 0.6 cases per 1000 patient-years). Five cases with Victoza® were reported as acute pancreatitis and two cases with Victoza® were reported as chronic pancreatitis. In one case in a Victoza®-treated patient,

MINNESOTA PHYSICIAN

DECEMBER 2011

pancreatitis, with necrosis, was observed and led to death; however clinical causality could not be established. One additional case of pancreatitis has subsequently been reported in a Victoza®-treated patient. Some patients had other risk factors for pancreatitis, such as a history of cholelithiasis or alcohol abuse. There are no conclusive data establishing a risk of pancreatitis with Victoza® treatment. After initiation of Victoza®, and after dose increases, observe patients carefully for signs and symptoms of pancreatitis (including persistent severe abdominal pain, sometimes radiating to the back and which may or may not be accompanied by vomiting). If pancreatitis is suspected, Victoza® and other potentially suspect medications should be discontinued promptly, confirmatory tests should be performed and appropriate management should be initiated. If pancreatitis is confirmed, Victoza® should not be restarted. Use with caution in patients with a history of pancreatitis. Use with Medications Known to Cause Hypoglycemia: Patients receiving Victoza® in combination with an insulin secretagogue (e.g., sulfonylurea) may have an increased risk of hypoglycemia. In the clinical trials of at least 26 weeks duration, hypoglycemia requiring the assistance of another person for treatment occurred in 7 Victoza®-treated patients and in two comparator-treated patients. Six of these 7 patients treated with Victoza® were also taking a sulfonylurea. The risk of hypoglycemia may be lowered by a reduction in the dose of sulfonylurea or other insulin secretagogues [see Adverse Reactions]. Renal Impairment: Victoza® has not been found to be directly nephrotoxic in animal studies or clinical trials. There have been postmarketing reports of acute renal failure and worsening of chronic renal failure, which may sometimes require hemodialysis in Victoza®-treated patients [see Adverse Reactions]. Some of these events were reported in patients without known underlying renal disease. A majority of the reported events occurred in patients who had experienced nausea, vomiting, diarrhea, or dehydration [see Adverse Reactions]. Some of the reported events occurred in patients receiving one or more medications known to affect renal function or hydration status. Altered renal function has been reversed in many of the reported cases with supportive treatment and discontinuation of potentially causative agents, including Victoza®. Use caution when initiating or escalating doses of Victoza® in patients with renal impairment. Macrovascular Outcomes: There have been no clinical studies establishing conclusive evidence of macrovascular risk reduction with Victoza® or any other antidiabetic drug. ADVERSE REACTIONS: Clinical Trials Experience: Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice. The safety of Victoza® was evaluated in a 52-week monotherapy trial and in five 26-week, add-on combination therapy trials. In the monotherapy trial, patients were treated with Victoza® 1.2 mg daily, Victoza® 1.8 mg daily, or glimepiride 8 mg daily. In the add-on to metformin trial, patients were treated with Victoza® 0.6 mg, Victoza® 1.2 mg, Victoza® 1.8 mg, placebo, or glimepiride 4 mg. In the add-on to glimepiride trial, patients were treated with Victoza® 0.6 mg, Victoza® 1.2 mg, Victoza® 1.8 mg, placebo, or rosiglitazone 4 mg. In the add-on to metformin + glimepiride trial, patients were treated with Victoza® 1.8 mg, placebo, or insulin glargine. In the add-on to metformin + rosiglitazone trial, patients were treated with Victoza® 1.2 mg, Victoza® 1.8 mg or placebo. Withdrawals: The incidence of withdrawal due to adverse events was 7.8% for Victoza®-treated patients and 3.4% for comparatortreated patients in the five controlled trials of 26 weeks duration or longer. This difference was driven by withdrawals due to gastrointestinal adverse reactions, which occurred in 5.0% of Victoza®-treated patients and 0.5% of comparator-treated patients. The most common adverse reactions leading to withdrawal for Victoza®-treated patients were nausea (2.8% versus 0% for comparator) and vomiting (1.5% versus 0.1% for comparator). Withdrawal due to gastrointestinal adverse events mainly occurred during the first 2-3 months of the trials. Tables 1, 2 and 3 summarize the adverse events reported in ≥5% of Victoza®-treated patients in the six controlled trials of 26 weeks duration or longer. Table 1: Adverse events reported in ≥5% of Victoza®-treated patients or ≥5% of glimepiride-treated patients: 52-week monotherapy trial All Victoza® N = 497 Glimepiride N = 248 (%) (%) Adverse Event Term Nausea 28.4 8.5 Diarrhea 17.1 8.9 Vomiting 10.9 3.6 Constipation 9.9 4.8 Upper Respiratory Tract Infection 9.5 5.6 Headache 9.1 9.3 Influenza 7.4 3.6 Urinary Tract Infection 6.0 4.0 Dizziness 5.8 5.2 Sinusitis 5.6 6.0 Nasopharyngitis 5.2 5.2 Back Pain 5.0 4.4 Hypertension 3.0 6.0 Table 2: Adverse events reported in ≥5% of Victoza®-treated patients and occurring more frequently with Victoza® compared to placebo: 26-week combination therapy trials Add-on to Metformin Trial All Victoza® + Placebo + Glimepiride + Metformin N = 724 Metformin N = 121 Metformin N = 242 (%) (%) (%) Adverse Event Term Nausea 15.2 4.1 3.3 Diarrhea 10.9 4.1 3.7 Headache 9.0 6.6 9.5 Vomiting 6.5 0.8 0.4 Add-on to Glimepiride Trial All Victoza® + Placebo + Glimepiride Rosiglitazone + Glimepiride N = 695 N = 114 Glimepiride N = 231 (%) (%) (%) Adverse Event Term Nausea 7.5 1.8 2.6 Diarrhea 7.2 1.8 2.2

DECEMBER 2011

MINNESOTA PHYSICIAN

Handoff from cover the ED speak directly and as a team to the nurses and physicians who will be caring for her on the floor. By the time the patient arrives on the floor, the nurse, resident physician, and attending physician are all on the same page with regard to her treatment plan and course. The transfer of information and responsibility for the care of a patient is called a handoff. It can be a spontaneous afterthought, as in the first scenario, or a carefully choreographed communication, as in the second. Intuitively, clear communication around patient care seems to be the correct path; however, the evidence for this is only beginning to be uncovered, and the cultural awareness of this in health care settings is not realized. According to the Joint Commission, communication errors are the leading cause of sentinel events in hospitals. As patients move through the health care system, they are particularly vulnerable to communication errors at the time of tran-

sitions. Nearly every type of transition of care—outpatient to inpatient, between physicians, between teams, between nurses, between departments, and from inpatient back to outpatient— has been implicated in the literature as a critical safety risk. In most cases, handoffs have developed organically out of necessity, and have not been intentionally designed to address the needs of the providers involved or of the specific care situations patients find themselves in. Studies of residents, nurses, and emergency department staffs have all shown a subjective sense that patients were harmed or potentially harmed because of a poor handoff process. However, there is not a prescriptive method available currently for how to solve the risks posed to patients due to handoffs. Most articles on this subject point to deficiencies in technology and human factors as the core issues leading to these negative outcomes. It’s clear that technology, in the form of a reliable, consistent electronic medical record,

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needs to be leveraged to support these processes. However, like nearly every aspect of medicine, a technological solution does not suffice. Studying “real-world” handoffs vs. staff perceptions

Two years ago the Joint Commission created the Center for Transforming Healthcare, an ambitious attempt to create best practices and disseminate them by working with the Joint Commission’s member hospitals. The center chose to use the Six Sigma DMAIC (“Define– Measure–Analyze–Improve– Control”) quality improvement methodology to identify and correct deficiencies in the health care system. University of Minnesota Medical Center Fairview/University of Minnesota Amplatz Children’s Hospital (UMMC/ UMACH) was invited to join nine other health care systems and the Center for Transforming Healthcare to collaborate in developing solutions to poor handoffs and provide recommendations to other institutions nationwide. In 2009, representatives from the 10 hospital systems met regularly to wrestle with the problems and solutions surrounding handoffs. The collaborative found handoff communication to be widely variable and minimally defined at all institutions. The group quickly realized that for all the literature showing that handoffs were a problem, there was scant evidence on how to actually fix them, or what, if any, best practices existed for handoffs. The best practices discussed in the literature were largely expert opinion or had been “harvested” from data from high-reliability organizations such as the aviation industry or nuclear power plants. The Joint Commission group decided to look at several metrics pertaining to handoffs, ranging from what components were present (and how much they mattered) to how satisfied people were with the process. UMMC/UMACH focused on physician and nurse handoff communication from the emergency department to two inpatient care units: one adult and

one pediatric. UMMC created focus groups of residents, physicians, nurses, care coordinators, and other members of the health care team to discuss the current state of handoffs. But trying to map out the handoff process between the emergency department and inpatient services presented a stumbling block. It turned out that there was no single process for communicating about a patient moving from the emergency department to the inpatient floor. Instead, there were many, poorly defined processes that often depended on the individual physicians and nurses. This presented a problem: Six Sigma DMAIC is a solid quality improvement methodology for improving an existing process, but there was no existing process on which to improve. Since the chosen methodology presumed an existing process, we chose to follow the collaborative’s timeline but to use quality improvement methodologies (e.g., Six Sigma DMADV [Define–Measure– Analyze–Design–Verify] and Innovation tools). In-situ simulation—videotaped simulations of handoffs followed by a debriefing session with those involved—was used to gather our most critical information on how handoffs happened in a real-world setting. The in-situ simulations showed clearly that successful handoffs were characterized by active listening, dynamic skepticism, situational awareness, and a shared “mental model” of the patient. In other words, the people involved in handoffs are a team—and the attributes of a successful handoff are the same as the attributes of successful teamwork. These factors, coupled with standardized clinical content, formed the foundation for our handoff improvements. Our research gave us a model for understanding handoffs and a process for changing them. We spoke of handoffs in the language of teamwork, a language that many of the emergency room and floor staff had already been trained in and understood. We showed the insitu simulation videos in many forums, from resident morning

reports to nursing staff meetings. Several common themes ran through all of the scenarios of poor handoffs: gaps in information, lack of active listening, time wasted by different members of the health care team saying the same thing, and a lack of alignment between the ED and the inpatient care teams. A new model

The UMMC/UMACH group used the results of the focus group meetings and debriefings, in combination with the research literature and in-situ simulations, to identify core elements of effective patient care handoffs. The intervention that emerged was a scheduled conference call among nursing and physician team members caring for a patient. Specifically, the emergency room resident, and attending physician, and nurse are conferenced in with the inpatient attending physician, resident, and nurse. The patient placement manager is also on the call, to facilitate communication and help to quickly get a

SEE 3 OPERAS FOR AS LITTLE AS

According to the Joint Commission, communication errors are the leading cause of sentinel events in hospitals. bed assigned and the patient transported. On the conference calls, the emergency room and inpatient service jointly review a high-level checklist that they jointly developed. The checklist is standardized to ensure that information is communicated in an expected order and is complete, regardless of what individual staff members are involved in the handoff. Beginning Dec. 14, 2010, the new handoff process, using the checklist and an interdisciplinary handoff via conference call, was rolled out for all pediatric units admitting patients through the emergency department. Results

Results of the implementation show that using the new handoff process improved standardization of clinical content of handoffs by 90 percent. The

$30

new handoff process reduced the number of handoffs from four to one while decreasing the time for the handoff by 50 percent. Extrapolating the time savings to all pediatrics emergency department admissions, we can predict a reduction of approximately 2,100 hours of clinical work spent on handoffs annually. The presence of the interdisciplinary members on the conference call has presented logistical challenges. Management of this change in process is critical because clinicians are not used to scheduling a time for ED-to-inpatient handoffs; handoffs are usually occurring when staff can fit it in between other clinical tasks. In addition, physicians are not accustomed to conducting handoffs with nursing staff present in the conversation.

Training about the process and information about the benefits to the patient are critical. Though adverse events are low in number, we are monitoring our impact on them. Our follow-up on staff perceptions of patient safety and teamwork has indicated that staff view this process as facilitating the patient experiencing improved continuity of care, and that staff from the ED and inpatient units feel more aligned. Perseverance in change management strategies such as employee sensing sessions, one-on-one meetings with leadership, and communication of progress were and continue to be critical to sustaining this project’s impact. Sommer Alexander, MS, is Lean Six Sigma Black Belt at University of Minnesota Medical Center, Fairview. Michael Aylward, MD, is assistant professor of medicine and pediatrics at the University of Minnesota Medical School, Minneapolis.

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Over the next 25 years, the number of Minnesotans over age 65 will double—from 600,000 to

FOCUS:

By Edward G. Hames III, MD, PhD, and Charles R. Watts MD, PhD

attention by health care providers to meeting the

cial focus looks at three types of care for seniors: medical treatment for head injuries from falls; a pilot project aimed at reducing unnecessary medications in nursing homes; and home care options to help seniors stay in their homes longer.

LONG-TERM

Chronic subdural hematomas in the elderly

will require increasing

lation. This month’s spe-

AND

Age-old injury, updated treatment

1.2 million. This shift

needs of the aging popu-

SENIOR

he horrible martyrdom so brutally inflicted on Pierrette by two imbecile tyrants—… led, medically speaking, to her being subjected by Monsieur Martener, with Bianchon’s approval, to the terrible operation of trepanning. … the calumniated Pierrette languished in suffering from the most terrible pains known to medical science.” —Honoré de Balzac (1799–1850 A.D.), “Pierrette”

According to Centers for Disease Control and Prevention (CDC) data for 2007, accidental trauma is the fifth-leading cause of death in all age groups and the ninth-leading cause of death

in individuals 65 years of age or older. The top three causes of injury are accidental fall, motor vehicle accident, and unspecified. Although heart disease, stroke, and cancer rank higher with regard to cause of death, accidental trauma is the leading cause of injury in the elderly, with accidental falls being by far the most prevalent etiology. The total cost of care (medical and loss of work) in 2005 for elderly individuals sustaining accidental injury with an associated traumatic brain injury was approximately $1.4 billion. This does not fully account for the emotional costs to the individ-

CARE

ual and family due to the loss of function, independence, and cognitive decline. Though the opening quotation from Balzac is perhaps the best-known literary example, the surgical treatment of intracranial disease (trephination) with survival of the patient dates back to Mesolithic times. There is fossil evidence of its widespread use in Western Europe and Asia, with healed cranial bones dating to 3000 to 2000 B.C. Although many of these procedures are hypothesized to have been done as part of a religious ritual, there is no convincing evidence to disprove that they may have been utilized to treat missile injuries to the head and skull fractures. The first medical treatise on the treatment of head injury that classified the types of injury amenable to trephination was written by Hippocrates of Kos (460 to 377 B.C.) and is considered the historical foundation of modern neurosurgery. With the decline and fall of the Roman Empire, little development occurred in the surgical

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FIGURE 1. A 76-year-old male with a three-month history of cognitive decline, increasing agitation, and worsening gait instability after sustaining a fall three months prior to presentation. (A) CT of the head demonstrating bilateral chronic subdural hematomas of mixed density with significant cerebral and ventricular compression. (B) CT of the head at two months post-bilateral bur hole drainage, demonstrating almost complete resolution of the subdural hematomas and restoration of normal ventricular volume. The patient experienced a nearcomplete resolution of symptoms.

sciences. Modern surgical treatment of traumatic brain injury is only 130 years old, at most, with the most dramatic changes in diagnosis and treatment occurring within the last 40 years with the advent of modern medical imaging (CT and MRI). In modern neurosurgical practice, the role of opening the skull via a craniotomy (trephination) or bur hole is to relieve pressure on the brain and restore a state of normal brain physiology and metabolism. With the exception of decompressive craniectomies (removal of part of the skull) done for treatment of severe cerebral edema, this usually involves the removal of a mass lesion. Types of hematomas

Traumatic mass lesions may occur from a variety of sources. Epidural hematomas occur due to a hemorrhage between the skull and lining of the brain (dura) and are usually associated with a skull fracture. The extent of the hemorrhagic collection is usually confined by the suture lines of the skull. The presentation is usually acute and requires rapid evaluation and potential surgical intervention. Intraparenchymal hematomas (contusions) are due to injury of the small perforating capillaries within the brain. They may present either acutely or in a delayed fashion within the first 24 to 96 hours of injury. Although surgical treatment may be required, they are often treated with intensive medical support of the patient. They are considered to be an indication of severe underlying injury to the brain parenchyma. Subdural hematomas (SDHs) are due to a hemorrhage between the brain and the dura. They are usually caused by a tear in a bridging vein that runs between the surface of the brain and a dural venous sinus but may also be caused by arterial injury. The extent of hemorrhage is not confined by the sutures lines of the skull. The presentation may be either acute, requiring emergent surgical evacuation, or

insidious over a period of weeks to months. SDHs developing between three days and three weeks after head injury are termed “subacute”; those that are manifest later than three weeks after injury are defined as “chronic.” The discussion below centers on chronic subdural hematomas in elderly patients. Etiology of chronic SDH

The incidence of chronic SDHs in the elderly is 7.4 per 100,000 people per year. Between 25 percent and 50 percent of these patients will have no history of head injury, and in those with a history of trauma, the injury is often mild. A significant proportion of patients are predisposed to SDHs because of chronic alcoholism, epilepsy, or coagulopathies (often related to Coumadin or antiplatelet agents, e.g., ASA and/or clopidogrel). Small amounts of hemorrhage into the subdural space or larger hematomas in patients with underlying brain atrophy may fail to produce symptoms within a week to 10 days. The initial hematoma is covered by an outer membrane beneath the dura. By three to four weeks, an inner membrane forms between the hematoma and the pial surface of the brain, completely enclosing the hematoma. During this period the

hematoma liquifies and becomes progressively more hypodense on CT scans. In the next weeks, in some patients the hematoma gradually enlarges, and in other patients there is a gradual re-absorption of the liquefied blood. An etiology of chronic SDH enlargement within the capsule has been postulated. The albumin/gamma globulin and total protein concentrations within the hematoma are much higher than in the serum, resulting in

a higher osmotic pressure within the hematoma. The higher osmotic pressure will draw water out of the serum into the hematoma via diffusion, thus enlarging the mass. A chronic SDH may also enlarge from recurrent smaller hemorrhages into its surrounding membranes. It is likely that a combination of the two mechanisms is at work in most large, expanding chronic SDHs. There is considerable CT evidence that some hematomas regress in size and do not need surgical treatment. It is likely there is a balance between hematoma production and re-absorption. If re-absorption exceeds production, the hematoma will shrink, and when production exceeds re-absorption, the hematoma will enlarge. Diagnosis and treatment of chronic SDH

The symptoms and signs of chronic SDH are extremely variable and are not necessarily pathognomonic. In elderly patients the insidious onset of BRAIN INJURY to page 38

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To get started visit www.longtermcarechoices.minnesotahelp.info DECEMBER 2011

MINNESOTA PHYSICIAN

SPECIAL

ou’re the physician on call for the weekend. At 9 p.m. on Saturday, you get a call from a nurse at a local nursing home saying they’ve tried everything to calm an agitated resident. They’re asking you to order something. This is still a very familiar scenario, even though the long-term care profession in Minnesota has made progress in decreasing the use of unnecessary drugs. To change the way antipsychotic drugs are used in nursing homes, Ecumen (a provider of senior housing and services in Minnesota) is going further, implementing a comprehensive program called Awakenings. The goal is to awaken Alzheimer’s and dementia patients to a fuller, richer life by decreasing their dependence on unnecessary medications. Physicians are key partners in this work. How Awakenings began

Awakenings was piloted at an Ecumen nursing home in Two Harbors, Minnesota in 2009. Based on those remarkable results and thanks to a $3.8 mil-

FOCUS:

SENIOR

AND

LONG-TERM

Awakenings Transforming Alzheimer’s care in Minnesota By Laurel Baxter, MA, RN lion, three-year state grant, the initiative is expanding to 15 other Ecumen nursing homes in Minnesota. We hope that what we learn from this expansion will provide Alzheimer’s “best practice” guidance to physicians and care centers in Minnesota and across the country. Earlier this year, a New York Times blog discussed the promise of this initiative (Paula Span, “Clearing the Fog in Nursing Homes,” New York Times, Feb. 15, 2011). The Two Harbors pilot demonstrated that residents with Alzheimer’s could enjoy a better quality of life if behavioral and environmental interventions, rather than antipsychotic drugs, were tried first. These drugs not only can rob residents of their personalities and energy; in some cases they actually worsen cognitive functioning

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among elderly dementia patients, and can speed their decline—making strokes, pneumonia, or serious adverse drug effects more likely. Despite the fact that antipsychotic drugs carry a Food and Drug Administration black-box warning that elderly patients who use them have an increased risk of death, their use has skyrocketed in recent years. Medicaid spends more on antipsychotics than any other class of drugs—including antibiotics, AIDS drugs, or medications to treat high blood pressure. As nursing home residents in Two Harbors were weaned off antipsychotics, staff members engaged more with them, taking them on walks, and playing games and exercising with them. Certified nursing assistants assumed a more important role. A variety of therapies using validation, reminiscence, music, aroma, and pets were employed to improve residents’ physical and cognitive functions. Within six months, the use of antipsychotics was eliminated among all residents, and antidepressant use decreased by 30 to 50 percent. Before the pilot project, the home was quiet; several residents preferred to stay in bed, and others had a far-off, vacant look. Today, residents are engaged in meaningful activities and relationships, and relationship-based care has become the normal routine for the entire home. Indeed, the Awakenings approach has far-reaching effects in reducing unnecessary psychotropic medications or other potentially unnecessary medication for any nursing home resident. Key strategies for change

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MINNESOTA PHYSICIAN DECEMBER 2011

This shift toward nonpharmaceutical interventions involves every staff member. Awakenings takes a holistic, individualized approach to Alzheimer’s care to get to the root cause of behavioral issues. Collaborative teams

CARE

—“circles of care”—are built around each resident, involving family, case workers, and the right doctors and nurses. A team evaluates the situation of each resident to find the right mix of care to help ensure best quality of life. Again, the focus of care becomes human relationships rather than solely drugs. One of the first steps in introducing Awakenings is recruiting project leads and rehabilitation nursing staff. Rehabilitation nursing is a key element of success, along with enhanced, personalized activities. Residents are less likely to get agitated when their individual preferences are met. These staff members, who are trained in several areas, including assessment for delirium and alternative care plan interventions, share this learning with all team members. The team considers the underlying causes of agitation before calling the physician. Training is also provided for administrators and directors of nursing in each care center, teaching them to ask “why” when they hear about a resident’s behavioral symptoms. Physicians are an important part of Awakenings care teams. Attending physicians and medical directors are invited to meet with a physician certified in psychiatry and neurology to share the latest knowledge about the use of psychotropic medications. Physicians are encouraged to consider underlying causes of agitation prior to ordering treatment with medication. Family members are also key members of the team. They are directly involved with resident activities and help share their relative’s life story, which is part of assessment and alternative care planning, including spiritual care. It’s crucial that staff understand as much about each resident’s needs and preferences as possible in order for relationship-based care to succeed. Teams also work with pharmacy consultants in creating individual care plans. This allows the pharmacist to understand more about a resident than can be gained by reading clinical records. If deemed beneficial by the attending physician,

the team has access to other health care professionals such as psychiatrists, behavioral psychologists, and clinical experts. Case studies

The stories of Marjorie and Louise (names have been changed) show the real-life effects this program can have. Marjorie’s team discovered that some of her behavioral problems were caused by her fear of incontinence. Antipsychotic drugs had failed to stop the behaviors. So her care team went beyond medications to get to the core of her anxiety and help restore her personality. Using talk therapy and interventions, engaging family members, building her self-confidence, stopping antipsychotic medications, and re-introducing exercise into her life have made an enormous difference. She’s eating and sleeping again, which has led to a new, healthy state of calm. Marjorie is awake and living, and her family shares the happiness she can still convey. Louise was taking too many tumbles—tripping over her own

feet, swaying and losing her balance, or simply running into furniture in her nursing home. Her care team scrutinized her medications and decided to discontinue her antipsychotic and antianxiety medications. As those two medications were phased out, she became steadier on her feet and felt more confident. Louise began engaging more in the community around her, helping set tables and clearing clutter from the nurse’s station. Her husband noticed she was more awake and responsive during his visits. She was even able to resume attending regular church services with him. Alzheimer’s disease will continue to claim more and more of Louise’s abilities, but for now, her family has a more alert Louise to enjoy and cherish. Measuring outcomes

Hard data support the positive effects of the Awakenings program. At the end of the threeyear Awakenings initiative grant, we will have measured several outcomes with an “at-risk” component that will result in a rate

decrease from the Minnesota Department of Human Services if outcomes goals are not met. First, on average, we intend that the collaborative of 15 nursing homes will achieve a 20 percent improvement over the baseline in the Minnesota risk-adjusted quality indicator “prevalence of antipsychotics without a diagnosis of psychosis.” (That translates to a 10 percent decrease the first year and 5 percent decreases in each subsequent year.) Since Awakenings was introduced in late 2010, the collaborative has improved 62 percent over that baseline. Second, we also anticipate a 6 percent improvement rate over baseline in the Minnesota Department of Human Services (DHS) Quality of Life Survey in two domains: Meaningful Activities and Relationships. The DHS Quality of Life surveys started in October 2011 and results will be forthcoming. Both the scale and innovation of Awakenings make it unique. We are retooling the entire approach to care, replacing a fragmented approach often

found in health care today with a holistic, integrated approach centered on the individual. The program builds on practices that have been proven through research, applying them in the real world of long-term care. In the process, we are radically changing the culture of medication use in nursing homes. A relationship-care approach like Awakenings can bring many of the estimated 27,000 Minnesota nursing home residents who are on antipsychotic drugs increased empowerment, vitality, joy, and dignity. Physicians will have backup from a team of professionals who provide accurate assessments to help assure proper diagnosis, documentation, and prescribing of psychotropic and other medications. More information about Awakenings, including a list of the Ecumen nursing homes now using this approach, is available at ecumen.org/aging-resources. Laurel Baxter, MA, RN, is the Awakenings project manager at Ecumen, based in Shoreview, Minn.

A Diverse and Vital Health Service

Boynton Health Service

Psychiatrist

Welcome to Boynton Health Service >ŽĐĂƚĞĚ ŝŶ ƚŚĞ ŚĞĂƌƚ ŽĨ ƚŚĞ dǁŝŶ ŝƟĞƐ ĂƐƚ ĂŶŬ ĐĂŵƉƵƐ͕ ŽǇŶƚŽŶ ,ĞĂůƚŚ ^ĞƌǀŝĐĞ ŝƐ Ă ǀŝƚĂů ƉĂƌƚ ŽĨ ƚŚĞ hŶŝǀĞƌƐŝƚǇ ŽĨ DŝŶŶĞƐŽƚĂ ĐŽŵŵƵŶŝƚǇ͕ ƉƌŽǀŝĚŝŶŐ ĂŵďƵůĂƚŽƌǇ ĐĂƌĞ͕ ŚĞĂůƚŚ ĞĚƵĐĂƟŽŶ͕ ĂŶĚ ƉƵďůŝĐ ŚĞĂůƚŚ ƐĞƌǀŝĐĞƐ ƚŽ ƚŚĞ hŶŝǀĞƌƐŝƚǇ ĨŽƌ ŶĞĂƌůǇ ϵϬ ǇĞĂƌƐ͘ /ƚ͛Ɛ ŽƵƌ ŵŝƐƐŝŽŶ ƚŽ ĐƌĞĂƚĞ Ă ŚĞĂůƚŚǇ ĐŽŵŵƵŶŝƚǇ ďǇ ǁŽƌŬŝŶŐ ǁŝƚŚ ƐƚƵĚĞŶƚƐ͕ ƐƚĂī͕ ĂŶĚ ĨĂĐƵůƚǇ ƚŽ ĂĐŚŝĞǀĞ ƉŚǇƐŝĐĂů͕ ĞŵŽƟŽŶĂů͕ ĂŶĚ ƐŽĐŝĂů ǁĞůůͲďĞŝŶŐ͘ ŽǇŶƚŽŶ͛Ɛ ŽƵƚƐƚĂŶĚŝŶŐ ƐƚĂī ŽĨ ϮϱϬ ŝŶĐůƵĚĞƐ ďŽĂƌĚ ĐĞƌƟĮĞĚ ƉŚǇƐŝĐŝĂŶƐ͕ ŶƵƌƐĞ ƉƌĂĐƟƟŽŶĞƌƐ͕ ƌĞŐŝƐƚĞƌĞĚ ŶƵƌƐĞƐ͕ D Ɛͬ>WEƐ͕ ƉŚǇƐŝĐŝĂŶ ĂƐƐŝƐƚĂŶƚƐ͕ ĚĞŶƟƐƚƐ͕ ĚĞŶƚĂů ŚǇŐŝĞŶŝƐƚƐ͕ ŽƉƚŽŵĞƚƌŝƐƚƐ͕ ƉŚǇƐŝĐĂů ĂŶĚ ŵĂƐƐĂŐĞ ƚŚĞƌĂƉŝƐƚƐ͕ ƌĞŐŝƐƚĞƌĞĚ ĚŝĞƟƟĂŶƐ͕ ƉŚĂƌŵĂĐŝƐƚƐ͕ ƉƐǇĐŚŝĂƚƌŝƐƚƐ͕ ƉƐǇĐŚŽůŽŐŝƐƚƐ͕ ĂŶĚ ƐŽĐŝĂů ǁŽƌŬĞƌƐ͘ KƵƌ ŵƵůƟĚŝƐĐŝƉůŝŶĂƌǇ ŚĞĂůƚŚ ƐĞƌǀŝĐĞ ŚĂƐ ďĞĞŶ ĐŽŶƟŶƵŽƵƐůǇ ĂĐĐƌĞĚŝƚĞĚ ďǇ , ƐŝŶĐĞ ϭϵϳϵ͕ ĂŶĚ ǁĂƐ ƚŚĞ ĮƌƐƚ ĐŽůůĞŐĞ ŚĞĂůƚŚ ƐĞƌǀŝĐĞ ƚŽ ŚĂǀĞ ĞĂƌŶĞĚ ƚŚŝƐ ĚŝƐƟŶĐƟŽŶ͘ ƩĞŶĚŝŶŐ ƚŽ ŽǀĞƌ ϭϬϬ͕ϬϬϬ ƉĂƟĞŶƚ ǀŝƐŝƚƐ ĞĂĐŚ ǇĞĂƌ͕ ŽǇŶƚŽŶ ,ĞĂůƚŚ ^ĞƌǀŝĐĞ ƚĂŬĞƐ ƉƌŝĚĞ ŝŶ ŵĞĞƟŶŐ ƚŚĞ ŚĞĂůƚŚ ĐĂƌĞ ŶĞĞĚƐ ŽĨ h ŽĨ D ƐƚƵĚĞŶƚƐ͕ ƐƚĂī͕ ĂŶĚ ĨĂĐƵůƚǇ ǁŝƚŚ ĐŽŵƉĂƐƐŝŽŶ ĂŶĚ ƉƌŽĨĞƐƐŝŽŶĂůŝƐŵ͘

ŽǇŶƚŽŶ ,ĞĂůƚŚ ^ĞƌǀŝĐĞ ŝƐ ƐĞĞŬŝŶŐ Ă WƐǇĐŚŝĂƚƌŝƐƚ ƚŽ ǁŽƌŬ ǁŝƚŚ Ă ůĂƌŐĞ ĂŶĚ ĚŝǀĞƌƐĞ ƉŽƉƵůĂƟŽŶ ŽĨ ƐƚƵĚĞŶƚƐ Ăƚ ƚŚƌĞĞ ůŽĐĂů ĐŽůůĞŐĞƐ͕ ŝŶ ĂĚĚŝƟŽŶ ƚŽ ƚŚĞ ,ĞĂůƚŚ ^ĞƌǀŝĐĞ͕ ĂƐ Ă ƌĞƉƌĞƐĞŶƚĂƟǀĞ ŽĨ ƚŚĞ ŵĞŶƚĂů ŚĞĂůƚŚ ĐŽŶƐƵůƚĂƟŽŶͬŽƵƚƌĞĂĐŚ ƉƌŽŐƌĂŵ͘ dŚĞ WƐǇĐŚŝĂƚƌŝƐƚ ǁŝůů ĂůƐŽ ƐĞƌǀĞ ĂƐ Ă ĐŽŶƐƵůƚĂŶƚ ƚŽ ŽƚŚĞƌ ,ĞĂůƚŚ ^ĞƌǀŝĐĞ ƐƚĂī ŵĞŵďĞƌƐ͕ ĂƐ ǁĞůů ĂƐ ƚŚĞ ĨĂĐƵůƚǇ ĂŶĚ ƐƚĂī ŽĨ ƚŚĞƐĞ ŽůůĞŐĞ ĂŶĚ hŶŝǀĞƌƐŝƚǇ ĐŽŵŵƵŶŝƟĞƐ͘ ůŝŵŝƚĞĚ ĂŵŽƵŶƚ ŽĨ ƉƐǇĐŚŽƚŚĞƌĂƉǇ ǁŝůů ĂůƐŽ ďĞ ŝŶǀŽůǀĞĚ͘ ƉƉůŝĐĂŶƚ ŵƵƐƚ ďĞ WE ďŽĂƌĚ ĐĞƌƟĮĞĚͬĞůŝŐŝďůĞ ŝŶ ƉƐǇĐŚŝĂƚƌǇ͘ ŽǇŶƚŽŶ ,ĞĂůƚŚ ^ĞƌǀŝĐĞ ŽīĞƌƐ Ă ĐŽŵƉĞƟƟǀĞ ƐĂůĂƌǇ ĂŶĚ Ă ƌĞǁĂƌĚŝŶŐ ƉƌĂĐƟĐĞ ĞŶǀŝƌŽŶŵĞŶƚ͘ WƌŽĨĞƐƐŝŽŶĂů ůŝĂďŝůŝƚǇ ĐŽǀĞƌĂŐĞ ŝƐ ƉƌŽǀŝĚĞĚ͘ dŽ ůĞĂƌŶ ŵŽƌĞ ƉůĞĂƐĞ ĐŽŶƚĂĐƚ 'ĂƌǇ ŚƌŝƐƚĞŶƐŽŶ͕ D͘ ͕͘ DĞŶƚĂů ,ĞĂůƚŚ ůŝŶŝĐ ŝƌĞĐƚŽƌ (612) 624-1444͘ ƉƉůǇ ŽŶůŝŶĞ Ăƚ ŚƩƉƐ͗ͬͬĞŵƉůŽǇŵĞŶƚ͘ƵŵŶ͘ĞĚƵ and ƌĞĨĞƌĞŶĐĞ ƌĞƋƵŝƐŝƟŽŶ ŶƵŵďĞƌ 174055͘ dŚĞ hŶŝǀĞƌƐŝƚǇ ŽĨ DŝŶŶĞƐŽƚĂ ŝƐ ĂŶ ƋƵĂů KƉƉŽƌƚƵŶŝƚǇ͕ ĸƌŵĂƟǀĞ ĐƟŽŶ ĚƵĐĂƚŽƌ ĂŶĚ ŵƉůŽǇĞƌ͘

ϰϭϬ ŚƵƌĐŚ ^ƚƌĞĞƚ ^ ͻ DŝŶŶĞĂƉŽůŝƐ͕ DE ϱϱϰϱϱ ͻ ;ϲϭϮͿ ϲϮϱͲϴϰϬϬ ͻ ǁǁǁ͘ďŚƐ͘ƵŵŶ͘ĞĚƵ

DECEMBER 2011

MINNESOTA PHYSICIAN

SPECIAL

For all ages and multiple conditions

The primary population creating the demand for home care is seniors. As 78 million baby boomers in the United States approach retirement age, our nationâ&#x20AC;&#x2122;s demographics are shifting significantly. Seniors will soon constitute 20 percent of the population. Itâ&#x20AC;&#x2122;s estimated that by the year 2020, 12 million older

SENIOR

By Amy Nelson Americans will need long-term care. A recent consumer survey conducted by AARP showed that home care is the preferred care choice for 95 percent of seniors and retiring baby boomers. Both groups are interested in staying out of what is commonly known as the â&#x20AC;&#x153;broken hip revolving doorâ&#x20AC;? of hospitals, rehab centers, and short-term nursing home placements. In addition to seniors, home care serves people of all ages who are recovering from health challenges, disabled, chronically ill, or in need of end-of-life care. Their ongoing needs may be medical, nursing, therapeutic, or assistance with the basic activities of daily living. Two growing service niches in home care are pediatric care (including premature babies)

Allina Hospitals & Clinics is known for its clinical quality, and an award-winning EMR. At Allina, physician leadership and involvement drive our success. The Clinic and Community Division features the Allina Medical Clinic, Aspen Medical Group, and Quello Clinics, as well as Home and Community Services. Our clinics, as well as our 11 hospitals, are located in the Twin Cities metro area, throughout Minnesota, and in western Wisconsin. Full- or part-time urban, suburban, and rural openings are available in the following specialties: t /FVSPMPHZ t 0CTUFUSJDT (ZOFDPMPHZ t 0SUIPQFEJD 4VSHFSZ t 1FEJBUSJDT .FE 1FET Hospitalist t 1FEJBUSJDT t 1FSJOBUPMPHZ t 1IZTJDBM .FEJDJOF 3FIBC 4$*

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Allina offers a competitive benefits and salary package. For more information, please contact: Kaitlin Osborn, Allina Physician Recruitment Toll-free: 1-800-248-4921 | Fax: 612-262-4163 Email: Kaitlin.Osborn@allina.com Website: allina.com/jobs EOE 9533 0611 ÂŠ2011 ALLINA HEALTH SYSTEM. ÂŽA REGISTERED TRADEMARK OF ALLINA HEALTH SYSTEM

LONG-TERM

Patient-preferred and cost-effective

Allina Hospitals & Clinics in Minnesota/Western Wisconsin

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Home care

s health care reform becomes a reality, momentum is building toward keeping patients in their homes whenever possible. Home care helps to achieve health care reform mandatesâ&#x20AC;&#x201D;such as reducing re-hospitalization ratesâ&#x20AC;&#x201D;by allowing care recipients to avoid expensive institutional alternatives like hospitals and nursing homes. Physicians will be integral to the success of these efforts. Patient-preferred and cost-effective, home care is becoming an integral part of the health care continuum, as it bridges the clinic-based model and the actual world patients live in.

FOCUS:

MINNESOTA PHYSICIAN DECEMBER 2011

and young disabled adults. Home care is now a viable option for children who would have been institutionalized or hospitalized long-term, or who would not have survived at all in years past. John McNamara, MD, medical director of Childrenâ&#x20AC;&#x2122;s Home Care & Hospice Program at Childrenâ&#x20AC;&#x2122;s Hospitals and Clinics of Minnesota, has said, â&#x20AC;&#x153;We have sent over 400 children home with trachs and vents and find home care to be a very good alternative with fewer infections and low readmission rates. Even children with acute illnesses have been successfully cared for at home.â&#x20AC;? Recent advances in medical technology have increased the population of patients now treated at home. Chronic patient needs being handled by home care nurses include tracheotomies, ventilators, gastrostomy tubes, IV therapies, and many cardiac conditions. Cancer and transplant patients are also able to recuperate at home. Recent advances in medical technology have increased the population of patients now treated at home. Common home medical interventions include: infusion therapies with central and peripheral lines, lab draws, parenteral and enteral nutrition, sleep diagnostic testing, respiratory assistive devices such as ventilators, CPAP, oxygen monitoring, CO2 monitoring, and airway clearance equipment and techniques. Additional technologies that improve home care include telehealth service management, electronic medical records, and a variety of assistive technologies such as home sensors. A nurse using telehealth equipment, for instance, can potentially make up to 15 visits a day rather than the standard five. Comparing costs

Home care is from five to 20 times less expensive than care in

CARE

an inpatient facility. A 2009 study published by Avalere Health estimated that early home care use was associated with a $1.71 billion reduction in Medicare post-hospitalization spending over a one-year period. Medical professionals and their patients (and patientsâ&#x20AC;&#x2122; families) can leverage home care to maximize care capacities while minimizing costs. In 2009, national charges by Medicare were $135 per home care visit, $622 per day for skilled nursing facilities, and $6,200 per day for inpatient hospital care. The numbers speak for themselves. The physicianâ&#x20AC;&#x2122;s role

Family practice physicians, gerontologists, and medical specialistsâ&#x20AC;&#x201D;for example, in orthopedics and cardiologyâ&#x20AC;&#x201D; can benefit from understanding how home care fits into the evolving health care paradigm. Points to consider: â&#x20AC;˘ Increasingly skilled private duty nurses, along with care managers, regularly meet complex medical needs in home settings. Physicians sign off on all such nurse activities. Patient care plans are recertified at a minimum every 60 days. â&#x20AC;˘ Cost savings, familiar surroundings, and community support services make home care a viable option for many care recipients. â&#x20AC;˘ Proactively discussing discharge planning, including home care, at the time of a patientâ&#x20AC;&#x2122;s hospital admission can be helpful. â&#x20AC;˘ Because hospitals have increased incentives to prevent re-hospitalizations, more phone follow-up by hospitals and doctors to home care placements is becoming commonplace. â&#x20AC;˘ Open communication on the part of physicians is key, including telling home care professionals what is needed to help physicians provide optimal care. Speak to and meet home care providers at least on an annual basis. â&#x20AC;˘ Physicians can refer patients to nonprofit resources, listed in the sidebar, to learn more about home care.

Nonprofit resources for home care • MN HomeCare Association: www.mnhomecare.org • Senior LinkAge Line: 800-333-2433 • Metropolitan Area Agency on Aging: www.tcaging.org/findinghelp/sll.html • PACER Center (advocacy group for children with disabilities): www.pacer.org • Disease management groups such as the Muscular Dystrophy Association (www.mda.org/), ALS Association (www.alsa.org/), Brain Injury Association of Minnesota (www.braininjurymn.org/), Autism Society of Minnesota (www.ausm.org/) • National Association for Home Care and Hospice: www.nahc.org Types of home care

Home care ranges from a onehour weekly visit to 24-hour livein care. It provides a one-on-one focus, which is difficult to obtain in hospitals or group facilities. Home care also respects cultural differences and ethnic diversities by assigning staff members not only by skill sets but also by language (from Spanish to Somali to sign) and behavioral criteria, such as not smoking or not consuming pork. In hospital settings, there is no choice as to who provides the patient care. Home care allows the patient to select the service provider upfront and provides care in a controlled setting. The checklist of questions above is designed to help physicians, patients, and families match the needs of the patient to home care provider skill sets. There are five basic home care service options: 1. Personal care assistants provide assistance with activities of daily living such as dressing, bathing, feeding, getting to doctor appointments, etc. They are not licensed by the state. This type of care typically is paid for by Medical Assistance, Minnesota’s Medicaid program. 2. Private duty care—basically private-pay care—provides assistance with nonmedical needs such as shopping, cooking, transportation, and companionship and involves household management services but no hands-on medical care. Some long-term care policies will cover such home care, but reimbursement terms and exclusion criteria vary. 3. Licensed home care agencies employ a variety of home health care professionals, including skilled nurses, ther-

apists, and home health aides. This type of care typically is paid for by private insurance, Medicare, and Medicaid. 4. Medicare-certified skilled home care typically is provided on an acute, intermittent basis, i.e., following an illness, injury, or change in disease status. Such services are physician-driven and reimbursement is contingent on the individual demonstrating progressive improvement while being homebound. 5. Extended-hour nursing offers high-level, one-on-one care, from four to 24 hours a day for patients with medically complex needs. Not all home care agencies offer this type of care. This is an intensive level of care provided for at-home patients requiring trachs, G-tubes, IV, and ventilation.

Finding the right match of patient needs, home care services Matching patients’ needs with home care providers’ skill sets is a primary consideration for physicians, patients, and families. These qualifier questions can help determine the optimal home care provider for any particular situation: 1. What process do you use to match employees with clients? 2. What type of training is given to your staff members? 3. Does your agency have licensed social workers on staff to address the emotional needs of clients and families? 4. How closely do your supervisors evaluate the quality of care provided? 5. How are problems addressed and resolved? 6. How do you manage scheduling? Is care available around the clock if needed? 7. What are the credentials of your employees who will be in the home? Can they provide individual references? 8. What procedures are in places in case of an emergency, such as a power failure or inclement weather? 9. Are all of your caregivers licensed in their fields? 10. Can you provide references, including doctors, hospital discharge planners, and clients? 11. How do you handle expenses and billing? Has your company ever been accused of fraud? 12. Will I receive a written care plan before service begins? rapidly moving from the periphery to the mainstream of patient care. The types of care now being handled at home are drastically different from care models even 10 years ago, and they will continue to evolve as technologies advance. Home is where families want their loved

ones to be, and home care supports the best quality of life for patients. Amy Nelson is founder, president, and CEO of Accurate Home Care, a provider of home care services in the Upper Midwest. AHC serves a wide range of medically complex pediatric and adult clients.

Who pays for home care?

Funding for home care is increasing. Many insurance companies now cover extendedhour nursing and care visits. A tracheotomy patient, for example, can be approved for 24hour-a-day care for one month and then be weaned into family care. Managed care companies such as Medica, HealthPartners, UCare, and Blue Cross and Blue Shield have come to understand that home care is safe, efficient, and cost-effective. Payment options for home care include self-pay, Medicare, Medicaid, Veterans Administration, community organizations, commercial health insurance companies, managed care organizations, CHAMPUS (military health plan), and workers’ compensation. Bringing it home

Home care is a critical component of collaborative care that is DECEMBER 2011

MINNESOTA PHYSICIAN

PROFESSIONAL

he American Diabetes Association’s (ADA) slogan is “Stop Diabetes.” If this is really possible, why is the prevalence of diabetes increasing at epidemic proportions? The number of people with diabetes in the United States increased by 17 million people from 1958 to 2010, according to the U.S. Department of Health and Human Services; more than 8 percent of the American population has type 2 diabetes now, and one in three children born after 2000 will develop diabetes unless strong preventive steps are taken. Furthermore, due to the insidious nature of the disease, by the time the diagnosis is made, many people have had the disease for anywhere from nine to 12 years, resulting in the presence of complications in as many as 39 percent of those with newly diagnosed diabetes. And we know that those who are at risk for diabetes are at similar risk for cardiovascular disease and peripheral vascular disease as those who have diabetes.

DIABETES

Bending the curve on diabetes Physician engagement can improve outcomes By Maggie Powers, PhD, RD, CDE; Teresa Pearson, MS, RN, CDE, FAADE; and Rita Mays, MS, RD, LN

The Minnesota Department of Health (MDH) reports that every year 20,000 Minnesotans are newly diagnosed with diabetes. Our goal is to bend the curve on the rising incidence of diabetes.

visits and tests, diabetes medications, and supplies. Additionally, people with diabetes often have more health problems than those without diabetes. Other health problems associated with the disease

More than 1 million people in Minnesota have prediabetes, but only 20 percent know they have it. There are a number of reasons to work hard at preventing diabetes. One important reason is the cost of having diabetes, including the cost of health care

Live in the relaxed lake country of Mille Lacs and practice medicine where you will make a difference. We’re looking for a Family Physician to join us at Mille Lacs Health System in Onamia, Minnesota. Loan forgiveness options may be available. Contact: Fern Gershone: fgershone@mlhealth.org or Dr. Tom Bracken: tbracken@mlhealth.org

Caring for body, mind and spirit. Onamia, MN • mlhealth.org • 877 - 535-3154 7 FAMILY PHYSICIANS • 8 PAs • 1 GENERAL SURGEON • CRITICAL ACCESS HOSPITAL ER STAFFED 24/7 • ATTACHED GERIATRIC UNIT & LTC FACILITY • 4 CLINICS

U P D AT E :

MINNESOTA PHYSICIAN DECEMBER 2011

increase the cost of health care, as they may require more expensive tests, medications, and hospitalizations. In Minnesota, diabetes costs almost $3 billion a year—about $12,000 for every person with diabetes. According to the ADA, health care costs for people with diabetes are three to four times higher than the costs for people without diabetes. There are also emotional costs associated with diabetes. In fact, 20 percent of Minnesotans who have diabetes also have depression, which can negatively influence diabetes management and self-care behaviors. Health professionals who care for people with diabetes understand the harm and costs of diabetes. At the same time they may be frustrated that they have little time to spend on diabetes care when patients present with multiple health issues. Identifying people at risk of developing diabetes—i.e., those with prediabetes—and knowing what resources are available can help physicians work with patients before the most serious complications of the disease develop.

Warning signs of type 2 diabetes and prediabetes

There is strong evidence that type 2 diabetes can be prevented or delayed. The warning signs of diabetes listed in the patient handout on p. 31 help identify which adults and children are at risk. In Minnesota, the most frequent risk factor is being overweight. More than 1 million people in Minnesota have prediabetes, but only 20 percent know they have it. That means 80 percent do not know that they have this health problem, are not addressing it, and are at increased risk of developing type 2 diabetes. Table 1 lists the latest criteria for diagnosing diabetes and prediabetes. Evidence for preventing diabetes

The National Institutes of Health-sponsored Diabetes Prevention Program (DPP) was stopped early because the results in one of the treatment groups were so dramatic that it would be irresponsible if the successful intervention was not offered to all study participants. The intervention that decreased participants’ risk of developing type 2 diabetes by 58 percent was a 16-session lifestyle education/support program. The primary goals were for participants to: • lose 5 to 7 percent of current body weight—about 10 pounds • moderately exercise for a total of 30 minutes a day, five days a week Some people think this is easy, but for most people it is not easy. Structured programs that guide and support individuals have proven to be very helpful. Patients’ perspectives

A 2009 ADA survey showed that people at high risk of developing diabetes report they follow a poor diet (67 percent), maintain an unhealthy weight (62 percent), and avoid doctors’ visits (50 percent). Admittedly, changing unhealthy behaviors is not easy for many people, yet research shows that change can

TABLE 1. ADA diagnostic criteria for prediabetes and diabetes

Patient handout: Warning signs of type 2 diabetes Do you have any of these warning signs of diabetes? If you do, talk to your doctor about how you can prevent or delay getting diabetes. • I have a close family relative (mother, father, brother, or sister) with diabetes. • I am not very physically active. I exercise fewer than three times a week. • I have high blood pressure or blood pressure equal to or greater than 140/90 mmHg. • I have low HDL cholesterol (the good cholesterol)—less than 35 mg/dL. • I have high triglyceride levels (fat in the blood)—more than 250 mg/dL. • I have an A1c (a special blood sugar test) equal to or greater than 5.7 percent. • I have had heart disease/problems. • I am very overweight. • I have acanthosisnigricans (a skin reaction that darkens the skin around the neck and under the arms). • I am a woman and have had gestational diabetes or a baby weighing more than 9 pounds. • I am a woman, and have PCOS (polycystic ovary syndrome). • I am part of an ethnic group that has a higher number of people with diabetes—Latino, Hispanic, African American, Asian American, American Indian, Pacific Islander. occur when knowledge and barriers are addressed. In the 2009 survey, more than half of the responders mistakenly stated that “eating too much sugar” is a risk factor for diabetes. On their own, patients may try to

eliminate sugar yet end up consuming more calories because they consume more high-fat foods. Others may mistakenly replace sugary soda pop with fruit juice, unaware that regular juice is very high in sugar, and

Normal

Prediabetes

Diabetes

A1c

≤5.6

5.7–6.4

≥6.5

Fasting plasma glucose (mg/dL)

<100

100–125

≥126

2 hr 75 gm OGTT (mg/dL)

<140

140–199

≥200

Random plasma glucose (mg/dL)

<140

N/A

>200 and classic diabetes symptoms

Confirm diagnosis of diabetes on a subsequent day unless there is evidence of unequivocal hyperglycemia. thus achieve no reduction in sugar, carbohydrate, or caloric intake. If losing body weight was easy, two-thirds of the American population would not be overweight or obese. Providing accurate information and support can help patients develop healthier eating and activity patterns that can reduce their risk—and physicians do not need to do all of this themselves. Minnesota action

The Minnesota Diabetes Plan 2015 focuses on stemming the tide of the diabetes epidemic and improving diabetes care.

The plan encompasses expanding and easing access to care, education, and food, and increasing accountability for care coordination, referring patients to appropriate resources, supporting diabetes self-management skills in prevention of type 2 diabetes, and making effective diabetes prevention programs (DPPs) available statewide. Minnesota has been a leader in piloting prevention programs. The state is now facilitating access to these programs while also actively supporting additional programs so DIABETES to page 36

Urgent Care Mankato Clinic is looking for exceptional Physicians, Physician Assistants and Nurse Practitioners to work in our busy Urgent Care Department. Customer service skills and the very best patient care are essential for these professionals who are the first point of contact for some patients. You will work with a team of highly skilled support staff in an efficient, fast-paced environment. There are full-time and casual shift opportunities available. Hours are weekdays 8 a.m.–8 p.m., Saturdays 8 a.m.–5 p.m., and Sundays noon–5 p.m. Care is provided in three locations, two full-service urgent care/occupational medicine facilities and one express service clinic located in Mankato’s shopping mall. Providers in full-time positions will enjoy an excellent benefits package including generous CME expense and time-off allowances; 401(k) profit sharing plan; EAP; employee discounts and more. Apply online at www.mankato-clinic.com, or contact Dennis Davito, Director of Provider Services at dennisd@mankato-clinic.com; Phone: 507-389-8654; Fax: 507-625-4353; Mankato Clinic, 1230 E. Main St., Mankato, MN 56001. Mankato Clinic is an Affirmative Action/Equal Opportunity employer.

www.mankato-clinic.com DECEMBER 2011

MINNESOTA PHYSICIAN

ANESTHESIOLOGY

Pain control

ames was surprised when his anesthesiologist wanted to talk about developing a plan for controlling the pain he may have on Thursdayâ&#x20AC;&#x201D;the third day after his upcoming surgery. â&#x20AC;&#x153;I thought he just took care of me in surgery, kept me asleep, and woke me at the end,â&#x20AC;? James said. In fact, there is much more to this specialty and much more to what anesthesiologists can do for patients. The role of the anesthesiologist has expanded over the past two decades. Before that, it was common practice for the anesthesiologist to be responsible for the patient in the immediate perioperative period. Typically, he or she met the patient just prior to inducing anesthesia and then transferred postoperative care to a nurse in the postanesthesia care unit (PACU). It was up to the surgeon or other physicians to deal with pain control beyond the immediate postoperative period. Now, though, there is a new paradigm within the specialty of anesthesiology. Todayâ&#x20AC;&#x2122;s anesthesiologists are involved with all aspects of care

Good news for patients By John P. Mrachek, MD

and they are the central figure in the continuum of surgical care. No longer is our responsibility limited to the care of patients exclusively during surgery. It is clear that what we do on Monday makes a difference on Friday. As perioperative physicians, we have a unique view of health care in the perioperative periodâ&#x20AC;&#x201D;before, during, and after surgery. We are perfectly positioned to coordinate all aspects of surgical care. We can offer so much to patients, our physician colleagues, our hospitals, and to health care as a whole. Our involvement may include making sure a patientâ&#x20AC;&#x2122;s hypertension is addressed postoperatively, or that patients who appear to have sleep apnea receive proper follow-up diagnosis and care. One of our primary

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Marshfield Clinic continues to redefine health care through our innovative technology and practices, but it doesnâ&#x20AC;&#x2122;t end there. Weâ&#x20AC;&#x2122;re also redefining what it means to be a physician practicing with us. Our setting in the heart of Wisconsin makes it possible for you to explore all of the lifestyle options that come with living in an environment rich in natural wonders and short on congestion. We have openings for BC/BE physicians in:

â&#x20AC;˘ Dermatology â&#x20AC;˘ Family Practice â&#x20AC;˘ IM â&#x20AC;˘ Neurosurgery â&#x20AC;˘ Orthopaedic Surgery â&#x20AC;˘ Pediatrics (general and subspecialty) â&#x20AC;˘ PM&R â&#x20AC;˘ Pulmonary Critical Care â&#x20AC;˘ Urology (please contact us if you donâ&#x20AC;&#x2122;t see your speciality listed) Marshfield Clinic is one of the largest physician-directed private group practices in the United States employing more than 800 physicians and over 6000 support personnel in 54 locations throughout northern, western and central Wisconsin. As one of the most respected and recognized names in health care delivery, Marshfield Clinic combines world class services with a solid commitment to quality of life for both patients and staff, which makes Marshfield Clinic and Wisconsin a very attractive place to get your career on the right path. To hear more about the numerous physician practice opportunities we have available and the very competitive compensation package we offer, please contact: Physician Recruitment, Marshfield Clinic, 1000 N. Oak Ave., Marshfield, WI 54449. Phone: 800-782-8581, ext. 15770; Fax #: 715-2215779; E-mail: physrec@marshfieldclinic.org; Website: www.marshfieldclinic.org/recruit; Facebook: www.facebook.com/marshfieldclinicphysrec 0DUVKĂ&#x20AC;HOG &OLQLF LV DQ $IĂ&#x20AC;UPDWLYH $FWLRQ (TXDO 2SSRUWXQLW\ HPSOR\HU WKDW YDOXHV GLYHUVLW\ 0LQRULWLHV IHPDOHV LQGLYLGXDOV ZLWK GLVDELOLWLHV DQG YHWHUDQV DUH HQFRXUDJHG WR DSSO\ 6RUU\ QRW D KHDOWK SURIHVVLRQDO VKRUWDJH DUHD

MINNESOTA PHYSICIAN DECEMBER 2012

responsibilities is to assure appropriate pain control beyond the immediate postoperative period. Most patients who are having surgery are primarily concerned about anesthesia or pain. Many studies have demonstrated that poor postoperative pain control leads to poor outcomes, low patient satisfaction, and increased costs. We feel that you cannot have excellent surgical care without having excellent postoperative pain control. As a result of the paradigm shift in anesthesia care, Northwest Anesthesia PA, which provides all anesthesia services at Abbott Northwestern Hospital and the Orthopedic Institute Surgery Center, has developed a comprehensive sophisticated Acute Pain Service (APS) to address postoperative and acute pain. The philosophy of the APS is simple: Provide superior postoperative pain control while minimizing the side effects related to such an effort. The APS uses a variety of mechanisms, skills, and techniques to control pain, including peripheral nerve blocks, multimodal preemptive analgesia, neuraxial blocks, and ketamine infusions. These nonnarcotic mechanisms for controlling pain avoid many of the untoward side effects of narcotic medication, including nausea, vomiting, constipation, itching, sedation, respiratory depression, and potential addiction. Orthopedic patients

Many orthopedic surgical procedures are associated with intense postoperative pain. We have developed multiple techniques for controlling postoperative pain. We tailor these techniques to both the surgical procedure and the patientâ&#x20AC;&#x2122;s needs. We use specific nerve blocks for every orthopedic surgical procedure performed. For example, we use a continuous interscalene nerve block for complex shoul-

der procedures such as rotator cuff repair and joint replacement. This nearly painless procedure involves placing a catheter to deliver local anesthetic to the nerves that provide feeling to the shoulder. We use ultrasound guidance to place the nerve block for patient comfort and to confirm catheter placement. The catheter is then connected to a disposable infusion pump that allows a continuous infusion of local anesthetic for excellent pain control. Total knee arthroplasty (TKA) is widely considered the most painful elective orthopedic procedure performed. Consequently, we place multiple nerve blocks for TKA including continuous femoral nerve blocks. As a result of implementing the APS pain protocol for TKAs, we have improved our patient satisfaction and clinical outcomes, reduced length of stay, decreased the percent of patients discharged to a skilled nursing facility, and reduced our costs. We do these procedures preoperatively as part of our preemptive analgesia. This technique provides superior pain control and significantly reduces the need for IV narcotics. As a result, we can conduct our nonjoint replacement shoulder surgery on an outpatient basis. Our patients are able to recover at home, avoiding unnecessary hospitalization or the need for convalescence in a hotel recovery unit. Superior postoperative pain control improves patient outcomes and satisfaction, increases safety, reduces use of health care resources, and increases inpatient capacity. This is a rare win-win-win-win situation: It is better for the patient, the physician, the hospital, and the payerâ&#x20AC;&#x201D;exactly the result that everyone is hoping to achieve with health care reform. Patient satisfaction

We continually survey our patients to measure their level of satisfaction and to make improvements to our program. Our patient satisfaction data have guided many of our clinical decisions as we improve and expand the APS program. The PAIN CONTROL to page 34

Sioux Falls VA Health Care System “A Hospital for Heroes” 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. They all come together at the Sioux Falls VA Health Care System.

We invite you to explore our opportunities in: In the heart of the Cuyuna Lakes region of Minnesota, the medical campus in Crosby includes Central Lakes Medical Clinic, a 30-physician multispecialty group, and Cuyuna Regional Medical Center, a critical access hospital offering superb new facilities with the latest medical technologies. Outdoor activities abound, and with the Twin Cities metropolitan area just a short drive away, you can experience the perfect balance of recreational and cultural activities. Enhance your professional life in an environment that provides exciting practice opportunities in a beautiful Northwoods setting. The Cuyuna Lakes region welcomes you.

• Family Medicine • Internal Medicine

• Orthopedic Surgeon • Emergency Department Physician

CENTRAL LAKES

• Chief of Primary Care and Specialty Medicine

MEDICAL CLINIC P.A.

To be a part of our proud tradition, contact:

Human Resources Mgmt. Service P O Box 5046 Sioux Falls SD 57117 605-333-6852

Contact: Todd Bymark, tbymark@cuyunamed.org (866) 270-0043 / (218) 546-4322 | www.cuyunamed.org

www.siouxfalls.va.gov

Family Medicine

Internal Medicine?

Yup.

St. Cloud/Sartell, MN

Family Medicine?

We are actively recruiting exceptional part-time or full-time BC/BE family medicine physicians to join our primary care team in Sartell, MN. This is an out-patient only opportunity and does not include labor and delivery or hospital call and rounding. Our current primary care team includes family medicine, adult medicine, OB/GYN and pediatrics. Previous electronic medical record experience is preferred but not required. We use the Epic electronic medical record system at all of our clinics and admitting hospitals.

NEW clinic in Mahtomedi, MN?

Internal and Family Medicine Opportunities Stillwater Medical Group is an 90+ provider multi-specialty group practice affiliated with Lakeview Hospital. For more than 50 years we have been providing comprehensive healthcare services in the St. Croix Valley, just east of the Twin Cities metro area.

Our HealthPartners Central Minnesota Clinics – Sartell moved into a new primary care clinic in the summer 2010. We offer a competitive salary, an excellent benefit package, a rewarding practice and a commitment to providing exceptional patient-centered care. St Cloud/Sartell, MN is located just one hour north of the Twin Cities and offers a dynamic lifestyle in a growing community with a traditional appeal.

Internal and Family Medicine Physician Opportunities: Stillwater Medical Group has exciting new Internal and Family Medicine Physician opportunities at our NEW Mahtomedi, MN clinic opening Fall 2012! Additional opportunities also available in Stillwater, MN. Mahtomedi, MN? (Ma-toe-me-dye) So what if you can’t pronounce it? We can help with that. Mahtomedi is located in Washington County, on the east shore of White Bear Lake. Residents appreciate the community’s small town charm, lakeside flavor, and close proximity to the Twin Cities Metropolitan Area. In addition, the Mahtomedi School District and other area colleges offer excellence in education. For further information please contact: Patti Lewis, Director Human Resources 1500 Curve Crest Blvd, Stillwater MN (651) 275-3304, plewis@lakeview.org stillwatermedicalgroup.com

For more information, please contact diane.m.collins@ healthpartners.com or call Diane at 800-472-4695 x3. EOE

healthpartners.com

DECEMBER 2011

MINNESOTA PHYSICIAN

Pain control from page 32 results demonstrate high patient satisfaction. For example, when we asked our first 200 patients whether they would they opt for a continuous peripheral nerve block if they needed the surgical procedure again, 100 percent of patients answered “yes.” When patients were asked if, based on their experience with the APS, they would recommend our hospital to a relative or friend, again, 100 percent of patients said they would recommend our hospital. And finally, 99 percent of patients said they were either extremely satisfied or highly satisfied with their postoperative pain control. Preventing chronic pain

Chronic pain is a devastating condition suffered by thousands of people throughout the United States. Conservative studies show that one in four adults in the U.S. report chronic pain and 50 percent of cancer patients have chronic pain, causing patients and family members significant suffering. A 2003

No longer is the anesthesiologist’s responsibility limited to the care of patients exclusively during surgery: It is clear that what we do on Monday makes a difference on Friday. study estimated the cost of chronic pain in the U.S. at $61.2 billion annually. Chronic pain often arises from acute pain episodes caused by a fracture or a surgical procedure. Pain from a surgical procedure, though often intense, should be transient and should resolve with time. Unfortunately, in some patients that acute episode is prolonged, leading to chronic pain lasting months, or even years. Could early, comprehensive pain control diminish or even eliminate some chronic pain syndromes? Significant scientific and clinical evidence demonstrates that excellent postoperative pain control leads to a decrease in the incidence of chronic pain.

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

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

• Pediatrics • Pulmonary/ Critical Care • Radiation Oncology • Rheumatology

For additional information, please contact: Kari Bredberg, Physician Recruitment karib@acmc.com, 320-231-6366 Julayne Mayer, Physician Recruitment mayerj@acmc.com, 320-231-5052 www.acmc.com

MINNESOTA PHYSICIAN DECEMBER 2012

This should be important to patients, physicians, and payers when considering options for surgery. It is an important element that is often overlooked, but may have as significant an impact as any other component of perioperative care. Patients and their physicians should consider postoperative pain control when choosing a facility for surgery. Are we preventing cancer from recurring?

Choosing regional anesthesia and analgesia for surgical procedures has obvious benefits, including deceased side effects from narcotics, decreased incidence of nausea and vomiting, improved pain control, earlier physical therapy, and better long-term outcomes. But could these procedures also prevent cancer recurrence? Abbott Northwestern’s APS offers comprehensive, coordinated, multimodal postoperative pain control. This includes the use of paravertebral nerve blocks for breast surgery. In this procedure, we inject local anesthetic near the nerve roots of the nerves that give feeling to the chest. Additionally, we place a small catheter to continue to infuse local anesthetic so that we can provide extended pain relief. Paravertebral nerve blocks allow us to create a band of numbness covering the surgical site, minimizing the need for deep general anesthesia and narcotic pain medicine. It provides a better experience for the patient while avoiding side effects such as nausea, vomiting, sedation, and sleep disruption. So, could these techniques also prevent certain cancers from recurring? Two recent studies have suggested support for this provocative theory. Surgical resection—i.e., lumpectomy and mastectomy—

remains the best treatment for breast cancer. However, residual disease is a real possibility. Metastatic spread of these residual cells is affected by many factors, especially the body’s natural ability to kill tumor cells via the immune system and development of new blood vessels at the site of disease. We know that volatile anesthetics, interaction between the nervous and endocrine systems in response to the stress of surgery, and opioids adversely affect these factors. One study looked at the recurrence of breast cancer after surgical resection over a 36month period (Exadaktylos, E.K. et. al., Anesthesiology, Oct. 2006). Fifty patients had surgery with paravertebral nerve anesthesia and analgesia combined with general anesthesia, and 79 patients had general anesthesia with morphine for postoperative pain relief. Recurrence and metastasis-free survival was 94 percent versus 82 percent at 24 months, respectively, and 94 percent versus 77 percent at 36 months in the patients receiving paravertebral- and general anesthesia. These results are compelling, and have prompted a larger study to confirm these findings. Another study looked at the recurrence of prostate cancer following prostatectomy. It, too, showed a decreased incidence of disease recurring following the use of regional analgesia instead of narcotics. Again, these results warrant a larger trial, but the initial results are compelling and exciting. It is clear that high-quality, comprehensive, postoperative pain control is a critical component of high-quality health care. The availability of such care should be an expectation of every patient requiring surgery. As James attests, “This pain control was great; I felt great, and I got back to living my life quicker.” John P. Mrachek, MD, a physician with Northwest Anesthesia PA, is director of acute pain service at Abbott Northwestern Hospital.

Growing multi-specialty group practice in Northern Minnesota is looking for a BC/BE Family Practice Physician, Internal Medicine Physician, Emergency Room Physician, OB/GYN Physician, Urologist as well as an Orthopaedic Surgeon. Join an existing group practice and take over existing practices from departing physicians. Grand Itasca Clinic & Hospital in Grand Rapids, Minnesota has recently opened a new state of the art clinic & hospital. Excellent salary guarantee with outstanding income potential, full benefits and sign-on bonus. Community located in the beautiful northern Minnesota lakes area.

Contact: Gail Anderson (218) 999-1447 gail.anderson@granditasca.org.

Come home. Where organizational strength lies in the diversity of people who call SANFORD HEALTH – home. Sanford Health – Fargo Region is redefining health care. Serving northwestern Minnesota and eastern North Dakota, we offer innovative technology, support of a multi-specialty organization, and dependable colleagues. Excellent practice opportunities exist in family-oriented communities that offer year-round outdoor activities, cultural events, and superior education districts that will allow you to balance your work & life. Our employment model features competitive salaries, a comprehensive benefits package, paid malpractice insurance, and a generous relocation allowance. Contact: Jean Keller Physician Recruiter Phone: (701) 280-4853 Jean.Keller@sanfordhealth.org

Cardiology Dermatology ENT Emergency Medicine Family Medicine Gastroenterology Hospitalists Internal Medicine Neurology Occupational Medicine Oncology Orthopedic Surgery Pediatric Specialties Psychiatry Pulmonology (Sleep) Rheumatology Urology

NEW POSITIONS:

Family Practice Urgent Care Dynamic, independent 3 location, single-specialty practice in northwest Minneapolis suburbs is seeking additional associates for its Rogers site and has Full Time/ Part Time shifts in the Crystal and Rogers Urgent Care. • • • • •

Partnership opportunity after 2 years Competitive salary with incentives Excellent benefits, 401k/employer paid pension Practice at one site/one hospital Physician-owned

Please contact or fax CV to: Joel Sagedahl, M.D. 1495 Highway 101 North, Plymouth, MN 55447 763-504-6600 • Fax 763-504-6622

Visit our website at www.NWFPC.com

DECEMBER 2011

MINNESOTA PHYSICIAN

The intervention that decreased participants’ risk of developing type 2 diabetes by 58 percent was a 16-session lifestyle education/support program.

Diabetes from page 31 all Minnesotans have easy access to diabetes prevention services. The Diabetes Program at the MDH provides a current listing of group diabetes prevention programs in Minnesota, including contacts, dates, locations, and costs of participation (go to www.icanpreventdiabetes .org/groups.html). Three 16-week DPP programs currently are offered in Minnesota: • Lifestyle Balance for American Indians (offered through the Indian Health Board in Minneapolis and tribal communities) • I CAN Prevent Diabetes (offered throughout the state with coordination by MDH) • Y-DPP (offered by the metroarea, Willmar, and Alexandria YMCAs) The I CAN Prevent Diabetes program has demonstrated that people who attend 80 percent or more of the 16-week session are more successful than those that don’t. The average weight loss for people who attend 13 or

more sessions has been 6 percent but only 4 percent for those attending 12 or fewer sessions. Other prevention programs are available in Minnesota and may be offered by registered dietitians, diabetes education programs, or community groups. Although the effectiveness of these programs may be untested or less vigorously tested, many have been successful. Action steps for physicians

Behavior change is a long-term process and physician engagement in setting expectations, making a referral, providing support and monitoring attendance, process and outcomes is key to success. Here are steps physicians and their staffs can take to help patients with prediabetes or diabetes achieve

desired outcomes. 1. Identify patients who have risk factors for diabetes and/or pre-diabetes. 2. Set clear expectations for patients with prediabetes based on the DPP recommendations to: a. lose 5 to 7 percent of body weight and b. be active 30 minutes, five days a week. 3. Provide patients with resources to make healthy lifestyle choices to reach their goals and help patients address barriers. a. Ask patients what would most help them be successful; what support/ resources previously resulted in behavior change.

Practice Well. Live Well.

Lake Region Healthcare is located in a magnificent, rural, and family-friendly setting in Minnesota lakes country where we aim to be the state’s preeminent regional health care partner.

b. Refer patients to a registered dietitian for medical nutrition therapy or to attend a group DPP lifestyle intervention program. If these resources are not available in your clinic or community, consider collaborating with others to make needed resources available. c. Offer encouragement! 4. Establish a system to check in with patients between physician visits. 5. Celebrate successes, large and small. Maggie Powers, PhD, RD, CDE, is a research scientist at the International Diabetes Center at Park Nicollet, Minneapolis. Teresa Pearson, MS, RN, CDE, FAADE, is a health care and clinical consultant with Halleland Habicht Consulting, LLC, Minneapolis. Rita Mays, MS, RD, LN, is a diabetes prevention planner at the Minnesota Department of Health.

Look for the friendly doctor in a MN based physician staffing service ...

Our award winning patient care and uncommon medical specialties set us apart from other regional health care groups. Lake Region’s physicians and their families also enjoy an unmatched quality of professional and personal life. Current opportunities including competitive salary and benefit packages available for BE/BC physicians are: • Dermatologist • Family Medicine • General Surgery

• Hospitalist • Internal Medicine • Pediatrics

For more information contact Barb Miller, Physician Recruiter bjmiller@lrhc.org • (218) 736-8227

712 Cascade St. S., Fergus Falls, MN 736-8000 • (800) 439-6424

Lake Region Healthcare is an Equal Opportunity Employer. EOE

www.lrhc.org

MINNESOTA PHYSICIAN DECEMBER 2011

Physicians: • Let us do your scheduling & credentialing • Paid Malpractice • Physician Friendly • Choose where and when you want to work • Competitve Rates • Courteous Staff

Clients: • Prevent loss of revenue • BC/BE physicians • Competitive rates • Quality coverage • Malpractice coverage paid by us

P-763-682-5906/F-763-684-0243 michelle@whitesellmedstaff.com www.whitesellmedstaff.com

Urgent Care We have part-time and on-call positions available at a variety of Twin Cities’ metro area HealthPartners Clinics. Evening and weekend shifts are currently available. We are seeking BC/ BE full-range family medicine and internal medicine pediatric (Med-Peds) physicians. We offer a competitive salary and paid malpractice.

Connecting your business to your market Advertise in Minnesota Physician

612-728-8600

For consideration, apply online at healthpartners.jobs and follow the Search Physician Careers link to view our Urgent Care opportunities. For more information, please contact diane.m.collins@ healthpartners.com or call Diane at: 952-883-5453; toll-free: 1-800-472-4695 x3. EOE Vo lum

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Brain Injury from page 25 symptoms may be interpreted as dementia. In other patients the onset of a motor, speech, or sensory deficit may be confused with a cerebrovascular accident, transient ischemic attack, or brain tumor. The diagnostic procedure of choice for evaluation of a chronic SDH is the CT scan without contrast. In the first week after injury, a chronic SDH appears hyperdense in relation to the brain. In the next two weeks, most hematomas will appear isodense. After three weeks, the vast majority will appear hypodense and assume a lenticular appearance. Nevertheless, because recurrent bleeding frequently occurs from the vascularized hematoma membranes, chronic SDH can appear as an admixture of hypo- and hyperdense material. Close monitoring of patients with serial CT scans allows determination of chronic SDH reabsorbtion or enlargement. Operative treatment of chronic SDH has been achieved with the use of craniotomy or

The advent of modern medical science and imaging has allowed for the early diagnosis and aggressive treatment of traumatic brain injuries with improved clinical outcomes. bur holes. Bur hole removal is effective if multiple membranes appear absent and the hematoma appears hypodense on CT (see Fig. 1). The presence of multiple membranes and mixed density hematomas with acute and chronic components requires craniotomy. The frequent use of post-op CT scans to follow the postoperative progress of patients with chronic SDH demonstrates that residual hematoma is quite common regardless of operative technique used. Generally, the small residual hematoma will gradually reabsorb over a period of weeks to months. True re-accumulation of the hematoma is reported to occur as often as 35 percent in some series and probably results from re-bleeding of vascular membranes. Infectious complica-

tions include subdural empyema, brain abscess, and meningitis. These complications are uncommon and occur in less than 1 percent of patients. Seizures are reported in 10 percent to 12 percent of cases and appear to be related to the size of the hematoma and underlying brain shifts. The morbidity following treatment of a chronic SDH is less than 8 percent in most large series and about 75 percent of patients resume normal functioning. Outcome correlates most closely with the patient’s neurological state at the time of treatment. Toward improved clinical outcomes

Much has changed since the accurate literary description of brain trauma by Honoré de Balzac in the early 19th century.

The advent of modern medical science and imaging, especially within the last 40 years, has allowed for the early diagnosis and aggressive treatment of traumatic brain injuries with improved clinical outcomes. Given the increasing size of the aging population and the high personal and societal expectations of maintaining a relatively high degree of physical functionality, the evaluation and treatment of traumatic brain injuries will continue to play an important role. Physicians should have a high index of suspicion in those elderly patients presenting with an unexplained neurological or cognitive decline, even in the absence of a history of perceived significant trauma. Edward G. Hames III, MD, PhD, and Charles R. Watts, MD, PhD, practice with the Spine and Brain Clinic at Fairview Southdale Hospital and are employed by University of Minnesota Physicians through the Department of Neurosurgery at the University of Minnesota.

continuing medical education Fundamental Critical Care Support Dermatology for Primary Care

February 24, 2012

26th Annual Family Medicine Today

March 8-9, 2012

30th Annual OB/Gyn Update

April 12-13, 2012

The Mind of a Child: Psychiatric Challenges for Today’s Youth

April 19, 2012

Psychiatry Update: Selected Topics for the Non-Psychiatrist

April 20, 2012

Pediatric Fundamental Critical Care Support Fundamental Critical Care Support 30th Annual Strategies in Primary Care Medicine Optimizing Mechanical Ventilation 13th Annual Women’s Health Conference

education that measurably improves patient care 38

February 23-24, 2012

MINNESOTA PHYSICIAN DECEMBER 2011

May 3-4 and November 8-9, 2012 July 19-20, 2012 September 20-21, 2012 October 26-28, 2012 November 2012

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