Minnesota Physician February 2013 by Minnesota Physician Publishing

Volume XXVl, No. 11

February 2013

The Independent Medical Business Newspaper

Decision aids in diabetes treatment Promoting the voice of the patient By Marc Matthews, MD, Kari Ruud, MEd, PMP, and Victor Montori, MD

ealth care in America is fundamentally broken, and the inability of patients to participate in clinical decision-making is a significant reason why. Yet, few physicians are ready to acknowledge that the inability of patients to participate in the decision-making process is a driver of poor outcomes and skyrocketing costs. We have allowed our health-care delivery systems to be designed in a way that rewards us for doing more and more things of questionable value to our patients instead of taking the time to listen to our patients and allow them to contribute to decisions that will have a significant and, often, direct impact on their quality of life. We forget that patients and communities often define health not as the absence of disease, but rather as the ability to live a functional and productive life DIABETES to page 12

Disruptive doctors

DISRUPTIVE to page 10

PAID

he physician bursts out of the exam room, glancing at the assistant for some needed information. In a short moment, the physician is yelling, slamming the phone down, and stomping down the hallway because the data was misfiled in the electronic record.

PRSRT STD U.S. POSTAGE

By Melanie Sullivan, EdD, MBA

The physician is a member of a medical practice that is respected in the community. And the physician is creating chaos. This deep, dark secret is never discussed outside of the realm of the owners and the administrator. This physician appears angry all the time and undermines any decisions the group makes. The tension is building: Staff members dread board meetings, planned changes

ILLNESS Page 20

Detriot Lakes, MN Permit No. 2655

Action strategies for clinics

SPECIAL FOCUS: CHRONIC

NEW ICD-10 DEADLINE:

OCT 1, 2014

2014 COMPLIANCE DEADLINE FOR ICD-10 The ICD-10 transition is coming October 1, 2014. The ICD-10 transition will change every part of how you provide care, from software upgrades, to patient registration and referrals, to clinical documentation, and billing. Work with your software vendor, clearinghouse, and billing service now to ensure you are ready when the time comes. ICD-10 is closer than it seems. CMS can help. Visit the CMS website at www.cms.gov/ICD10 for resources to get your practice ready.

Official CMS Industry Resources for the ICD-10 Transition

www.cms.gov/ICD10

CONTENTS

FEBRUARY 2013 Volume XXVI, No. 11

FEATURES Disruptive doctors Action strategies for clinics

MINNESOTA HEALTH CARE ROUNDTABLE

By Melanie Sullivan, EdD, MBA

Decision aids in diabetes treatment Promoting the voice of the patient

By Marc Matthews, MD, Kari Ruud, MEd, PMP, and Victor Montori, MD

T H I R T Y- N I N T H

SESSION

DEPARTMENTS CAPSULES

MEDICUS

INTERVIEW

By Andrew W. Grande, MD

PHARMACY Assessing the new drugs of 2012 18

James Welters, MD

By Heidi Mandt, PharmD

Northwest Family Physicians

PEDIATRICS The National Children’s Study

RESEARCH Making the leap from bench to bedside

PROFESSIONAL UPDATE: UROLOGY Kidney stones 28 By Thomas J. Stormont, MD

Creating measures that work

By Patricia McGovern, PhD, MPH, and Deborah Hendricks, MPH, RN, APHN-BC

TRANSPLANTATION Pediatric kidney transplant

Thursday, April 25, 2013 32

By Priya Verghese, MD, and Michael Mauer, MD

SPECIAL FOCUS: CHRONIC ILLNESS Pillars of prevention

By Courtney Jordan Baechler, MD, MS, and Thomas E. Kottke, MD, MSPH

Virtual care

Patient engagement

By JoAnn M. Sperl-Hillen, MD and Patrick J. O’Connor, MD, MPH, MA

1:00 – 4:00 PM • Duluth Room Downtown Mpls. Hilton and Towers

Background and focus: The next step in health care reform involves the patient becoming more actively engaged with staying healthy. New physician reimbursement models reward improved population health but bring new dynamics into the exam room. Incorporating patient attitude and lifestyle choices into health care delivery is necessary, but how should it be done? Creating conceptual and empirical clarity around this question may be best addressed by the term Patient Activation Measure (PAM).

Objectives: We will examine the development of PAM, what it means and how it works. We will explore patient engagement methods that have been successful and the role of health insurance companies and employers in this process. We will explore how PAM may be used across the continuum of care and whose job it will be to implement and track these measures. We will discuss the challenges that are inherent within the concept of PAM and how it may realize its best potential. Panelists include:

High performance By Jill Heins Nesvold, MS

Coaching in the clinic

By Renee Gust, RN, MA

Vivi-Ann Fischer, DC, Chief Clinical Officer, Chiropractic Care of Minnesota, Inc. Peter Mills, MD, CEO, nGage Health

The Independent Medical Business Newspaper

William Nersesian, MD, MHA, Chief Medical Officer, Fairview Physician Associates Pam Van Zyl York, MPH, PhD, RD, LN, MDH Health Promotion and Chronic Disease Division Sponsors: ChiroCare • nGage Health

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

Please send me tickets at $95.00 per ticket. Mail orders to Minnesota Physician Publishing, 2812 East 26th Street, Minneapolis, MN 55406. Tickets may also be ordered by phone (612) 728-8600 or fax (612) 728-8601. Name Company Address City, State, Zip Telephone/FAX Card #

Minnesota Physician is published once a month by Minnesota Physician Publishing, Inc. Our address is 2812 East 26th Street, Minneapolis, MN 55406; phone (612) 728-8600; fax (612) 728-8601; email mpp@mppub.com. We welcome the submission of manuscripts and letters for possible publication. All views and opinions expressed by authors of published articles are solely those of the authors and do not necessarily represent or express the views of Minnesota Physician Publishing, Inc., or this publication. The contents herein are believed accurate but are not intended to replace legal, tax, business or other professional advice and counsel. No part of this publication may be reprinted or reproduced without written permission of the publisher. Annual subscriptions (12 issues) are $48.00. Individual issues are $5.00.

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FEBRUARY 2013 MINNESOTA PHYSICIAN

CAPSULES

Study: Skin Issues Are Top Cause Of Clinic Visits A Mayo Clinic study finds that most common causes for primary care visits are skin issues, joint disorders, and back pain. Researchers used a comprehensive study of medical records from Olmsted County over a five-year period to determine the most common health issues for which people see providers. The study found that other top disease groups include cholesterol problems; upper respiratory conditions (not including asthma); anxiety, depression or bipolar disorder; chronic neurologic disorders; headaches and migraines; and diabetes. “Surprisingly, the most prevalent nonacute conditions in our community were not chronic conditions related to aging, such as diabetes and heart disease, but rather, conditions that affect both genders and all age groups,” says Jennifer St. Sauver, PhD, primary author of the study.

St. Sauver found that almost half the study population had some type of skin disorder. She adds that the finding suggests there should be further study of why these conditions result in so many visits and whether changes in care delivery approaches might result in fewer clinic visits due to skin conditions.

HealthPartners, Park Nicollet Merger Finalized The merger of HealthPartners and Park Nicollet Health Services became official on Jan. 1, creating the largest health system in the metro area, and the largest in the state after Rochester-based Mayo Health System. The new entity will operate under the HealthPartners brand and will maintain similar executive leadership. Mary Brainerd will continue to be president and CEO of the company. David Abelson, MD, formerly president and CEO of Park Nicollet, will

serve as president of Park Nicollet HealthPartners Care Group. “Park Nicollet and HealthPartners, each formed through many strong partnerships and combinations over the decades, have shared a common mission for years,” says Brainerd. “With this combination, we intend to focus on making people healthier, making health care more affordable, and creating the best possible experiences for patients and members.” The organization will now serve more than 1.4 million medical and dental members through HealthPartners’ insurance division, and more than a million patients annually through the clinical care division. Officials say the combined organization will provide stronger coordination of patient care, shared planning, and capital investments, and new links between care and insurance that will lead to more transparency, choice, and value for consumers.

Lawmakers Embrace Health Insurance Exchange Plans for a Minnesota health insurance exchange took a giant step forward in January when a bipartisan group of state legislators announced that one of their top priorities would be passing legislation to make the concept a reality. At a St. Paul press conference, legislative backers said the exchange, required as part of the federal Affordable Care Act (ACA), would be in place in time to meet deadlines of Oct. 1 for enrollment and Jan. 1, 2014, for the beginning of plan coverage. The timeline is tight; the Dayton administration has told the U.S. Department of Health and Human Services that the state Legislature would have the plan approved by March 31. Last year’s Republican-led Legislature declined to act on exchange legislation, but with the DFL in the majority, lawmakers seem eager to move ahead.

Are you satisfied with your claims processing? You will be with ClaimLynx! Every medical practice depends on cash flow. Very few people understand the required processes between when a doctor sees a patient and how/when insurance reimbursement is disbursed. We make these steps simple for you. Among the services we offer: • Direct, real time verification of eligibility • Secure online access to claims tracking • Secure online access to claims correction • Never miss a payment due to late filing • We handle every kind of insurance and every medical specialty • Less time on paperwork, more time with patients

ClaimLynx is used by many national clearinghouses. You may already be using our services and not know it. Shorten your submission route and remittance time—go straight to the payer using ClaimLynx. Every practice is unique and whether a solo practitioner or large multi-specialty group (and everything in between) we can tailor a solution to your claims processing needs that will maximize your benefits.

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For more information please contact: Russel Campbell info@claimlynx.com 10700 Old County Road 15 Suite 200, Plymouth, MN 55441

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952-593-5969

MINNESOTA PHYSICIAN FEBRUARY 2013

“Minnesota has a unique and historic opportunity to lead the country in health reform, and help roughly 300,000 uninsured Minnesotans gain coverage by 2016,” said Sen. Tony Lourey (DFL–Kerrick). “A Minnesota-based exchange allows Minnesota the opportunity to modernize our public systems. With this exchange, we can ensure that Minnesota moves forward in providing individuals with access to affordable, quality health care.” The bill (S.F. 1, H.F. 5) would create an online exchange where individuals and small businesses would purchase health insurance coverage, choosing from a range of products, with subsidies built in for lower-income Minnesotans. Holding up a tablet computer at the press conference, Representative Joe Atkins (DFL–Inver Grove Heights) said, “A year from now, as a result of this legislation, I hope that Minnesotans will be able to buy their insurance on a device like this.” He added that the exchange is projected to eventually serve up to 1.3 million people in the state. The bill has 22 cosponsors in the House and four in the Senate. Lawmakers touted the bipartisan support for the bill, even as some Republicans acknowledged they were not on board with every detail.

2012 Adverse Events Report: Death, Serious Harm Up The latest adverse events report from the Minnesota Department of Health (MDH) showed that 2012 saw an increase in death and serious harm occurring in health care settings. Overall, the number of adverse events stayed about the same from 2011 to 2012. Most of the increase in deaths and serious harm was related to falls, state officials say. There were 14 deaths in 2012 compared with five in 2011, and 89 serious injuries compared with 84 in 2011. The report found hospitals and surgical centers improved

during 2012 in a number of areas. These include the total number of pressure ulcers (bedsores), which declined by 8 percent. This is the first decline of this magnitude in the nine years of reporting, officials say. In addition, medication errors dropped by 75 percent from the previous year and were at the lowest level in all nine years of reporting. “This yearʼs report shows that as a state we really need to redouble our efforts to reduce falls in hospitals,” says Minnesota Commissioner of Health Ed Ehlinger, MD. “While falls in health care settings can be very difficult to prevent, we also need to look at all opportunities to prevent injury when falls do occur, by focusing interventions on each patientʼs specific risk factors.” Lawrence Massa, president and CEO of the Minnesota Hospital Association, says that although patient harm numbers have declined over the past five years, there is still much room for improvement. “We are disappointed to see an increase in deaths and patient harm. Each of these events affects a patient and a family, and we take each one very seriously,” says Massa. “Behind the numbers, though, there is a remarkable story of the great strides that Minnesota hospitals are making to continuously improve hospital quality and prevent adverse events from happening again.” Health experts in the state say the Minnesota reporting system identifies problem areas and helps hospitals and providers know where to focus their patient safety efforts. “Minnesota has been a leader in developing innovative programs to improve patient safety and deliver quality health care,” says Jennifer Lundblad, president and CEO of Stratis Health, a quality improvement organization. “In our collaborative environment, we have combined resources across the health care community to build greater momentum for improvement. Together, weʼve used the science of human factors to

REQUEST FOR NOMINATIONS

2013 HEALTH CARE ARCHITECTURE & DESIGN

HONOR ROLL NOMINATION CLOSING: FRIDAY, MAY 10, 2013 PUBLICATION DATE: JUNE 2013

Seeking Exceptionally Designed Health Facilities In order to qualify for nomination, the facility must have been designed, built or renovated since January 1, 2012. It also must be located within Minnesota (or near the state border within Wisconsin, North Dakota, South Dakota or Iowa). Color photographs are required. If you would like to nominate a facility, please fill out the nomination form below and submit the form, three to eight 300-dpi-resolution color digital photographs, and a brief project description by Friday, May 10, 2013. For more information, call (612) 7288600.

Minnesota Physician announces our annual Health Care Architecture & Design Honor Roll. We are seeking nominations of exceptionally designed health care facilities in Minnesota. The nominees selected for the honor roll will be featured in the June 2013 edition of Minnesota Physician, the region’s most widely read medical publication. Eligible facilities include any structure designed for patient care: hospitals, individual physician offices, clinics, outpatient centers, etc. Interiors, exteriors, expansions, renovations, and new structures are all eligible.

2013 HEALTH CARE ARCHITECTURE & DESIGN HONOR ROLL NOMINATION FORM FACILITY NAME TYPE OF FACILITY LOCATION OWNERSHIP ORGANIZATION OWNER CONTACT NAME and PHONE OWNER ADDRESS CITY, STATE, ZIP ARCHITECT/INTERIOR DESIGN FIRM ARCHITECT CONTACT NAME and PHONE ARCHITECT ADDRESS CITY, STATE, ZIP ENGINEER CONTRACTOR COMPLETION DATE TOTAL COST SQUARE FEET NUMBER OF COLOR PHOTOS ENCLOSED [Note: Please include a caption for each photo] NOMINATION PROCEDURE: Submit the information on this form, along with a project description (150–250 words) and 300-dpi-resolution color 8”x10” digital photographs (no more than eight) to mmacedo@mppub.com For further information, please phone (612) 728-8600, fax (612) 728-8601 or e-mail comments@mppub.com.

CAPSULES to page 6

FEBRUARY 2013

MINNESOTA PHYSICIAN

CAPSULES Capsules from page 5 understand what leads to errors, fostered organizational culture that focuses on safety, and developed comprehensive programs to prevent adverse events.â&#x20AC;?

will be staffed by doctors from Abbott Northwestern Hospital who specialize in emergency medicine,â&#x20AC;? says Ben Bache-Wiig, MD, president of Abbott Northwestern.

Mayo Clinic, Optum Announce Collaboration

Allina Health Opens WestHealth ED Facility Allina Health officially opened the Abbott Northwestern WestHealth Emergency Department and Urgent Care facility in Plymouth in early January. The facility provides ED and urgent care services in one stand-alone location. WestHealth will be open 24/7, officials say, and staffed with emergency physicians. In addition, a pediatric emergency physician will be on-site in the evenings Saturdays through Tuesdays. â&#x20AC;&#x153;This new facility integrates WestHealthâ&#x20AC;&#x2122;s successful urgent care model into the expanded capabilities of a full-service emergency department that

Mayo Clinic and Optum, the information technology arm of insurance giant UnitedHealth Group (UHG), have launched a collaborative effort called Optum Labs that will combine data from patient care and claims information in a larger effort to improve care delivery. Officials with Rochesterbased Mayo Clinic and Minnetonka-based UHG say the collaborative effort will combine information assets, technologies, and scientific expertise from the two organizations. Optum Labs will then serve as a resource for other groups such as academic institutions, life sciences companies, commercial and government payers, and other care

providers. â&#x20AC;&#x153;As a founding partner of Optum Labs, Mayo Clinic is excited to work with Optum and other organizations to address the challenges and issues facing health care in order to help us provide better care to our patients, and help lead improvements to the delivery of care,â&#x20AC;? says John Noseworthy, MD, president and chief executive officer of Mayo Clinic. â&#x20AC;&#x153;Our strategic research alliance with Optum Labs will leverage what we believe to be the largest combined source of clinical and claims information, providing a more comprehensive picture of patientsâ&#x20AC;&#x2122; diagnoses, progression of diseases, comparative treatments, and outcomes.â&#x20AC;? The effort will be based in Cambridge, Mass., and will employ approximately 50 people its first year. Officials say the Cambridge area was chosen because it is known as a corridor for health care technology and research, with a rich academic infrastructure nearby. Optum Labs will initially focus on three main areas:

finding optimal treatments for conditions in a given setting; understanding variations in care; and examining the effectiveness of patient care programs and approaches. Officials say that the combination of claims data from Optum and the longitudinal clinical expertise of Mayo Clinic providers will be a potent combination of health care data. â&#x20AC;&#x153;Bringing together in one location health information and insights from many contributors can provide a deeper understanding of important trends and patient care issues that no single organization could achieve on its own,â&#x20AC;? says Andy Slavitt, group executive vice president of Optum. â&#x20AC;&#x153;At Optum Labs, we have the opportunity to generate insights and develop practical innovations that care providers, life sciences companies, and government agencies can begin using today to improve patient care.â&#x20AC;?

Urgent orthopaedic care you can trust for the patients who trust you. As a health care provider, you want quality care for your patients. As your partner, St. Croix Orthopaedics is here to help. Our orthopaedic and sports medicine physicians are on-site to support you and your patients with urgent care hours at High Pointe in Lake Elmo. No appointments necessary. X Our orthopaedic urgent care will take walk-in patients:

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MINNESOTA PHYSICIAN

FEBRUARY 2013

MEDICUS Mayo Clinic has named Sherine Gabriel, MD, dean of Mayo Medical School in Rochester. Gabriel will oversee undergraduate medical education activities on Mayo Medical School campuses. Gabriel joined Mayo Clinic in 1993. In 2000, she became a professor of medicine and professor of epidemiology in the College of Medicine. In 2005, she was named the William J. and Charles H. Mayo Professor. Gabriel has held Sherine Gabriel, MD many leadership positions at the school and has received many awards, including the Mayo Distinguished Educator Award. Two members of the Minnesota Academy of Family Physicians were honored at the Family Medicine Midwest Conference, held in November in Illinois. Jeremy Springer, MD, of Park Nicollet, was named Family Medicine Teacher of the Year; and Jon Hallberg, MD, medical director of Mill City Clinic, Minneapolis, received the Mid-career Faculty Award. The conference united residents, faculty, and medical students from a 12-state Midwest region. Lisa Fish, MD, recently joined the medical staff at Hennepin County Medical Center. She cares for patients with all types of endocrine problems, and has a particular interest in endocrine and diabetes issues during pregnancy. Fish graduated from medical school at Brown University in Providence, R.I., and completed her residency in internal medicine at the UniverLisa Fish, MD sity of Minnesota, where she also completed a fellowship in endocrinology. The Lake Superior Medical Society (LSMS) has honored the following physicians with its 2012 awards: Steven Long, MD, Mount Royal Clinic, Duluth—Physician of the Year, a community-nominated award; Jay Parker, DO, Essentia Health, Duluth Clinic—Thomas A. Stolee Exceptional Dedication to the Practice of Medicine Award, given to a member physician who has demonstrated a lifetime of exceptional dedication to the practice of medicine; Kenneth Ripp, MD, Raiter Clinic, Cloquet—John B. Sanford Community Service Award, given to a member physician who has demonstrated exemplary service to the community through extensive volunteer activities outside the field of medicine; Randy Rice, MD, Gateway Family Health Clinic, Moose Lake—Elizabeth C. Bagley Merit Award, recognizing commitment to the medical profession and the Lake Superior Medical Society; Deborah Ralston, MD, Duluth Internal Medicine Associates, Educator Award for excellence in teaching and education; Charles Gessert, MD, Essentia Institute of Rural Health, Duluth—Arthur Aufderheide Scientific Award, recognizing outstanding scientific achievements; and George Apostolou, MD, Duluth Internal Medicine Associates—2012 LSMS President’s Gavel Plaque, in appreciation Eric Saterbak, MD of outstanding leadership and commitment to the LSMS. Two new general surgeons recently joined Lakeview Health, Stillwater. Eric Saterbak, MD, earned his medical degree at the University of Minnesota Medical School. He completed his surgical residency at Hennepin County Medical Center in Minneapolis. He is a member of the American College of Surgeons, the Hitchcock Amy Fox, MD Surgical Society, and the Minnesota Surgical Society. Amy Fox, MD, earned her medical degree at the University of Minnesota Medical School. She completed her surgical residency at Washington University/Barnes Jewish Hospital in St. Louis, followed by an endocrine surgery fellowship at the University of Michigan.

Savvy and practical legal solutions by attorneys with decades of health care experience

FEBRUARY 2013

MINNESOTA PHYSICIAN

INTERVIEW

Small, independent, and No. 1 ■ Please give us some background on Northwest

Family Physicians.

James Welters, MD Northwest Family Physicians James Welters, MD, is president and chief medical officer of Northwest Family Physicians, an independent medical clinic serving the northwest metro area. Welters, who was born and raised in St. Paul, received his medical degree from Brown University, Providence, R.I., and did his residency at the University of Wisconsin—Madison. He also serves as a consultant and speaker for clinics implementing electronic health records. In August 2012, Northwest Family Practice was named by Consumer Reports as the top clinic in the Twin Cities in terms of both cost and quality. The clinic system has three primary care locations and two urgent care clinics.

ing with patients to manage chronic disease?

We’re an independent family practice group. The clinic originated in the early 1950s in north Minneapolis. We currently have three offices and 14 physicians. We’re all family physicians. We also run urgent care at two of our offices. We’re affiliated with North Memorial Hospital. Luckily, as an independent group, we’ve still managed to be profitable. We offer high-quality, lower-cost care. One of the things people ask us, how do we do it? I think it’s a lot of factors: our relationship with North Memorial—they’ve been very helpful—and we’ve worked with a couple of organizations, with other independent groups. We’ve always been very focused on providing care to our patients here in our office rather than sending them elsewhere. ■ When you say any services,

does that include specialty?

■ What tools are important for providers in work-

I think it’s nearly impossible to do it at this point without an electronic health record. We’ve had an EHR since 2004, so it’s been fully implemented now for nine years. Out of that we’ve run databases and call lists, updating what people need, and making sure that people are called if they are not getting in. That’s so hard to do with ink and paper. One of our staff is in charge of managing all of those databases and notifying nurses that they need to call this person. ■ What are your views on health insurance

exchanges?

Actually, one of our clinic managers is a member of the state committee on health insurance exchanges. I think it’s a boon and something that’s long been needed. As an independ- Unfortunately, everybody has prosystems, so no one wants ent group, we’ve prietary to share any information.

We have both. For example, I’ve still managed to done stress testing for 20 years, ■ Are the health insurance including nuclear stress testing, be profitable. exchanges designed more stress echoes. We do colonofor the big systems? scopies in our office. We’ve done endoscopy in the past, allergy testing, imaging. We The whole system is designed for big systems. have an imaging center at our Crystal office. We do Right now we’re working with North Memorial and bring in some specialists, including ear, nose, and with other independent groups, trying to establish throat; general surgery; and rheumatology. accountable care networks and and other networks People like knowing [the services are] in our to contract directly with the insurance companies. building. Interestingly, when we started doing There is the risk that we’re going to be squeezed colonoscopy at Plymouth, our rates of colonoscopy out. Right now, there are products that are marjumped dramatically, even though formerly we keted to big employers, and we’re sort of squeezed referred people to WestHealth, which is just a out of that. couple of miles away. Yet people were much more This is really disappointing because if I were a comfortable and willing to do it in our building business owner purchasing insurance from them, rather than go someplace else. I would want to see groups like us in the network because we are less expensive for the same or bet■ What can you tell us about your Living Well ter quality. workshops and the topic of patient activation? ■ Do the exchanges give you some opportunities We’ve been doing Living Well workshops now there to say, “Hey, we’re on this list and we’re for several years. We do them three times a year. less expensive.” Are you going to be able to The response has been fabulous. It’s just a totally deliver that message? different way for people with chronic illness to be involved with their care. We have our care coordinators who run it, and it’s a great experience for the people running them as well. There are a series of weekly meetings, six to eight weeks, in a small group, usually no more than 10 to 15 people. The idea is to teach people with chronic illnesses or multiple medical problems ways to cope with their conditions. There is some instruction by facilitators, but the biggest part is the patients themselves sitting and talking with each other. It’s a mixture of support group but also skill building, designed to teach skills, to manage pain, to handle having a chronic illness, and to help family members understand.

MINNESOTA PHYSICIAN FEBRUARY 2013

Hopefully we will. The problem is a lot of times the language of cost and quality is very hard to understand for patients. Hopefully when the exchanges are up, people can look up information and realize, “Oh, I see these are my options that I could purchase, and here’s a clinic, and here’s how they do in these measures.” It is a hard message to push. Especially, unfortunately, with cost. When patients hear the term “cost-effective,” they think that means you limit care or ration care or don’t give good care. That’s why we’ve been working with both North Memorial and other independent groups, so we can offer a product with good quality health care at a good cost.

■ What do you see as the biggest chal-

lenges facing independent practice and primary care? The biggest challenge is twofold. The biggest one is the ability to recruit other physicians. That’s what has doomed several of the independent groups I know in the area. They just couldn’t compete. They were getting lower reimbursement, which led to lower salaries, so they couldn’t get more doctors. For people coming out of medical school and residency, all they’ve seen, where they’ve trained, is the big systems. On the financial side—luckily, because we’ve implemented our EHR for so long, it’s paid for, and that’s not an ongoing cost— but for a lot of smaller groups that are still doing that, that’s a big cost concern. ACOs, access to the health exchanges, selling to patients, selling to insurers, all of that is challenging. It really will be a huge loss to the system and to patients if people like us go away. One of the things we have as a small group, and it’s kind of like the WalMart argument: it’s what a little neighborhood hardware store can offer against WalMart. One of the things is hopefully better service, and lower prices on certain things. I was at a conference two years ago where one of the big systems in town presented a quality process that they’d put in place, saying it took about 18 months and

2013 CME Activities

(All courses in the Twin Cities unless noted)

MARCH - SEPTEMBER 2013 Fundamentals of Critical Care Support March 18-19, 2013 Advanced Critical Care for Hospitalists March 18-21, 2013 Maintenance of Certiﬁcation in Anesthesiology (MOCA) Training March 23, 2013 June 15, 2013 Integrated Behavioral Healthcare Conference April 12, 2013 Chronic Pain: Challenges & Solutions for Primary Care April 19-20, 2013

they had hired 12 staff to implement it. They showed that they’d saved a half-million dollars, and their quality numbers had improved. It was a good presentation. Except I was thinking, we’d done the same thing five years ago: One physician wrote the protocol and trained the staff; we piloted it for a month; we added no extra staff; and we were using it everywhere within two months. We did it with no added cost and our results were 15 percent better. Obviously, they did a good job, but it was like, okay, this is what small clinics can do. We can implement things. If they don’t work, we can modify them faster.

■ If you could fix one thing about how

the health care delivery system works today, what would that be and how would you do it?

■ Northwest Family Physicians was recently

ranked the top clinic in the Twin Cities by Consumer Reports for both cost and quality. With so much emphasis on bigger-isbetter, what should we take from this? I think it says that bigger isn’t necessarily better, that smaller independent groups can provide equal to better quality and definitely better cost. The group that was right behind us was Entira, which is another independent group over in St. Paul. They’re a little bit larger than we are, but still the same model. I think it does say we are on the right track. I know physicians with large organizations, they’re good doctors. It’s just a little different emphasis.

A magic wand solution: As a first step, everybody would have a primary care doctor that would see them on a regular basis. This, in some ways, is based on the British model in the sense of proceduralists and specialists who are primarily hospital-based, with most care delivered by primary care doctors in the community. In the 1990s, capitation was out and sort of got a bad name. Patients didn’t like it, and as a doctor I didn’t always like it either because some people didn’t really want to see me [as a gatekeeper]. The advantage was that it did reduce cost, and actually a lot of people found that hey, you know, family docs can in fact take care of a lot of this stuff, we don’t need to go to somebody else. Accountable care organizations really are sort of “capitation light,” and it’s the same kind of concept, that you’re getting a certain flat amount of money to provide care and shared savings contracts and all those things. It’s really kind of the same thing, trying to be a little bit more flexible and not quite so rigid.

www.cmecourses.umn.edu Cardiac Arrhythmias: An Interactive Update for Internal Medicine, Family Medicine, & Pediatrics April 26, 2013 Integrative Medicine Conference: Healthy Eating & Lifestyles May 3, 2013 Global Health Training (weekly modules) May 6-June 2, 2013 Topics & Advances in Pediatrics in cooperation with MN-AAP May 30-31, 2013 (NEW DATES!) Midwest Cardiovascular Forum: Controversies in CVD June 1-2, 2013

ONLINE COURSES (CME credit available) www.cme.umn.edu/online U Fetal Alcohol Spectrum Disorders (FASD) - Early Identiﬁcation & Intervention U Global Health - 7 Modules to include Travel Medicine, Refugee & Immigrant Health

Update in Gastrointestinal Surgery & Bariatric Education Days June 5-8, 2013 Workshops in Clinical Hypnosis June 6-8, 2013 Lillehei Symposium: Cardiovascular Care for Primary Care Practitioners September 5-6, 2013 (NEW DATES!) Ofﬁce of Continuing Medical Education 612-626-7600 or 1-800-776-8636 email: cme@umn.edu

Promoting a lifetime of outstanding professional practice FEBRUARY 2013

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Disruptive from cover can’t move forward, and the group is being held hostage by the disruptive behavior. The group’s physician leader and the administrator meet frequently to discuss the issue but do not know how to rectify the situation. This is the highest-producing physician in the group, and if the group leadership addressed the disruptive behavior, would the physician react by leaving the group? If so, how would the practice recover the lost income? The physician leader ultimately decides to ignore the behavior and hope it just goes away. Several months later there is another incident, this time escalating to the point that the physician tosses an instrument in clinic. Now what? An issue of growing interest

Disruptive behavior like that described above is all too familiar to those who work in health care settings. A 2008 sentinel event alert issued by the Joint

One of the purposes of this research was to provide a forum for health care leaders to talk about the challenges they experience with physician disruptive behavior.

demands of these two divergent roles creates conflict for physicians— and a perfect environment for disruptive behavior to ensue. Background

Commission noted, “There is a history of tolerance and indifference to intimidating and disruptive behavior in health care” (Joint Commission, Sentinel Event Alert, July 9, 2008). The Joint Commission’s document defined disruptive physician behavior as verbal outbursts, physical threats, foul or threatening language, inappropriate non-verbal behaviors (such as facial expressions or manners), refusing to perform assigned tasks, quietly exhibiting uncooperative attitudes during routine activities, and/or covertly participating in behaviors that undermine the medial practice reputation. The sentinel event alert emphasized that these types of physician behaviors, in addition to their disruptive effects on practice operations and the staff, were potentially harmful

MINNESOTA PHYSICIAN FEBRUARY 2013

to patients and to the care being delivered. Other potential outcomes of intimidating and disruptive behavior included poor patient satisfaction, increased cost of care, damage to staff morale, and more frequent staff turnover. The issue of disruptive physician behavior has garnered increasing interest from health care organizations, physician training programs, nursing staff, consultants, and numerous other parties over the past decade. However, a review of the literature reveals an abundance of information related to hospital management of physician disruptive behavior, but a paucity of information related to independent physician groups. One reason for this is that hospitals (and large medical plans) have specific rules and processes for addressing this type of behavior, making their data on this type of behavior much more accessible. In contrast, disruptive physician behavior in an independent practice typically is “buried in the boardroom” and not discussed—because of fear, discomfort, and difficulty in approaching a peer, colleague, and fellow owner. There is a culture of secrecy and sense of protectionism among the group’s physicians when this type of behavior occurs. And, nearly always, there is the hope that the disruptive physician will miraculously resolve the behavior. In addition, most physicians have conflicting roles within a medical practice. In one role, as the “producers” of care, they are expected to treat patients, consistently achieve high-quality outcomes, and be flawless in delivering care. In their other role, they are expected to have a robust knowledge of the business of health care and the ability to understand the complexities of this environment. Meeting the

Against this background, and after four years of research and scouring more than 1,000 articles and research references, the author designed a research study to explore how addressing physician disruptive behavior by applying the principles of “action learning” might affect a medical group’s culture and performance. Conceived and developed by British educator Reginald Revans, action learning is now practiced by businesses, governments, nonprofits, and educational institutions worldwide. Action learning embraces the belief that the most powerful learning involves asking questions about real-life issues for which there are no readily apparent answers. Rather than trying to change a situation or behavior through instruction, action learning uses a group process to acknowledge and address the situation. It begins with a small group that is given the authority to solve real organizational problems. Every person in the group is committed to challenging common assumptions and asking questions, rather than rendering judgments. This process empowers individuals to ask questions and explore alternatives to problems when there is no known solution. As group members share their perspectives, reflect on the learning, and evaluate processes of change, new knowledge evolves and different behaviors ensue. Research study

The author’s research study assessed the potential of action learning to approach the difficult issue of disruptive physician behavior. The research focused on independent, singlespecialty surgical practices with eight or more physician owners. The 23 participants were administrators, medical directors, or physician shareholders, geographically dispersed across

FIGURE 1. Physician disruptive behavior model disruptive behavior. Based on multiple conversations with the participants and with other colleagues in the industry, this is a decision that medical groups frequently make. The inability or unwillingness to confront the disruptive physician equates to the status quo. With this decision, the group compromises its ability to maximize its performance, and potentially creates a patient and staff safety issue. Results and discussion

(source: Melanie Sullivan, EdD thesis) the United States. The participants collectively had 696 years of experience in the health care industry (30 years was the median length of employment in health care), and their groups represented 350 physicians. Using a structured interview approach, each participant from a medical group was asked 30 empirical questions designed to determine whether and how often disruptive behavior occurred in the group, how the medical group handled disruptive behavior when it occurred, and whether the outcome was desirable (e.g., disruptive behavior was modified and physician continued the relationship with the group) or undesirable. Questions about demographic information (e.g., the participant’s title, age and gender, length of time employed in health care, length of time with the group, educational background) were also included in the survey To maximize participant confidentiality, which was a major concern for every individual who agreed to contribute, the interviews were not tape-recorded; rather, notes were taken and transcribed for each interview. After the interviews were completed, they were reviewed and compared with a Physician

Disruptive Behavior model developed by the author to gauge whether action learning had occurred within the medical groups that had dealt with physician disruptive behavior (see Fig. 1). For the purposes of this research, the action learning group for each medical practice was considered to be composed of the medical director or another physician/owner representative, the problematic physician, and the administrator/executive. The medical groups’ health and performance were then evaluated based on the outcome of the group’s handling of the physician disruptive behavior. • Desirable outcomes included retaining the disruptive physician in the group and improving the organization’s health and performance. • Undesirable outcomes included no change in the disruptive physician’s behavior; referral of the physician to an outside resource that did not result in changed behavior*; and discontinuation or termination of the physician’s relationship with the medical group. (*Referral that resulted in modification of the disruptive behavior and the physician continuing a relationship with

the group was considered a desirable outcome.) • Another undesirable option within the model is that the group ignores or tolerates the

The research showed that when medical groups were willing to address the disruptive physician through action learning, a desirable outcome was achieved: the physician modified his or her behavior and remained in the group, and the group’s health and performance improved. Twenty cases supported the theory that using action learning principles had improved the organization’s health and performance when addressing physician disruptive behavior. DISRUPTIVE to page 38

FEBRUARY 2013

MINNESOTA PHYSICIAN

Resources Diabetes from cover free of worry about medical conditions. Qualitative research in our clinics consistently shows that patients are conditioned to think of the physicianâ&#x20AC;&#x2122;s time as being too valuable to be spent discussing all of the patientâ&#x20AC;&#x2122;s relevant medical concerns. Patients report feeling that they cannot question their physicianâ&#x20AC;&#x2122;s decision because of the way it is presented to them or because they feel the physicianâ&#x20AC;&#x2122;s time is too valuable. A theme we hear too commonly is that patients who have questioned a physicianâ&#x20AC;&#x2122;s decision felt their future care might be compromised because of how the physician reacted to his or her authority being questioned. These findings underscore the importance of the patientâ&#x20AC;&#x2122;s commitment to and engagement in the decisionmaking process regarding medical treatment. The Shared Decision Making National Resource Center at Mayo Clinic aims to advance patient-centered care

â&#x20AC;˘ Shared Decision Making National Resource Center at Mayo Clinic: http://shareddecisions.mayoclinic.org/ â&#x20AC;˘ Electronic version of the shared decision-making tool for diabetes medication: http://diabetesdecisionaid.mayoclinic.org/ through promotion of shared decision-making by clinicians and their patients. One approach the center uses to improve this two-way communication incorporates the use of patient-centered and evidence-based decision aids, which are tools or interventions designed to facili-

informed patient. The resource center has implemented several aids to facilitate shared decision-making in the clinical setting. These aids range from simple cards that list overall health goals to highly refined and detailed cards for diabetes treatment options.

To achieve better outcomes, we need to ensure that the treatment prescribed is most consistent with patientsâ&#x20AC;&#x2122; values and preferences. tate a conversation during the clinical encounter. These tools help clinicians convey information consistent with the best available evidence, while designing a treatment plan that reflects the values and preferences of the

Creating a space for discussion

Type 2 diabetes causes loss of quality and diminished duration of life for more than 24 million Americans, with great costs and heavy burden of treatment both for society and for affected fami-

lies. A lack of patient involvement in treatment decisionmaking may contribute to poor diabetes outcomesâ&#x20AC;&#x201D;for example, when patients fail to initiate medication, skip dosages, or stop taking medication because of unpleasant side effects. To achieve better outcomes, we need to ensure that the treatment prescribed is most consistent with patientsâ&#x20AC;&#x2122; values and preferences. Decision aids can help clinicians involve patients in making choices about the options available for disease management. Our pilot projects incorporating shared decision-making have shown that diabetes medication cards can help patients choose among alternative anti-hyperglycemic treatmentsâ&#x20AC;&#x201D;heretofore a â&#x20AC;&#x153;technical decisionâ&#x20AC;? made by the physician. With greater patient involvement, we hypothesized, come greater safety and efficacy in health care delivery. The resource center developed a diabetes decision aid that allows patients and their doctors to compare six commonly prescribed drugs, or classes of

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drugs: metformin, insulin, pioglitazone, liraglutide/exenatide, sulfonylureas, and gliptins. The decision tool comprises seven cards, each detailing an important outcome of using one of six medications: weight change, low blood sugar, blood sugar, side effects, daily routine, daily sugar testing, and cost. In the clinic setting, the physician presents the seven cards to the patient at a regular office visit and asks which of the seven issues is most important to the patient personally in describing which medications to take. This begins a conversation in which patients review as many cards as they need to in order to arrive at a treatment decision with the clinician. (Our research has shown â&#x20AC;&#x153;weight changeâ&#x20AC;? to be the card most often selected first by patients.) The aids allow the conversation to be structured yet free flowing. As the physician and patient walk through each of the major principles of diabetes treatment, the aids remain visible for reference. This means patients can keep their beliefs and interests in mind rather than trying to remember and juggle a flood of information. The patient can dive into a conversation about the most important treatment principle and then smoothly transition to another principle just by choosing a new card. Our research has shown that regardless of the decision being discussed, decision aids have a significant impact on the clinical encounter. Physician and patient body language and position are often the first thing noted. The decision aids create a shared point of focus, as the participants huddle around them. From a physicianâ&#x20AC;&#x2122;s perspective, this change in focus makes the discussion feel more collaborative than the typical situation in which the physician talks at the patient from behind a computer screen where the patientâ&#x20AC;&#x2122;s electronic medical record is displayed. The aids create a space for discussion that is sorely lacking in most clinical encounters. From a physicianâ&#x20AC;&#x2122;s perspective, the discussion usually feels much more thorough and col-

laborative, without taking any more time than â&#x20AC;&#x153;usual care.â&#x20AC;? The patientâ&#x20AC;&#x2122;s goals and desires are very clear at the end of the discussion, and the clinical decision feels less like a prescription and more like a statement of common interest. Impact on the physician-patient relationship

We are continuing to evaluate decision aids for diaFIGURE 1: Victor Montori, MD, at right, and a diabetes patient at Mayo Clinic use decibetes and other sion aids cards during an appointment. conditions within local clinics and Mayo Clinicâ&#x20AC;&#x2122;s Knowledge and Evaluation with the goals of improved collaborator clinics. Thus far, we Research Unit in the Division of Endocripatient outcomes and improved have seen that implementation nology, Diabetes, Metabolism, and patient experience with lower of decision aids has resulted in Nutrition. Victor Montori, MD, is a health care expenditures. notable improvements in the professor of medicine at Mayo Clinic, heads the Knowledge and Evaluation experience of care at the frontMarc Matthews, MD, is a practicing Research Unit, and is director of the Health lines. physician and medical director of a resiCare Delivery Research Program in the dency clinic in Kasson, Minn., and is a By creating a space for Mayo Clinic Center for the Science of consultant to the Mayo Clinicâ&#x20AC;&#x2122;s Departpatients to air their goals and Health Care Delivery. ment of Family Medicine. Kari Ruud, interests, this type of interaction MEd, PMP, is a research associate at the also allows for a more meaningful relationship to develop between physician and patient. In a broader sense, this relationship is the critical component of health care reform. It allows us as physicians to understand our patientsâ&#x20AC;&#x2122; needs and provide medical care that enhances their quality of life. It allows patients to begin rehabilitating their trust in the medical system that has been lost because of the poor design of our medical encounters. If we make a conscious effort to redesign medical practice and are able to include more shared decision-making, we will be able to make significant strides toward restoring the patient-physician relationship. The Shared Decision Making National Resource Center will continue to design, implement, and assess decision aids and shared decision-making interventions. Future efforts will focus on broader dissemination (including electronic access everywhere), training of | SUPPLIES | EQUIPMENT | HOME MODS | SERVICES | patients and clinicians, and Innovative programs. Outstanding customer service.â&#x201E;˘ tools and technologies for 1 t 5' t XXX LFZNFEJDBMTVQQMZ DPN patient-centered care. In all, ÂŠ2013 Key Medical Supply, Inc. Registered trademark of Key Medical Supply, Inc. All rights reserved. we hope to be the research engine for a patient revolution,

Bringing Healthcare Home

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MINNESOTA PHYSICIAN

P E D I AT R I C S

ven though most children today grow up healthy, the rates of asthma, diabetes, obesity, and other health problems continue to rise. The National Children’s Study (NCS) was designed in response to the call for new knowledge about children’s health and well-being outlined by Congress in the Children’s Health Act of 2000. Since that time, concerns about the state of children’s health have continued to emerge. In 2008, the Centers for Disease Control and Prevention (CDC) reported that major structural or genetic birth defects affect approximately 3 percent of births in the United States. They are a major contributor to infant mortality and result in expenditures of billions of dollars for health care and other services. According to the March 30, 2012, Morbidity and Mortality Weekly Report of the CDC, the estimated prevalence of autism spectrum disorders among 8-year-olds increased by 23 percent from 2006 to 2008, and now affects at least one in 88 children in that age group.

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The National Children’s Study Working together for children’s health By Patricia McGovern, PhD, MPH, and Deborah Hendricks, MPH, RN, APHN-BC Asthma and allergies among children continue to rise, impacting many children whose lives are already compromised by poverty, social stresses, and other chronic conditions.

Families and children who participate in the study are making an important contribution to the health of future generations. Just as the Framingham Heart Study provided new insights into the determinants of heart disease in adults, the NCS hopes to provide new findings related to genetic and environmental influences on child health. These insights may form

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the basis of child health guidance, interventions, and policy for generations to come. The NCS is an observational research study that will follow 100,000 children from before

MINNESOTA PHYSICIAN FEBRUARY 2013

birth through their 21st birthdays. Study researchers collect detailed questionnaires from parents, beginning during the mother’s pregnancy and continuing until the child becomes a young adult. In addition, researchers collect and analyze biological and environmental samples from participants to learn how factors such as air and water quality, biological and chemical exposures, social factors, genetics, and behavioral and cultural influences may interact and ultimately affect the health of children and adults. The NCS is led by the Eunice Kennedy Shriver National Institute of Child Health and Human Development of the National Institutes of Health (NIH) in collaboration with a consortium of federal government partners including the National Institute of Environmental Health Sciences of the NIH, the CDC, and the Environmental Protection Agency. Vanguard Study—first phase

Over the past three years, the NCS Vanguard Study has been implemented in multiple locations across the country by 40 Study Centers, resulting in the enrollment of more than 6,000 families nationwide. Through the Vanguard Study, more than 200 NIH-funded formative research projects have successfully pilot-tested many scientific

methods, protocols, instruments, and procedures. This pilot phase has been an effective tool for demonstrating efficiencies in recruitment and enrollment, as well as in conducting general study operations. For example, Minnesota, in collaboration with eight other NCS Study Centers, studied the use of ulnar length measurement among infants and young children as a surrogate measure to estimate total body height and weight. In addition to calculating the correlation between ulnar length and other parameters of size by ethnicity, age, and gender, the study was designed to identify the field conditions under which these anthropometrics are reliably measured and to recommend tools for training. In this geographic area, the University of Minnesota (UMN) led the NCS Vanguard phase in Ramsey County. South Dakota State University (SDSU) implemented the NCS with a cluster of rural counties—Brookings County in South Dakota and Yellow Medicine, Lincoln, and Pipestone counties in Minnesota. Thanks to the support of local communities, health care providers, and study supporters, we were successful in recruiting several hundred families in our Minnesota locations and we made significant contributions to testing various study methods. Both UMN and SDSU have engaged the leadership of hospitals in their areas and made arrangements to work with labor and delivery staff to collect data from mothers and newborns at the time of birth. In response to Ramsey County’s racial and ethnic diversity, the UMN Study Center reached out to leaders in the Hmong, Hispanic, African American, and American Indian communities to inform them about the NCS, participating in dozens of community festivals and health fairs. By engaging in dialogues with diverse communities about the importance of research, we learned about their reservations about participating in a study such as the NCS and were able to address the concerns they raised. We were also gratified by the enthusiasm and support demonstrated by many

community members—and felt the disappointment expressed by families who wanted to be part of the study but were not eligible to enroll due to geographic limitations. Vanguard Study—second phase

At this time the NIH is moving into the next phase of the NCS Vanguard Study by centralizing activities into four Regional Operations Centers (ROCs). Each ROC will be responsible for study operations and data collection for participants from 10 NCS study locations within a geographic region—East, South, Central, or West. ROCs will manage and execute the collection of data for all the study locations within their region, administering questionnaires and conducting biological and environmental specimen collections, including child saliva, urine, and blood; and child blood pressure and anthropometric measures. Minnesota and South Dakota are part of the Central ROC being managed by NORC, affiliated with the University of Chicago. The full transition will

The study’s findings will be valuable in developing prevention strategies and health and safety guidelines and in guiding future research. occur in early 2013, as NORC works closely with staff from each study location to ensure a smooth transition that retains participants and continues to build community support for the NCS. All families currently enrolled in the Vanguard Study will continue to be integral and active participants in the Vanguard phase of the study for the next 21 years, including those enrolled in Ramsey County and southwestern Minnesota and South Dakota. Local health care providers can play an important role in encouraging their patients who may be enrolled in the NCS to continue their participation in the coming years. Families and children who participate in the study are making an important contribution to the health of future generations, here in

Minnesota and across the country. The study’s findings will be valuable in developing prevention strategies and health and safety guidelines and in guiding future research that will benefit children, families, and health care providers. Main Study

Looking ahead, a larger Main Study with the goal of enrolling about 100,000 children from across the U.S. will be launched in 2013. The Vanguard Study and Main Study will continue in parallel, with the Vanguard Study continuing its role in testing new protocols, instruments, and procedures ahead of implementation in the Main Study. While recruitment for the Vanguard phase of the NCS was primarily community-based, recruitment for the Main Study is likely to be based on a provi-

der-based sampling strategy, in order to maximize efficiency and cost-effectiveness. Consequently, the involvement and support of health care providers in obstetrics and family practice will be crucial to the enrollment of pregnant and preconception women into the Main Study. Questions about the National Children’s Study in Ramsey County can be directed to the University of Minnesota Study Center at 612-626-KIDS (5437) or info@ncs.umn.edu. Additional information about the NCS can be found on the national website at www. NationalChildrensStudy.gov Patricia McGovern, PhD, MPH, is Bond Professor of Environmental and Occupational Health Policy; principal investigator for the National Children’s Study; and deputy director of the Midwest Center for Occupational Health and Safety, at the University of Minnesota School of Public Health. Deborah Hendricks, MPH, RN, APHN-BC, is assistant director of community-engaged research programs, Office of Community Engagement for Health, in the Clinical and Translational Science Institute at the U of M. She formerly was director of community engagement for the NCS/Ramsey County location.

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RESEARCH

Telephone Equipment Distribution (TED) Program

few months ago, a local physician called me with a medical question that was also a family matter. Six months earlier, he explained, his father had suffered a stroke and the effects had been devastating, involving partial paralysis and speech problems. After looking through medical literature and all over the Internet, he wanted to know whether stem cell therapy might help his father overcome the neurological damage wrought by the stroke. These days, a quick Internet search will turn up an abundance of websites touting stem cell studies underway around the world. And, in fact, some may sound quite promising. During the last decade, a wide range of exciting results in the lab have highlighted that this is a field with tremendous promise: Stem cells may have a range of therapeutic capabilities in damaged brain tissue. However, even as my heart went out to the physician on the phone, I had to tell him that much research lies ahead until stem cell therapy

Making the leap from bench to bedside The promise and present state of stem cell therapy in treating stroke By Andrew W. Grande, MD can restore the brain functions disrupted by a stroke. Progress in treatment approaches

My lab at the University of Minnesota has been focusing on the use of stem cell therapy, particularly in the treatment of stroke. It’s an area of pressing need. Nearly 800,000 strokes occur in the U.S. each year— about one every 40 seconds— representing the leading cause of long-term disability. Since 1995, the treatment of ischemic stroke has focused on acute care. The mainstay has been the clot-busting drug tissue plasminogen activator, or tPA, administered

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MINNESOTA PHYSICIAN FEBRUARY 2013

intravenously within three hours of an event; studies have shown that the treatment improves outcomes for 30 percent of patients. In 1999, the PROACT II Study, published in JAMA, demonstrated that tPA given intraarterially could extend treatment to six hours, increasing positive outcomes in patients to 40 percent. However, as researchers publishing in the journal Stroke found, an astounding 96 percent of stroke sufferers don’t receive tPA. Some have contraindications that preclude the use of the drug, but most simply don’t present to the hospital within the treatment window. What’s greatly needed is a treatment that can extend the window of acute care. Just as significantly, however, our hope is that the treatment approach will also regenerate the neurons and neural circuits that have suffered damage. That’s what stem cell therapy may be able to do. An ever-growing body of research suggests that stem cells have the capability to be both neuroprotective and regenerative. Early on, studies at the University of Minnesota in 2001 showed in animal models that human umbilical cord cells, injected intravenously, could improve outcomes after a stroke. The infusion of stem cells even reduced the size of a stroke by 50 percent, suggesting that the cells are capable of improving the healing environment around the ischemic tissue. The idea, still being investigated, is that the cells release various substances, including cytokines and growth factors, that prevent apoptosis and also promote the formation of blood vessels. Moreover, while neuroprotective drugs given to patients have a three-hour window of benefit,

researchers saw positive results from stem cells in animal models as long as 48 hours after an ischemic event. While the neuroprotective findings were exciting, the studies prompted further studies into whether the stem cells could grow new neurons. Transplanted stem cells raised several concerns. At first, the use of embryonic stem cells not only raised sociopolitical issues, but also presented the complication of causing both immunorejection and brain tumors. A tremendously exciting finding in the early 1990s showed the brain actually has its own stem cells, in an area known as the subventricular zone. Studies in adult rodents showed that the endogenous cells produce immature neurons, which travel along the rostral migratory stream to the olfactory bulb, where they mature. The same pattern of stem cell generation has turned up in the brains of mice, rats, zebrafish, and even primates, and there’s now evidence the process occurs in humans as well. Moreover, when the brain is injured, the production of neural stem cells appears to ramp up, suggesting the body sends out a signal. Subsequently, in vitro studies showed that some newly generated neurons actually will be drawn toward an injured site. The findings prompted widespread interest in capturing the neurogenic potential of stem cells and directing them to the site of an injury to regenerate neurons. Challenges remain

Despite the promising research, the development of a therapy using stem cells remains challenging for several reasons. One is a matter of homing in on the destination. The brain’s endogenous stem cells don’t migrate far, and studies have shown that it’s hard to get the native stem cell supply to the cortex, where most stroke damage occurs. One route my lab is taking is investigating the use of a microcatheter threaded into the brain as a means of steering endogenous stem cells from the subventricular zone and the hippocampus to

an injury in the cortex. But another issue is numbers. The brain tends not to produce enough stem cells—only about 1 percent of the 100,000 or so needed—to regenerate an injured area. Thus, in recent years researchers have continued to explore the idea of transplanting stem cells to bolster the numbers. Another route my lab has been investigating is injecting transplanted cells at the site of a stroke. Around the world, several sources of stem cells are being tested. As it became clear that stem cells could be isolated from a patient’s own bone marrow, studies in rodents showed that these cells could be beneficial in the case of stroke. In order to test the cells in humans, they must go through the Food and Drug Administration approval process. We’re just now getting to phase 1 trials to test the safety of a therapy using a patient’s own bone marrow stem cells. Another approach turned up five years ago, when research in Japan introduced induced pluripotent stem cells, or IPS

One of the most challenging issues is the inherent complexity of the neural system. A stroke injures a wide variety of neurons, and an effective therapy must replace each type. cells: an individual’s own skin cells that could be steered back in development to stem cell stage. In the brain, these cells improved immunorejection and reduced the formation of tumors that occurred with embryonic stem cells, but didn’t necessarily eliminate either problem. But just two years ago, scientists began a process of direct reprogramming of fibroblasts, cells typically found in skin, which could be turned directly into neurons. So far, in animal studies using direct reprogrammed cells, immunorejection hasn’t been a problem. Because the fibroblast never reenters the cell cycle, there shouldn’t be the potential for tumors, either. A new tack of research is now exploring the potential of using these cells. Finally, one of the most

challenging issues is the inherent complexity of the neural system. A stroke injures a wide variety of neurons, and an effective therapy must replace each type. No studies so far have been able to selectively generate specific types of neurons. In addition, in the brain, regenerated neurons have to extend axons toward other neurons and receive axons from established neurons, to form neuronal circuits. A few labs have demonstrated in rodents that new neurons will extend axons to appropriate targets. However, nobody has yet directed old axons toward newly generated neurons. Poised to move forward

What’s clear, as I told the physician on the phone, is that much work lies ahead in making the leap from bench to bedside.

Positive outcomes in rodents don’t necessarily translate into therapy for humans, whose brains are larger, more complex, and more intricately folded. We still need to establish the benefits of stem cells in large animal models, such as primates. If we do, we will be able to move swiftly into phase I safety trials for humans. In addition, we are still in need of a basic science understanding of the mechanisms of neural regeneration. Even so, I’m enthusiastic that the field is in a stage of rapid progress and is poised for these investigations to move forward, with a greater variety of stem cell sources than ever before. I believe this approach ultimately will enable us to treat greater numbers of stroke sufferers and to restore damaged neural networks so that people can return to their lives. Andrew W. Grande, MD, is an assistant professor in the Department of Neurosurgery at the University of Minnesota, Minneapolis. He co-directs the Earl Grande Stroke and Stem Cell Laboratory in the Stem Cell Institute at the University of Minnesota, Minneapolis.

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Inspirational design l Lasting relationships FEBRUARY 2013

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PHARMACY

t is a perpetual struggle to answer the question, “What new drugs affect the way that I should practice?” As new Food and Drug Administration (FDA) approvals surface, it is difficult to sift through non-inferior “me-too” medications and superfluous reformulations to find the handful of novel therapies and truly beneficial reformulations that could change practice guidelines. Yet ultimately, we owe it to our patients to know about new medications that will provide them benefit beyond previously available drugs. Ideally, we are also aware of the medications that may simply cost more without providing any additional benefit. With these goals in mind, here is a brief look at of some of the best and worst new primary care medications that entered the market last year.

The best

While the drugs listed below are not perfect, they are some of the more promising medications approved by the FDA in 2012.

Assessing the new drugs of 2012 The best and worst of FDA-approved medications By Heidi Mandt, PharmD

Bydureon. Type 2 diabetic patients wanting to reduce quantity of injections may benefit from Bydureon, the new, onceweekly injectable formulation of exenatide, released in January 2012. This product is the same compound as Byetta, the twicedaily GLP-1 agonist, and thus also competes for the market with Victoza (liraglutide), the once-daily GLP-1 formulation. A 26-week comparison study of Bydureon to Victoza (liraglutide) was unable to demonstrate non-inferiority for efficacy (A1c drops were 1.3 and 1.5, respectively). However, the amount of nausea experienced by patients taking Bydureon was significantly less (9 percent vs. 20 per-

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MINNESOTA PHYSICIAN FEBRUARY 2013

cent), and this achieved statistical (and likely clinical) significance. The once-weekly formulation is understandably enticing, but be aware that the patient has to reconstitute the product from a vial before each injection, so thorough counseling on administration is required. It is also important that patients be aware that the needle required for correct administration is a much larger bore (23 gauge) than they may be used to with pen devices (31–32 gauge). Patients starting Bydureon should hope to see its full effect in six to seven weeks of therapy. Myrbetriq (mirabegron). This is a first-in-class medication indicated for treatment of overactive bladder. Its B-3 adrenergic agonistic action relaxes the detrusor muscle in the bladder, providing relief without the anticholinergic side effects associated with all other commonly used therapies. However, its efficacy is about the same as the other therapies, generally only modestly reducing the number of events per week instead of resolving the problem altogether. Thus, non-pharmacological measures (bladder training, avoiding irritants, etc.) should remain the first-line treatment and central focus of therapy for these patients. Belviq (lorcaserin) and Qsymia (phentermine/topiramate). Two new weight-loss drugs were approved this year, which is impressive considering that the FDA had not approved any weight-loss medications since orlistat (Xenical, Alli) in 1999. The new serotonin 2C receptor agonist Belviq (lorcaserin) was approved in June and the new combination stimulant/antiepileptic formulation Qsymia (phentermine/topira-mate) arrived in

July. The FDA has approved both drugs for “adults with a body mass index … of 30 or greater … or adults with a BMI of 27 or greater… who have at least one weight-related condition such as high blood pressure …, type 2 diabetes, or high cholesterol ...” Unfortunately, the excitement over these two medications may start to fade as patients experience the side effects and limited efficacy associated with them. In trials, patients taking Belviq demonstrated only 3 percent to 3.7 percent weight loss in one year, and only half of the patients completed the study. Qsymia fared slightly better, boasting 8 percent to 10 percent weight loss in one year for patients that completed the study. Both medications are contraindicated in pregnancy, and Qsymia is contraindicated in patients with glaucoma and hyperparathyroidism as well. Qsymia is classified as a Drug Enforcement Agency (DEA) schedule IV medication, and prescribing is controlled by the FDA’s Risk Evaluation and Mitigation Strategy (REMS), which requires training for providers and dispensing through certified mail-order pharmacies only. Belviq also will be a schedule IV medication but does not have REMS requirements. It is important to continue to keep diet and exercise at the forefront of these patient’s minds, as there is still no substitute or better treatment than these two cornerstones of weight loss. Linzess (linaclotide). This new medication was approved in August for chronic idiopathic constipation (CIC) and irritable bowel syndrome with constipation (IBS-C). It deserves mention because these patients have only a handful of options. Linzess is a guanylatecyclase-C agonist, which is a novel mechanism, though the ultimate effect is the same as Amitiza’s (lubiprostone’s) chloride channel activation: increased intestinal fluid secretion, promoting motility. Its once-daily formulation makes it more convenient than twicedaily Amitiza, and it appears that cost will be similar to Amitiza at around $300 per month.

The worst

These medications are not inherently bad; however, you may only have one or two patients who will find more benefit from them than from currently established treatments. Rayos (prednisone). This new formulation of prednisone delays release of the active drug into the system by four hours, allowing patients with morning pain and inflammation to wake up with significantly lower pain and stiffness. Patients take Rayos at night before going to bed. When compared to immediate-release prednisone taken at the same time, patients with rheumatoid arthritis saw a 22 percent greater reduction in morning stiffness. The tradeoff is the cost, which will be at least one order of magnitude higher than the cost of generic prednisone. Tudorza Pressair (aclidinium). This twice-daily, long-acting anticholinergic bronchodilator, indicated for chronic obstructive pulmonary disease (COPD), provides the same coverage as once-daily Spiriva.

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However, it can be argued that the inhaler is easier to use than Spirivaâ&#x20AC;&#x2122;s Handihaler, so it might be good for those patients who have difficulty loading and inhaling capsules. Arcapta (indacaterol). This new, long-acting beta agonist for COPD provides the same relief as Foradil or Serevent, but in just one daily dose. Despite the convenience, cost may be a concern. Stendra (avanafil). Yet another phosphodiesterase-5 inhibitor, Stendra (avanafil) is now available for management of erectile dysfunction, with efficacy similar to all other available therapies. Vascepa (icoasapent ethyl). The second prescription omega3 fatty acid product, Vascepa (icoasapent ethyl) is now available for patients with triglycerides greater than or equal to 500 mg/dL. There are no headto-head trials between Vascepa and Lovaza, its clear market competitor, but Vascepa was able to demonstrate efficacy in lowering triglycerides without raising LDL, something Lovaza

was not able to do. Cost of these two medications is the same. Binosto (alendronate). Binosto (alendronate) is a new, effervescent tablet formulation of Fosamax that is dropped into water, creating a strawberryflavored solution. This reformulation does not prevent the risk of gastrointestinal irritation or damage associated with alendronate, but likely increases appropriate administration of alendronate (with a full glass of water). Asthmanefrin (racepinephrine). Now that Primatene Mist (epinephrine) has been removed from the market due to its chlorofluorocarbon content, Asthmanefrin (racepinephrine) is an eco-friendly option available over the counter for mild asthma symptoms. Dose for dose, Asthmanefrin cost more than the more effective prescription albuterol inhaler. The atomizer device also requires daily cleaning and may be difficult for patients to use. Onfi (clobazam). Onfi (clobazam) is a benzodiazepine indicated in adjunct treatment

of Lennox-Gastaut syndrome seizures. It is one of many benzodiazepines that can be used to treat this and other seizure disorders. Qnasl (beclomethasone). This is the first powdered HFA nasal spray for allergic rhinitis. It may benefit patients that complain of postnasal drip from their aqueous steroid nasal sprays, but it will likely be more costly for them as well if they are currently taking a generic nasal steroid. Remembering the big picture

When considering new therapies, keep your patientsâ&#x20AC;&#x2122; concerns and preferences as well as their clinical needs in mind. A new medication with remarkable efficacy data will help patients only if they are physically and financially able to take it. More often than not, an older generic drug may work just as well. Heidi Mandt, PharmD, is a board-certified medication therapy management provider for Fairview Health Services in Minneapolis.

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FEBRUARY 2013

MINNESOTA PHYSICIAN

SPECIAL Chronic disease costs the United States $1.5 trillion

dollars spent on health

By Courtney Jordan Baechler, MD, MS, and Thomas E. Kottke, MD, MSPH

care. It’s projected that

will have a chronic disease, with asthma, diabetes, and heart and lung diseases highest on the list of chronic conditions. This month’s special focus looks at what Minnesota providers are doing to prevent these conditions and to improve outcomes for patients who have them.

ILLNESS

Improving care of patients with heart disease

about three of every four

230 million Americans

CHRONIC

Pillars of prevention

a year, and represents

by 2023, more than

FOCUS:

ack in the 12th century, the rabbi Moses Maimonides, who was a physician to the sultan of Egypt, proclaimed, “As long as a person takes plenty of exercise, does not eat to excess, and keeps his bowels regulated, he will contract no illness. But, whoever sits idle and takes no exercise, even though he eats wholesome foods, will suffer all his life and his strength will decline.” Nearly a thousand years later, with tremendous innovation in research and technology, even with our ability to open acutely blocked arteries and to place drug-coated stents, Maimonides’ pillars of prevention cannot be overemphasized. In 2004, A.H. Mokdad and colleagues at the Centers for

Disease Control and Prevention published an article in the Journal of the American Medical Association noting that a minimum of 40 percent of all deaths were secondary to four root causes: tobacco, hazardous drinking, physical inactivity, and poor nutrition. The same year, a Lancet article reported on the results of the INTERHEART study, which aimed to determine the risk factors for acute myocardial infarction (MI). The study was conducted in 52 countries in Africa, Asia, Australia, Europe, the Middle East, North America, and South America, representing every inhabited continent. The researchers found that over 90 percent of the risk for acute MIs was attributable to smoking, lipids, hypertension, diabetes, obesity, diet, inadequate physical activity, hazardous drinking, and psychosocial factors. What the numbers tell us

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MINNESOTA PHYSICIAN FEBRUARY 2013

Heart disease remains the leading cause of death for Americans. According to the American Heart Association (AHA), we spend more than $200 billion on coronary heart disease per year. The majority of our time and money is focused on the acute events of heart disease. Studies show that we do a fairly good job of treating patients in the acute setting. Indeed, a 2008 study by HealthPartners showed that more than 90 percent of those patients had received the evidenced-based interventions. However, the numbers don’t look so impressive when we analyze the data preceding and following the acute events. The largest number of deaths that could be prevented or postponed would come from improving the health of those who are at risk of developing heart disease. In the hospital setting, the largest number

of deaths that could be prevented or postponed would come from improving care for those patients who have heart failure and an ejection fraction <35 percent. Yet, with our existing highlevel technology, we could expect to prevent or postpone only about 2 percent of deaths with improved care in nSTEMI (nonST elevation myocardial infarction) and STEMI (ST elevation myocardial infarction). Prevention recommendations of the AHA include avoiding tobacco, drinking alcohol in moderation, maintaining a body mass index (BMI)<25, and being physically active for 30 minutes, five days a week. National data suggest that only about 5 percent of Americans practice all four behaviors. Smoking remains the No. 1 cause of preventable death. However, with smoking rates continuing to decrease and obesity rates continuing to rise, it’s expected that within the next decade obesity will become the No. 1 cause of preventable death. So, how are we doing at helping to prevent heart disease in our patients? Not so well. According to the SHAPE (Survey of the Health of All the Population and the Environment) survey, which reports on the health of children and adults in Hennepin County, only about 31 percent of overweight adults report ever receiving advice to lose weight from a health care practitioner. Although we know this problem will not be solved in the doctor’s office alone, evidence emphasizes that “no message sends the wrong message.” Prevention programs addressing the problem

Since most patients live their lives outside of the walls of the doctor’s office, communities have united with health care organizations to reduce heart disease. In the 1970s, Finland’s North Karelia Project used a multi-pronged approach addressing the environment, culture, and economy to alter lifestyle behaviors. The project team had three goals: reduce cholesterol, lower hypertension, and cut smoking rates. As the program targeted the population’s risk factors over 25 years,

cardiovascular mortality in the region dropped by 75 percent. Closer to home, a number of Minnesota health organizations have launched programs aimed at preventing heart disease by promoting healthy lifestyles. The state’s SHIP (Statewide Health Improvement Program) aims to connect communities, schools, worksites, and medical offices to collaborate in solving problems of obesity and tobacco abuse. When SHIP started in 2008, the state awarded $47 million to primary prevention efforts involving obesity reduction and decreased tobacco use. Within the SHIP initiatives, the medical arm of SHIP focused on implementing the Institute for Clinical System Improvement guideline on healthy lifestyles (available at www.icsi.org). Medical interventions included assessing BMI for all patients at chronic disease visits and, where appropriate, advising and referring patients who were not achieving the four AHA-recommended behaviors (physical activity, smoking, hazardous alcohol use, and BMI<25).

What becomes clear in projects like SHIP is the importance of a strong collaboration between public health and community organizations to address what has become an epidemic of obesity, metabolic syndrome, and diabetes, which then manifests as heart disease. The Heart of New Ulm project, now in its fifth year, is a partnership between the Minnesota Heart Institute Foundation, Allina Hospitals & Clinics, and the town of New Ulm, Minn. The project focuses on reducing heart disease while addressing the town’s higherthan-normal risk factors for heart disease. So far, New Ulm has seen improvements in many biometrics (e.g., cholesterol), as well as a plateau in obesity rates—a substantial improvement in comparison with obesity statistics for most of Minnesota. The Twin Cities Obesity Prevention Coalition is a team of individuals and organizations united to reduce rates of obesity. Run by the Twin Cities Medical Society, the organization works with community policymakers

to implement strategies aimed at reducing the incidence of obesity among children and adults. Allina Health is currently collaborating with 13 rural communities in Minnesota and western Wisconsin on primary prevention and wellness, with a goal of touching 150,000 lives. In less than six months, more than 1,500 health risk assessments have been done, after which individuals are connected to programming in their communities to help make the healthy choice the easier choice. Changing the course of heart disease

The data support the notion that heart disease is preventable and that recurrent heart disease can be prevented. In 2008, research by Khaw and colleagues, published in PLoS Med, showed that adequate physical activity, nutrition, tobacco avoidance, and blood pressure control have been associated with a fivefold mortality risk reduction in women and a 10- to 14-year increase in lifespan in men and women.

Our epidemic of chronic heart disease has been nearly 75 years in the making and certainly will not go away overnight. Nevertheless, addressing—in the office setting—the behaviors that are at the root of heart disease and referring to trusted community resources will be key as we attempt to reverse the trend which suggests that, for the first time, the younger generation may live shorter lives than their parents because of these very behaviors. The role of physicians in advocating for community solutions will be paramount in the future. Courtney Jordan Baechler, MD, MS, is the director of the Preventive Cardiology Clinic at United Heart & Vascular Clinic in St. Paul. She is vice president of Allina Health’s Penny George Institute for Health and Healing. Thomas E. Kottke, MD, MSPH, is associate medical director for population health at HealthPartners. He is a clinical cardiologist, epidemiologist, and health services researcher at Regions Hospital Heart Center in St. Paul and the HealthPartners Research Foundation in Minneapolis, and is also a professor in the Department of Medicine at the University of Minnesota.

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n 2011, 4.1 percent of Minnesotans reported ever having been told they had chronic obstructive pulmonary disease (COPD). That translates to an estimated 164,652 Minnesotans with COPD. Among all ages, 3.9 percent of men and 4.3 percent of women in Minnesota have COPD. Health care for these Minnesotans could be improved. One-third of Minnesotans with COPD still smoke; comorbid conditions often accompany COPD; daily COPD medications are underutilized (44 percent of those diagnosed do not take a daily medication for their COPD); and hospitalizations are numerous and expensive. In 2011, the average cost per hospitalization for COPD (excluding professional fees) was $20,151, according to a recent report by the American Lung Association in Minnesota. On the national level, there is also evidence that patients with COPD do not receive recommended care, despite the availability of clinical practice guidelines. Currently, only

FOCUS:

CHRONIC

ILLNESS

High performance Making the case for improved COPD quality indicators By Jill Heins Nesvold, MS 30 percent to 55 percent of patients with COPD receive recommended care from providers (Mularski RA et al., 2006, CHEST 1306). A recent study showed that only 54 percent of primary care providers prescribe long-acting bronchodilators in patients with COPD

Very few performance measures have been developed for COPD in comparison with other chronic conditions. The lack of COPD measures reduces patient and provider awareness of COPD, diverts quality improvement resources to other conditions for which measures

Very few performance measures have been developed for COPD in comparison with other chronic conditions. (FEV1<80 percent) (Perez X, et al., March 2012, Respiratory Medicine 106 (3)). The inadequacy of COPD care attests to the need for increased provider accountability through performance measures.

already exist, and negatively affects COPD care. While a number of groups have taken action to develop performance indicators, creating quality indicators is challenging, and there is much work to do. Challenges of COPD quality measures

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MINNESOTA PHYSICIAN FEBRUARY 2013

Developing COPD quality measures presents several challenges: • Regardless of the care provided, over time the patient’s disease will progress. This complicates the development of quality and performance measures. • The extent to which comorbid conditions are associated with COPD presents special challenges for development of performance measures. (Heart disease, diabetes, renal disease, and depression are the four leading conditions comorbid with COPD in Minnesota.) It is more difficult to develop quality measures for chronic diseases (especially when, regardless of the care provided, the patient’s condition will worsen over time) than for acute, single episodes of care. • Quality measures can assess either the treatment process (the specific care or action provided for a medical condition, such as assessing for smoking, or writing a prescrip-

tion for long-acting bronchodilator) or the treatment outcome (for example, reduced dyspnea, increased lung function, or decreased smoking rates). • A number of steps are needed to develop quality indicators, including identifying the target population, defining exclusion, identifying data sources, and determining a scoring system. COPD experts working on this issue have pointed out, in frustration and with tongue in cheek, that it would be simpler to assign a negative measure for COPD—something that indicates poor quality of care (such as stand-alone prescription for inhaled corticosteroid or lack of short-acting bronchodilator prescription)—than to create a positive measure. Nonetheless, the challenges should not deter Minnesota from moving forward to identify, recommend, and adopt quality measures for COPD. History of COPD quality measures

In 2006, the National Committee for Quality Assurance’s Healthcare Effectiveness Data and Information Set (HEDIS) put in place one COPD measure— spirometry lung function testing—in the assessment and diagnosis of COPD. In 2007, relative resource use measure by COPD patients was added; and in 2008, HEDIS added pharmacotherapy management for COPD exacerbation and relative resource use. Of note, the spirometry measure relates only to the diagnosis of COPD, and both spirometry and pharmacotherapy management are process measures. A review of Health Quality Alliance meeting minutes from 2007 to 2009 identified no discussions regarding COPD performance measures (Heffner JE, 2010, CHEST 137 (5)). In the March 2009 National Quality Forum’s National Health Quality Report, which assessed health in the U.S., none of the 220 measures assessed pertained to COPD, which is the third-leading cause of death in the U.S. However, the American Medical Association’s Physician Consortium for Performance

Improvement (PCPI) has shown interest in COPD: Eight of the 266 PCPI measures published in 2009 related to COPD. And in Minnesota, for 2010, 2011, and 2012 reporting (prior-year dates of service), Minnesota Community Measurement selected the use of spirometry testing in the assessment and diagnosis of COPD. The Minnesota Health Care Exchange Measurement and Reporting Workgroup is charged with providing technical assistance and information on options for the reporting of information about cost, quality, and satisfaction for health insurers, benefit plans, and providers through the Minnesota Health Insurance Exchange currently under development. According to the website and meeting minutes, the workgroup is exploring five COPD-related measures: 1. Pharmocotherapy management of a COPD exacerbation (percent of members 40 years of age and older who have acute inpatient discharge or ER between Jan. 1 and Nov. 30 of the measurement year with a principal diagnosis of COPD who were dispensed appropriate medications) (NCQA) 2. Relative resource use by people with COPD (NCQA) 3. Use of spirometry testing in assessment and diagnosis of COPD (NCQA) 4. COPD admission rate per 100,000 population (AHRA) 5. Management of poorly controlled COPD (percent of patients 18 years of age and older with poorly controlled COPD who are taking a longacting bronchodilator (ActiveHealth Management) Work of the Minnesota COPD Coalition

The Minnesota COPD Coalition, a statewide network of health care professionals committed to improving the health outcomes of Minnesotans with COPD, has been focused on recommending and moving COPD quality measures forward. In the summer of 2012, the coalition began reviewing evidence that supports or refutes specific COPD quality measures, including measures

Table 1. Clinic-based indicators and quality measures suggested by the Minnesota COPD Coalition Indicator of quality process

Measure of quality outcomes

Spirometry evaluation (FEV1 and FEV1/FVC) with documented results in assessment and diagnosis of COPD

Spirometry evaluations (FEV1 and FEV1/FVC) with documented results in assessment and diagnosis of COPD

Advanced care plan (including comorbid conditions) discussed with patient and is documented Long-acting bronchodilator prescribed Vaccinations (pneumonia and influenza) Referrals to medication therapy management and pulmonary rehabilitation

Smoking cessation rate among patients with COPD

Written COPD action plan, including medications and referrals to smoking cessation and pulmonary rehabilitation

Annual dyspnea score, quality of life score, functional level

from HEDIS, the National Quality Forum, and Minnesota Community Measurement. The coalition leadership team then produced a list of possible quality measures for COPD and plotted this extensive list across the continuum of care. In addition, the coalition held facilitated in-person meetings and online discussions. During this process, the coalition found there are numerous existing indicators and measures for COPD. Most of the indicators were process measures of care delivered to the patient. However, the quality measures would take it one step further to measure the health outcome or quality. The coalition has identified several critically important issues in selecting indicators and quality measures: • Any measure for COPD must be based on a solid body of evidence. A flawed performance measure will produce inaccurate assessments of clinic practice. • The selected indicators need to be reliably and consistently retrievable from an electronic medical record (EMR). The data source for these quality indicators would have to be the clinic electronic medical record. While on the surface this requirement seems attainable, work is needed to provide a consistent place to record these data elements in an EMR. • The recommended quality

indicators must go beyond the normal process of delivering patient care. (e.g., beyond, “Yep, did that.”) What indicators mark vital steps of care? What indicators are realistic, even if a bit of a stretch? Table 1 lists the clinic-based indicators and quality measures the Minnesota COPD Coalition has recommended and will be

suggesting to Minnesota Community Measurement, health plans, and Health Care Exchange Quality and Measurement Workgroup. During the coalition’s September 2012 annual statewide summit, the group agreed upon three indicators: • Documented spirometry results for the assessment and management of COPD • Smoking rate among patients with COPD • An annual dyspnea score. This is consistent with the 2012 GOLD (Global Initiative for Chronic Obstructive Lung Disease) Guidelines, which include a dyspnea score in the assessment of COPD. The coalition’s next step is to advocate for the recognition and adoption of the quality indicators. Only through broad adoption of quality measures will Minnesota see an improvement in health outcomes for individuals with COPD. Jill Heins Nesvold, MS, is director of respiratory health for the American Lung Association in Minnesota.

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MINNESOTA PHYSICIAN

SPECIAL

he safety and quality of diabetes care in the United States are suboptimal, with less than half of diabetes patients achieving all their optimal care targets for glucose, blood pressure, and lipid control. Based on a survey of U.S. physicians published in Academic Medicine, most physicians today perceive their medical training for outpatient care of chronic disease as inadequate, and many experts agree that better training of health providers is needed to better prepare health professionals to treat the growing number of people with chronic conditions such as diabetes. Virtual simulations have been widely and effectively used in military and aviation settings to deal with safety issues related to training inexperienced personnel. For similar reasons, simulated learning techniques are increasingly used to teach medical students and resident providers medical procedures, often with high-fidelity mannequins.

FOCUS:

CHRONIC

ILLNESS

Virtual care Internet-delivered diabetes education for health professionals By JoAnn M. Sperl-Hillen, MD, and Patrick J. O’Connor, MD, MPH, MA

A newer application of simulation technology has recently emerged using computerized virtual patients to teach the cognitive aspects of managing patients with chronic medical conditions. This virtual patientsimulation activity can overcome many limitations of in-person ambulatory medical education for chronic diseases, such as limited exposure to a complete variety of patient presentations, minimal long-term continuity-of-care experiences in training programs, and the cost and lack of consistency in training that inevitably occurs when using live faculty. Simulated learning activity has many potential advantages: convenient

delivery on any device with Web access (e.g., PC, laptop, iPad, or tablet), complete coverage of key clinical issues, increased standardization of the clinical approach, rapid updates of content as knowledge advances, good scalability, and low cost per provider engaged. Moreover, such an approach to learning can be used throughout one’s career and tailored to clinical issues or domains that are especially challenging for an individual practitioner. The diabetes education program described below uses simulation technology to teach practitioners ways to improve their diagnostic skills, prescribe medications more effectively, and help “virtual patients” prevent complications and achieve better diabetes outcomes. The program has virtual case-based design characteristics consistent with adult learning principles such as interactivity, problem-centered orientation, and self-directed learning that are believed to lead to more successful learning outcomes. A “learning by doing” approach

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No .7

2007

SiMCare Diabetes is a provider education activity that trains physicians, advanced practice providers, pharmacists, and other health care professionals to effectively diagnose and treat type 1 and type 2 diabetes. The dynamic interface allows users to be immersed in tasks of caring for a patient as if it were a real-world experience, and each virtual case is managed across a series of encounters until the desired clinical goals are achieved. The program consists of: • A curriculum embedded within 18 explicit virtual cases with type 1 or type 2 diabetes

• A web-based EHR-like interactive interface • A simulation model that operates “behind the curtain” to calculate physiologic outcomes of provider actions • A library of tailored learning feedback and messages that are deployed to critique and guide provider actions The curriculum evolved through an assessment of needs and knowledge gaps using data and analysis of treatment appropriateness and medical errors observed in practicing physicians. The following are examples of learning gaps discovered and clinical elements covered in the learning program: screening and diagnostic criteria for diabetes; timely initiation and titration of glycemic medications such as basal and prandial insulin; avoidance of drugs such as metformin in contraindicated situations; compliance with recommended frequencies of screening tests for microvascular complications such as foot, eye, and kidney disease; and the recognition and treatment of common comorbidities such as heart disease, depression, and sleep apnea. The content is consistent with the latest national guidelines for diabetes, hypertension, and lipid management (American Diabetes Association [ADA], Joint National Committee on Hypertension [JNC7], National Cholesterol Education Program [NCEP], and Institute for Clinical Systems Improvement [www.icsi.org]). To keep it up to date, SiMCare Diabetes is modified annually (or more frequently as needed) as new evidence emerges in the literature and as guidelines change. The web-based interface mimics an interactive electronic health record and engages the provider in care actions over longitudinal visits with the virtual patient. The user is challenged to help each virtual patient achieve all of his or her optimal diabetes care goals within six months of simulated time. Users respond to each medical scenario by prescribing medications; starting and adjusting insulin; ordering labs and diagnostic tests such as electro-

cardiograms, chest X-rays, and sleep studies; making referrals; giving patient advice; viewing self-monitored blood sugar (SMBG) results and changing SMBG frequency; and, finally, scheduling phone or visit followup at any desired frequency. The simulation model uses formulas derived from published literature to compute realistic physiologic responses to provider actions. The effects of insulin and drugs are observed at subsequent encounters and distributed over self-monitored blood sugar results and other observed clinical patient states (e.g., blood pressure, lipid values). The effects are modified realistically by the virtual patientâ&#x20AC;&#x2122;s level of insulin resistance, comorbidities (e.g., renal disease, sleep apnea, depression), and adherence to medications and lifestyle behaviors. Primarily, providers are â&#x20AC;&#x153;learning by doing,â&#x20AC;? when they see realistic clinical responses after each encounter to the treatment actions taken. Second, in between each encounter with the patient, the provider learns to anticipate the accumulated effects of treatment decisions through graphic and numerical representations of the projected clinical goals at six months of virtual patient time. This is important because the effects of some diabetes medications are immediate while others may take months to fully affect blood sugars. In addition, some important blood tests such as A1c, take months to change even after blood sugars improve. In the virtual world, the provider can learn to anticipate both the immediate blood sugar effect (at days or weeks) and the full A1c effect projected out to six months. Last, a predefined rule management system gives providers textual feedback between encounters to suggest future actions and critique past actions taken related to many aspects of medical care, including: â&#x20AC;˘ Accuracy of screening, diagnosis, and goal-setting â&#x20AC;˘ Ability to start medications and intensify as needed to achieve care goals

â&#x20AC;˘ Advising the patient on lifestyle and self-care â&#x20AC;˘ Conducting physical exams and screening tests to prevent complications â&#x20AC;˘ Addressing safety issues such as drug interactions, hypoglycemia, and monitoring for side effects â&#x20AC;˘ Recommending SMBG monitoring at a reasonable frequency and recognizing abnormal patterns â&#x20AC;˘ Selecting an appropriate follow-up interval for the clinical situation At the case conclusion, learners are provided with actions taken by an expert to help the virtual patient achieve care goals, and the learners can repeat the case if they want to. With each case, the userâ&#x20AC;&#x2122;s care decisions lead to a unique trajectory of goal achievement and individualized feedback; learning becomes a completely personalized experience based on the knowledge and actions of the user. For example, if a provider has difficulty in the virtual world with recognizing blood sugar patterns and adjusting insulin accordingly in appropriate amounts and in a timely fashion, or has trouble knowing how to initiate blood pressure medications for stage 2 hypertension, he or she will receive personalized feedback to focus on those aspects of treatment.

formance testing (ability to achieve optimal care goals on simulated assessment cases) than residents who did not participate in the educational activity. In general, providers in all studies were very satisfied with SiMCare, with over 90 percent recommending it to colleagues, and they indicated it increased their confidence in managing diabetes, especially pertaining to insulin use. SiMCare Diabetes was funded by more than 12 years of federally funded research and developed by a team of medical experts and researchers at HealthPartners Institute for Education and Research, in collaboration with the Carlson School of Management at the University of Minnesota. The program is recommended for prescribing clinicians such as physicians, nurse practitioners, physician assistants, and pharmacists trained in medical therapeutics management. It provides up to six continuing medical education credits and is fully accredited by the

ACCME, the largest accrediting body in the U.S. It is now available for licensing or purchase through SiMCare Health, a joint venture between HealthPartners and Vital Simulations, a health care development company in Minnesota that promotes and advances best practices through innovative, engaging, and immersive simulations for health care professionals. The evaluation of SiMCare Diabetes suggests that virtual educational technology can be effective at training clinicians with a range of clinical experience, and can help to meet a strong unmet need to influence provider behavior and improve outcomes for patients with diabetes. JoAnn M. Sperl-Hillen, MD, is a senior clinical investigator with HealthPartners Institute for Education and Research and is medical director for HealthPartners Diabetes Education Program. Patrick J. Oâ&#x20AC;&#x2122;Connor, MD, MPH, MA, is a senior clinical investigator with HealthPartners Institute for Education and Research.

Development, testing, and evaluation

SiMCare has been tested using rigorous randomized trial designs in several different settings, including a large care system with practicing providers and in primary care resident physicians in 19 U.S. residency programs. Results of studies published in Diabetes Care in 2009 and 2010 by the authors showed improved glucose control outcomes one year later in patients of providers exposed to 1â&#x20AC;&#x201C;3 hours of online virtual patient cases compared to non-exposed providers. In another study, after completing the 18 cases in the latest SiMCare Diabetes educational curriculum, resident physicians in all postgraduate years scored higher on knowledge and per-

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nationwide increase in efforts targeting chronic disease prevention and management is allowing Hennepin County Public Health Promotion (PHP) to develop partnerships with Hennepin County clinics and other primary care providers that enhance clinic processes and outcomes. PHP’s three experienced nurses who are practice facilitators play a direct role in helping more than 30 clinics in Hennepin County improve the treatment of patients who have or may develop chronic conditions. In addition, funding from a Community Transformation Grant through the Centers for Disease Control and Prevention allows clinics to pull staff from direct patient care so they can participate in developing new clinic processes, testing their effectiveness, and measuring outcomes. Many clinics are welcoming the help. Until now, funding has not been available to help clinics reorganize staff and improve patient care processes. Yet, with the passage of federal and state

FOCUS:

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ILLNESS

Coaching in the clinic A public health program teaches providers health-coaching techniques By Renee Gust, RN, MA

health reform legislation, the pressure is on for Minnesota clinics overall to improve outcomes and become “health care homes,” in which primary care providers, families, and patients work together to improve health

providers in health care homes will depend on their success in partnering with patients and families to help them achieve goals for health outcomes on certain quality measures.

Clinics want a more coordinated way of treating patients and motivating them to be healthier—all within their clinic system. outcomes and quality of life for individuals with chronic health conditions and disabilities. As part of the state health reform legislation passed in May 2008, payments to primary care

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What do clinics need most?

Advances in technology and pharmacology offer improved treatment of injuries and diseases, but they have also complicated management of patients’ conditions. In addition, as chronic conditions such as diabetes, obesity, and heart disease have increased in the U.S. population, clinicians feel added pressure to manage complicated regimes of medications, procedures, and treatments within the time frame of a short clinic visit. As a result, what is often missing during the clinic visit is an effective discussion and monitoring of behavior patterns regarding the patient’s diet and physical activity. At the same time, payers are recognizing the importance of clinical interventions that focus on prevention. For example, Medicare now will reimburse primary care physicians and other qualified practitioners for administering face-to-face behavioral counseling to patients with a body mass index of 30 or more. However, because of the varied and complex nature of the patients they treat, physicians often don’t have the time or the expertise to talk about healthy lifestyles. In fact, 72 percent of primary care physicians in a STOP Obesity

Alliance survey published in 2010 said nobody in their practices had been trained to address weight loss issues, although 89 percent agreed it was their job to do so. Yet, carefully designed interventions to foster behavior change have been shown to work in clinic settings, and some clinic staff and providers are committed to focusing on diet and exercise as primary prevention and treatment for their patients. Over the past two years, leaders in a number of Hennepin County clinics started asking for more education on how the on-site staff could become health coaches, rather than outsourcing this aspect of care. Bringing the health coaching model to the clinic

Health coaching historically has been offered or paid for by health insurers outside of the clinic system, and has been done mostly by phone and by trained nurses. This model of coaching attempted to address gaps in the ambulatory care delivery system and primarily addressed healthy lifestyle behaviors. Now, however, in part due to the development of certified health care homes, clinics are saying they want a more coordinated way of treating patients and motivating them to be healthier—all within their clinic system. To address the clinics’ requests for health coach training, the PHP team selected the trainer and curriculum from the University of California, San Francisco (UCSF) Center for Excellence in Primary Care. This two-day health coach training teaches clinicians techniques in patient self-management and goal setting. Core UCSF training concepts include: • Decreased wasted visits. The Agency for Healthcare Research and Quality reported that half of patients leave medical visits without understanding the clinician’s advice. The health coaching model is designed to help clinicians provide clear instructions and motivate patients to participate in the plan for managing their condition(s).

• Teamlet model. This model uses one or two health coaches to one physician. It incorporates a pre-visit with the coach, the visit with the clinician plus the coach, a postvisit with the coach, and between-visit telephone calls or visits with the coach. • “Ask-Tell-Ask” approach. This technique allows clinicians to start by eliciting information from patients (by asking questions such as “What do you know about heart-healthy foods?” and “What would you like to know about diabetes?”). They then provide the patient with information while continuing to ask questions to keep the patient engaged (e.g., “Eating more fruits and vegetables may help you lose weight. What do you think about that?”). When patients are asked about their thoughts and feelings, they are in essence being asked to participate in their care plan. This approach also allows the patients to talk about barriers they may have in managing their conditions. If these questions aren’t asked, patients don’t often disclose their fears or concerns because they don’t want to disappoint their providers. They also may not want to admit that they don’t understand how to take a medication or follow a treatment plan. • Medication reconciliation coaching. Health coaching addressing medication adherence is particularly important, as many patients either are not taking their medications at all or are taking only a portion of their meds. The training explains strategies for conversing with patients regarding their thoughts, feelings, and actions related to the medications prescribed to them. • Setting the agenda. Setting the agenda at the start of a clinic visit will help to cover both the patient’s and the coach’s concerns. When the health coach and patient do this before the provider arrives, it can save time and frustration for everyone. The training allows clinicians to practice prioritizing agenda items with the patient, to help

Essentially, training staff in health coaching techniques has allowed clinics to extend the patient visit. them focus on what items are most important to cover during the clinic visit. • Action planning. The action plan is an agreement between the patient and the care team specifying a behavior change the patient is willing to make. The training demonstrates how to engage patients in creating action plans that allow patients to choose which lifestyle changes they want to focus on. It also teaches the coach how to help patients figure out what they can do to improve their health, and how to set realistic goals that are concrete and specific. • Closing the loop. Using this strategy, the health coach asks the patient to retell the information the clinician provided and helps the patient retain it, e.g., by having the patient repeat the information a few times until the recall is correct. More than 90 clinical staff from metro and suburban communities attended the PHPfunded training in October 2012. The training included all levels of medical personnel, including medical assistants, community health workers, nutritionists, health educators, social workers, pharmacists, nurses, physician assistants, nurse practitioners, dentists, physicians, and health insurers. The goal is to train all staff within a clinic as health coaches in order to reduce dramatic differences among staff in patient care, education, and goal-setting. Essentially, training clinic staff in health coaching techniques has allowed clinics to extend the patient visit. Previously, a patient would see one provider, who had to try to cram all of the necessary information about the patient’s illness(es), meds, lifestyle, and other concerns into a 15-minute appointment. Now, the physician meets for 15–20 minutes with the patient, and then the health coach follows up with goal-setting, confidence-building, and

problem-solving with the patient. This approach allows the patient, physician, and health coach to review the patient’s health status, mutually agree to health-related goals, and create a care plan designed to achieve those goals, including recommended frequency of visits and desired self-management steps. For some patients, the plan calls for an in-person visit every few months; for others, it calls for more frequent visits and/or contact by phone or email. The health coach and physician review the health status of all patients on an ongoing basis to determine patients’ progress and which patients may need more or less follow-up. Continuing work

The PHP practice facilitators were trained as health coaches

and trainers in October as part of the UCSF training, and plan to continue to train clinic staff as health coaches. The aim is to improve patient outcomes by working with health systems in Hennepin County that have an interest in training their staff members as health coaches. In addition to working in clinic settings, PHP staff are working to influence healthy lifestyle behaviors in schools, worksites, and communities. These broader public health education initiatives are crucial in supporting and reinforcing the care and medical treatment that these dedicated health-care providers deliver. Renee Gust, RN, MA, is a senior health promotion specialist and practice facilitator for the Hennepin County Human Services and Public Health Department. This article is supported by the Cooperative Agreement number 5U58DPOO3598-02 from the Centers for Disease Control and Prevention. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention.

Family Medicine St. Cloud/Sartell, MN We are actively recruiting exceptional full-time BE/BC Family Medicine physicians to join our primary care team at the HealthPartners Central Minnesota Clinics - Sartell. This is an out-patient clinical position. Previous electronic medical record experience is helpful, but not required. We use the Epic medical record system in all of our clinics and admitting hospitals. Our current primary care team includes family medicine, adult medicine, OB/GYN and pediatrics. Several of our specialty services are also available onsite. Our Sartell clinic is located just one hour north of the Twin Cities and offers a dynamic lifestyle in a growing community with traditional appeal. HealthPartners Medical Group continues to receive nationally recognized clinical performance and quality awards. We offer a competitive compensation and beneﬁt package, paid malpractice and a commitment to providing exceptional patient-centered care. Apply online at healthpartners.jobs or contact diane.m.collins@healthpartners.com. Call Diane at 952-883-5453; toll-free: 800-472-4695 x3. EOE

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dd another illness to the list of those on the rise in America: kidney stones (nephrolithiasis). While kidney stone demographics have evolved, so has their management. This is increasingly relevant to the primary care practitioner (PCP), who is usually involved at all stages of this disease. This update, written from a urologist’s perspective, reviews current medical management for both acute stone episodes and lifestyle changes for longterm prevention.

Demographics

The number of Americans suffering from kidney stones has nearly doubled since the 1990s and it is now more common than diabetes or coronary artery disease. While about 12 percent of men and 7 percent of women get a stone at some point in their lives, the rates are rising faster in women. Though kidney stones are most often diagnosed in adults in their 30s and 40s, their incidence is increasing in younger adults and teens. A family history of stones will increase

UROLOGY

Kidney stones Medical management for primary care By Thomas J. Stormont, MD

the risk by three times, as can chronic dehydration, increased body weight and bariatric surgery, and a diet high in salt and animal protein. The most serious acute complication of an obstructing kidney stone—

rate of about 50 percent at five years. Pathophysiology

Kidney stones develop when solutes in the urine become supersaturated and precipitate

The number of Americans suffering from kidney stones has nearly doubled since the 1990s and it is now more common than diabetes or coronary artery disease. urinary tract infection (UTI)—is also more prevalent, especially in women. Also, there is increasing recognition that stones could raise the risk of later chronic renal disease. Unfortunately, kidney stones have a recurrence

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to form crystals that may aggregate and become a calculus (Latin for “pebble”). Supersaturation is dependent not solely on solute concentration but also on urine pH (acidic urine is a typical risk factor) and the presence of stone inhibitors (i.e., citrate). Calcium-containing stones— either pure or mixed—are estimated to make up nearly 90 percent of all kidney stones. The most common specific types include calcium oxalate, calcium phosphate, and uric acid stones. There are numerous other stones (struvite, cystine, xanthine, indinivir) that are rarely seen. Acute management

Symptomatic kidney stones usually occur when the stone is moving and/or obstructing the ureter. Various treatment strategies have been proposed. Figure 1 presents a clinical algorithm for acute management, derived from urology literature. Imaging. While IVP has been the traditional imaging study of choice, now there is a more efficient method to evaluate acute flank pain: a noncontrast abdominal and pelvic CT scan (i.e., CT stone run). CT is more sensitive than KUB and/or renal ultrasound (US), and it identifies stones of all composition and location. CT also provides the best prognostic infor-

mation (stone size and density, number, and location). While CT does not necessarily quantitate the degree of obstruction, it accurately shows signs of obstruction (hydronephrosis, perinephric stranding, or urinary extravasation). Low-dose CT is preferred for all patients with a BMI<30 and may significantly reduce radiation exposure. Renal ultrasound is the study of choice in pregnant patients. Pain. Analgesia choice is critical. Nonsteroidal antiinflammatory drugs (NSAIDs) are the mainstay and have proven to provide equal or greater pain relief with faster onset and fewer side effects than the traditional narcotics. Ketorolac (Toradol, 30 mg iv) is usually given acutely; however, NSAID use is usually limited to five consecutive days and is contraindicated in patients with ulcer history, renal failure, or bleeding disorders, or in women who are nursing or pregnant. Facilitating stone passage. Contrary to popular belief, research has proven that aggressive hydration (oral or intravenous) does not improve stone passage. Nor does forcing fluids help with pain control; in fact, it may be counterproductive by stimulating colic. Instead, the patient should drink enough fluids to prevent dehydration. However, there are proven methods to assist passage of stones, also known as medical expulsive therapy (MET). MET therapy has been studied mainly on distal ureteral stones under 10 mm in size, although its use has expanded to mid and proximal stones as well. Alpha blockers, which reduce ureteral spasm, can enhance stone passage by up to 50 percent, decrease analgesic use, and reduce the risk of surgical intervention. Tamsulosin (0.4 mg daily) is the most commonly used alpha blocker and is safe and effective for children but contraindicated in pregnancy. There is no difference in efficacy among the different alpha blockers. Calcium channel blockers (Nifedipine XL, 30 mg daily) have a similar expulsion rate as alpha blockers and are a reasonable alternative. Corticosteroids (Deflazacort,

FIGURE 1. Algorithm for acute stone management 30 mg daily) are not effective when used alone, but there may be some added benefit to expulsion when used in combination with alpha blockers. Follow-up and when to intervene. While nearly twothirds of stones pass (usually within four weeks), the decision on a trial of medical therapy depends on a number of factors, including symptom control, overall renal function, evidence of sepsis, patient preference, and stone location and size. Numerous studies have shown that the size and location of stones help predict stone passage (see Fig. 2). How closely a patient is followed must be individualized, but it is reasonable to track the patient within a week with imaging to monitor progress—a KUB with or without renal US is the mainstay. Be wary of a “silent obstruction”; symptom resolution does not always mean a ureteral stone has passed. It must be assumed that an asymptomatic patient has not passed a stone unless he or she collected one on straining or there is radiographic evidence of resolution. Research shows irreversible loss of renal function occurs at four weeks of renal obstruction; thus, intervention is usually recommended if a stone has not passed within one month. Signs of UTI (pyuria, bacteriuria, fever, leukocytosis, hemodynamic changes), especially in a diabetic or immunocompromised patient, suggest the possibility of an infected and obstructed kidney, which is potentially life threatening and should be considered a surgical emergency. Stone intervention. There are a variety of options for stone intervention beyond the scope of this article. Oral stone dissolution is possible only for the rare nonobstructing uric acid stone. The vast majority are managed with extracorporeal shock wave lithotripsy (ESWL) or ureteroscopy. Rarely, more complex stones are managed by percutaneous nephrolitomy or open/laparoscopic stone removal. Chronic management

Because stones recur and risk is often dependent on lifestyle, an

understanding of the Non-contrast CT pathogenesis of UA, Electrolytes,WBC stones combined with some basic lab evaluation and dietary modification is Stone without obstruction Stone with obstruction in the patient’s best interest. It is notable that the recurrence rate can be decreaGood control Poor control of symptoms Signs of infection No signs of infection of symptoms sed by 50 percent or solitary kidney with sustained and adequate prophylaxis—the mainstay Assess stone (location, size, composition) Admit for emergent being long-term Admit— and patient preference drainage of kidney, urine dietary changes. drain kidney if solitary cultures and antibiotics Medications—mainly potassium citrate and diuretics—for Larger and/or more Smaller distal stone, recalcitrant cases are proximal stone and/or good control of symptoms poor control of symptoms best guided by a complete metabolic workup and are not Outpatient strainer, Consider admit for the focus of this analgesics, MET therapy; close observation and follow-up within review. possible intervention a week with imaging Metabolic eval(Adapted from Pearle MS, Management of acute stone events, AUA Update Series, Vol. 27, 2008) uation. For all stone formers, it is recom(orange juice, lemonade, or nomical, and readily available. mended that at some point the citrus sodas), as they may Water hardness or “mineral” patient have a CT stone run; increase urine pH and the water has not proven to affect serum tests for electrolytes, calinhibitor citrate levels, but risk. Most research supports cium and uric acid; urinalysis; the benefits of citrus drinks and stone analysis. These tests can determine if there are multiple stones, hyperparathyroidism, renal insufficiency, renal tubular acidosis, gout, or a noncalcium stone. If these complicating factors are found, consider a stone specialist referral when 24-hour urines are necessary. General dietary recommendations. Regardless of the underlying cause or type of stone, some commonsense advice about long-term lifestyle habits may best come from a PCP. Maintaining an ideal body weight and following some general dietary guidelines may be all that is needed for stone prophylaxis. Patient compliance with these recommendations can be a problem. • Fluids. The mainstay of all stone prevention is to maintain a high urine volume, about 2–2.5 L/day. An easy way for patients to monitor this is to drink enough fluids (>3 L/day) to keep the urine straw colored and not dark yellow. It is clear that the volume of fluid trumps the type of fluid ingested and that water is low in calories, eco-

KIDNEY STONES to page 30

Family Medicine HealthPartners Medical Group – Hugo, Minnesota We are actively recruiting exceptional fullrange BC/BE family medicine physicians to join our primary care team at our new Hugo clinic, scheduled to open in May 2013. This is a full-time family medicine (no OB) position and is outpatient only. Our primary care team will include family medicine physicians, pediatricians, advanced practice providers and chiropractic services. We will be partnering with pediatricians from Children’s Hospital and Clinics of Minnesota. Previous Epic experience is helpful, but not required. We use the Epic medical record system in all of our primary care and specialty care clinics, and admitting hospitals. HealthPartners Medical Group continues to receive nationally recognized clinical performance and quality awards. We offer a competitive salary and beneﬁt package, paid malpractice and a commitment to providing exceptional patient-centered care. For more information, please contact diane.m.collins@ healthpartners.com or call Diane at 952-8835453; toll-free: 800-472-4695. Apply online at healthpartners.jobs and search for Job ID 25408. EOE

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FIGURE 2. Rates of natural stone passage Kidney stones from page 29 caloric intake may negate their benefits. Often, 120 mL of concentrated lemon juice in 2 L of water is recommended. There is not enough evidence to support an increased stone risk from cola, tea, or coffee, probably because the increase in fluid ingested will override those drinks’ minor oxalate contribution. • Animal protein. Animal protein (including fish) ingestion correlates with an increased stone risk, by an ill-defined mechanism that lowers urine pH and citrate and increases urine calcium. Protein type is important—for example, vegetable protein (nuts, legumes) does not increase stone risk. Animal protein restriction to 12 oz./ day is generally recommended. • Sodium. Salt intake correlates with stone formation by increasing urine calcium and decreasing urine citrate levels. A “no added salt” diet or 2 gm/day of sodium may be helpful. • Calcium. It is usually not

Stone Size <4 mm: 55 percent 4–6 mm: 35 percent >6 mm: 8 percent

Location in ureter Proximal: 12 percent Mid: 22 percent Distal: 45 percent

advisable to restrict dietary calcium because this can actually increase the risk of stone formation and can adversely affect bone health. Vitamin D and calcium supplement risk is not as clear. If there is a need to supplement, the best method may be to prescribe calcium citrate taken at mealtime and then to monitor the urine calcium for the development of hypercalciuria. • Oxalate. Since only a small amount of dietary oxalate (spinach, nuts, chocolate, coffee) is absorbed, it is difficult to influence the urine levels of oxalate with restriction. Dietary oxalate restriction can be especially important in bariatric patients or those with chronic diarrhea, since they absorb much more intestinal oxalate than average. Vitamin C supplementation raises urinary oxalate levels more than

any other food source. Long-term imaging. There are no rules on the frequency, duration, or type of imaging to monitor for stone growth or recurrence. General principles are to base the frequency of the studies on the aggressiveness of the disease and to use the least radiation possible. KUB and/or renal US every one to two years for five years would be a reasonable benchmark to ensure stone stability. Take-home message: Seven things PCPs should know

Primary care providers often have the dual role of managing acute episodes and initiating long-term lifestyle changes in stone formers. The following list will help guide PCPs: 1. Kidney stones are affecting more people, earlier. The risk for women, including teenagers, is rising the fastest.

2. Be wary of the serious risks of infection with stone obstruction and “silent obstruction.” 3. NSAIDs are usually superior to narcotics for analgesia. 4. MET therapy will augment stone passage; superhydration will not. 5. Noncontrast CT is the best imaging with an acute event. 6. Certain lab tests are crucial, even with first-time stone formers. This helps to identify metabolic risk and guide prevention. Consider referral to a stone specialist to help with testing and/or long-term management. 7. The best dietary advice for stone-formers is to maintain body weight and strive for lifelong high fluid intake— mainly water, but including citrate. There is usually no benefit to restricting dietary calcium, but it may help to avoid excess sodium, animal protein, and oxalate. Thomas J. Stormont, MD, is a urologist with Stillwater Medical Group.

Minneapolis VA Health Care System The Minneapolis VA Health Care System is a 341-bed tertiary-care facility affiliated with the University of Minnesota. Our patient population and case mix is challenging and exciting, providing care to veterans and active-duty personnel. The Twin Cities offers excellent living and cultural opportunities. License in any state required. Malpractice provided. Applicants must be BE/BC. Opportunities for full-time and part-time staff are available in the following positions: • Chief, Radiation Oncology • Chief, Surgery/Specialty Care Director • Chief, Emergency Medicine • Chief, Ophthalmology • Cardiac Anesthesiology • Compensation & Pension Examiner • Emergency Medicine • Gastroenterology • Imaging o Resident Coordinator o Interventional Radiology o Neuro Radiologist

• Internal Medicine or Family Practice • Hematology/Oncology • Hospitalist • Outpatient Clinics: Internal Medicine or Family Practice o Maplewood, MN o Ramsey, MN o Chippewa Falls, WI o Rice Lake, WI

• Outpatient Clinics: Psychiatry o Superior, WI o Ramsey, MN o Rice/Hayward, WI–V-tel and on-site o Maplewood, MN –V-tel and on-site • Medical Director, Rochester Outpatient Clinic • Pathology • Radiation Oncology • Rheumatology • Spinal Cord Injury and Disorder

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

For more information: Visit www.usajobs.gov or email Brittany.Sierakowski@va.gov EEO employer

MINNESOTA PHYSICIAN FEBRUARY 2013

The perfect match of career and lifestyle. Affiliated Community Medical Centers is a physician owned multispecialty group with 11 affiliate sites located in western and southwestern Minnesota. ACMC is the perfect match for healthcare providers who are looking for an exceptional practice opportunity and a high quality of life. Current opportunities available for BE/BC physicians in the following specialties: • ENT • Internal Medicine • Psychology • Family Medicine • Med/Peds Hospitalist • Pediatrics • General Surgery • OB/GYN • Pulmonary/ Critical Care • Geriatrician/Outpatient • Oncology Internal Medicine • Radiation Oncology • Orthopedic Surgery • Hospitalist • Rheumatology • Psychiatry • Infectious Disease

Orthopaedic Surgery Opportunity Live in Beautiful Minnesota Resort Community

Live and work in a community that offers exceptional schools, a state university with NCAA Division I hockey and community symphony and orchestra. With over 500 miles of trails and 400 surrounding lakes, this active community was ranked a “Top Town” by Outdoor Life Magazine. Enjoy a fulfilling lifestyle and rewarding career. To learn more about this excellent practice opportunity contact: Celia Beck, Physician Recruiter Phone: (218) 333-5056 Fax: (218) 333-5360 Email: Celia.Beck@sanfordhealth.org

For additional information, please contact:

Kari Bredberg, Physician Recruitment karib@acmc.com, (320) 231-6366

An immediate opportunity is available for a BC/BE orthopedic surgeon in Bemidji, MN. Join three board certified orthopedic surgeons in this beautiful lakes community. Enjoy practicing in a new Orthopedic & Sport Medicine Center, opening spring 2013 and serving a region of 100,000.

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Julayne Mayer, Physician Recruitment mayerj@acmc.com, (320) 231-5052

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

Sioux Falls VA HCS, SD Urologist Psychiatrist Hospitalist Family Practice

Orthopedic Surgeon Cardiologist Internal Medicine

Sioux Falls VA HCS (605) 333-6858 www.siouxfalls.va.gov

Emergency Medicine Emergency Practice Associates has immediate full-time, part-time and locums opportunities at our sites in:

Hibbing Little Falls Park Rapids Alexandria Austin For more information contact Tina Dalton or Mike Coulter at 800-458-5003, email:

recruiting@epamidwest.com or visit our website at

www.epamidwest.com Applicants can apply online at www.USAJOBS.gov

Your Emergency Practice Partner FEBRUARY 2013

MINNESOTA PHYSICIAN

T R A N S P L A N TAT I O N

idney transplant has emerged as the preferred treatment for most children with end-stage renal disease (ESRD). Chronic kidney disease (CKD) is the irreversible deterioration of renal function that gradually progresses to end-stage renal disease (ESRD) when dialysis or transplant is necessary for preservation of life. CKD has emerged as a serious public health problem. Unfortunately, the incidence of the chronic kidney disease in children has steadily increased in recent decades, with poor and ethnic minority children disproportionately affected. Since 2000, the adjusted incident rate of ESRD for children ages 0–19 has increased 5.9 percent to 15 per million population in the United States. Transplantation offers these children freedom from dialysis and the best opportunity for growth and development with a high quality of life. Over the past two decades, pediatric kidney transplant results have markedly improved. Yet, despite the success of transplant in older chil-

Pediatric kidney transplant How young is too young?t By Priya Verghese, MD, and Michael Mauer, MD dren, it has not been widely accepted for infants and very young children. As a result, very young children with kidney disease may have to live for years on dialysis—an inferior treatment and quality of life. Dialysis carries significant potential for serious complications and death, increasing the overall risks and suffering for these tiny ESRD patients. In the past, all too often young and small patients were not considered for transplant until they were older and bigger. Unfortunately, many did not live long enough to receive a transplant. Since the early 1970s, we have taken the approach that rather than subject these tiny individuals to long, arduous, and risky dialysis, kidney trans-

plant could work well for them. Benefits of transplantation include improved patient survival, improved growth and development, improved quality of life, and avoidance of dialysis complications. Experience and outcomes have shown that through careful selection of donors, precise care before and after surgery, and appropriate immunosuppression, infants can receive a transplant with results equivalent to those of older children and adults. Our center’s outcomes have borne this out. Indications and contraindications

There are distinct geographic differences in the reported causes of CKD in children, in part due

to environmental, racial, genetic, and cultural differences. However, a substantial percentage of children develop CKD early in life, with congenital renal disorders such as obstructive uropathy and aplasia/hypoplasia/dysplasia being responsible for almost half of all cases. This is quite different from adults, in whom the etiology of ESRD is often glomerulonephritis, diabetes mellitus, or hypertension. Adults therefore frequently have post-transplant issues secondary to their primary diseases, unlike pediatric congenital renal disorders that do not recur post-transplant. Any disease causing ESRD in children can be treated with renal transplantation. Contraindications for pediatric kidney transplant vary from center to center, but few centers would transplant a kidney into a child with advanced cardiopulmonary disease, active malignancy, severe local or systemic infections, or conclusive evidence of significant nonadherence. Most centers have ethics boards where TRANSPLANT to page 34

Sanford Health is the largest not for profit rural integrated health care system with over 1200 primary and specialty care physicians in over 140 clinic locations. The following communities are looking for BE/BC Family Medicine Physicians: Aberdeen, SD: • Large newer clinic attached to brand new 48-bed hospital • Current call 1:7 • OB is optional • Numerous onsite hospital services • Specialty physicians include Anesthesiologists, General Surgeons, and Interventional Cardiologists • Population over 25,000 • SD has no state income tax Windom, MN: • Current call is 1:7 for admits only and shared with community physicians • OB is a must

• Population over 4,300 • MN Medical school loan repayment available • J1 physicians may apply Worthington, MN: • Medical staff of primary care and some specialists • Current call 1:4 • Population over 10,000, service area 35,000 • City is 200 miles Southwest of Minneapolis/St. Paul • MN Medical school loan repayment available

Excellent benefits package including Paid Malpractice and Tail Coverage Competitive compensation and generous incentive

Dedicated to the work of health and healing

For more information, contact: Mary Jo Burkman, Physician Placement Associate Sanford Health (605)328-6996 or (866)-312-3907 Mary.Jo.Burkman@sanfordhealth.org Visit: www.practice.sanfordhealth.org

MINNESOTA PHYSICIAN FEBRUARY 2013

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. 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 • Emergency Medicine

• Medical Oncologist • Pediatrics • Urology NP/PA

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

Here to care At Allina Health, we’re here to care, guide, inspire and comfort the millions of patients we see each year at our 90+ clinics, 11 hospitals and through a wide variety of specialty care services throughout Minnesota and western Wisconsin. We care for our employees by providing rewarding work, ﬂexible schedules and competitive beneﬁts in an environment where passionate people thrive and excel. Make a difference. Join our award-winning team. Madalyn Dosch, Physician Recruitment Services Toll-free: 1-800-248-4921 Fax: 612-262-4163 Madalyn.Dosch@allina.com allinahealth.org/careers EOE/AA 10127 0213 ©2013 ALLINA HEALTH SYSTEM ® A TRADEMARK OF ALLINA HEALTH SYSTEM

www.lrhc.org

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

Pediatrics

Orthopedic Surgery

Obstetrics/Gynecology

Radiology/Oncology

Family Practice

Internal Medicine

Emergency Medicine

Psychiatry

Ophthalmology

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

Urgent Care We have part-time and on-call positions available at a variety of Twin Cities’ metro area HealthPartners Clinics. We will be opening a new Urgent Care clinic in Hugo, MN in the spring of 2013! 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. 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

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

www.averamarshall.org

healthpartners.com JANUARY 2013

MINNESOTA PHYSICIAN

Transplant from page 32 these criteria can be reviewed and discussed if issues arise in an individual patient. Overcoming challenges

Although the technical challenges of transplant in infants may be greater than they are for older children, dialysis is also extremely challenging for these young patients. Because of their comparatively minute total circulating volume, as well as the technical challenges associated with catheters in the small blood vessels of these patients, hemodialysis can be difficult to perform. Peritoneal dialysis is also associated with recurrent infectious episodes, technical problems and major stresses on family members who need to carry out this treatment at home. Donor selection. One crucial factor for success is proper donor selection. Adult donors are preferred, even in infants and small children. Because adult kidneys are larger, surgery is less complex than using a kidney from a deceased pediatric donor.

We routinely perform transplantation of adult kidneys into children as small as 15 pounds. Deceased pediatric donors are rarely available. In addition, experience indicates that using living donors is the key to successful transplant in infants and toddlers; therefore, wherever possible, living donors (related or not) should be used. An analysis of living donor transplants indicates that the age of a recipient per se is not a factor in whether the recipient’s body accepts or rejects the kidney transplant. Use of living donors also reduces the risk of delayed graft function, which tends to be more common in the youngest patients. Careful attention to surgical detail and perioperative care go a long way toward minimizing the incidence of delayed graft function. Surgical procedure. In order to accommodate infants’ smaller bodies, we have made some technical modifications to the surgical procedure of kidney transplantation. The kidney is placed in an intraperitoneal position instead of the usual

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retroperitoneal position used for children weighing more than 44 pounds. The right colon is mobilized to create space for the kidney. Inflow is achieved by an end-to-side anastomosis to the distal aorta and outflow is to the inferior vena cava. In order to maximize inflow, we use the abdominal aorta in infants. Monitoring central venous pressure ensures adequate cardiac volume intraoperatively, which is especially important before clamping and reperfusing the new kidney. It is best to raise the central venous pressure before reperfusion to minimize hemodynamic instability. The ureter is implanted into the bladder using a standard LeadbetterPolitano technique. Often a stent is placed across the ureteral anastomosis, using a Silastic feeding tube. Post-transplant infection and malignancy

Given the improved potency of newer immunosuppressive agents, the risk of the body’s immune system rejecting the transplanted kidney has been

markedly reduced, with increased risk of serious infections and infection-related malignancies. Infections are now the No. 1 cause of hospitalization post-kidney transplant. Even more worrisome, the cause of death of approximately 27 percent of patients who die with a functioning graft is related to infectious or malignant complications with malignancy being the third-largest cause of death in primary renal transplants. While bacterial and fungal infections are a major concern, viral infections are of particular significance. Two of the herpes viruses, Epstein-Barr virus (EBV) and cytomegalovirus (CMV), have the greatest negative impact. CMV disease can manifest post-transplant as fever, leukopenia, or mild to severe organ involvement. EBV can present post-transplant as infectious mononucleosis syndrome, hepatitis and, in the worst-case scenario, can initiate a potentially fatal lymphoproliferative process (post-transplant lymphoproliferative disorder, or PTLD). MoreTRANSPLANT to page 36

Heart of Minnesota Lakes Country Practice Opportunities Sanford Clinic North – Excellent practice opportunities in communities located in the ‘Heart of Minnesota Lakes Country’. Good call arrangements and modern well-managed community-owned hospitals. Alexandria • Dermatology • Family Medicine • Hospitalist/IM • Internal Medicine • Obstetrics/ Gynecology Detroit Lakes • Dermatology • Family Medicine • General Surgery • Internal Medicine • Pediatrics

East Grand Forks • Dermatology • ENT • Family Medicine • IM/Peds • Orthopedics Moorhead • Family Medicine New York Mills/ Perham • Family Medicine • Orthopedic Surgery

Thief River Falls • Family Medicine • General Surgery • Hospitalist/IM • Internal Medicine • Optometry • Podiatry • Urology Wheaton • Family Medicine

Sanford Health, serving western Minnesota, eastern North Dakota and South, is redefining health care. Sanford offers innovative technology, support of a multi-specialty organization and dependable colleagues. Our employment model includes: market competitive salary, comprehensive benefits, paid malpractice insurance and a generous relocation allowance. To learn more contact: Shannon Ellering, Physician Recruiter Email: Shannon.Ellering@sanfordhealth.org

Phone: (701) 280-4817 Visit our website at www.NWFPC.com

MINNESOTA PHYSICIAN FEBRUARY 2013

EOE/AA

Opportunities available in the following specialties: Adult Psychiatry Child Psychiatry Southeast Clinic

Olmsted Medical Center, a 150-clinician multi-specialty clinic with 10 outlying branch clinics and a 61 bed hospital, continues to experience significant growth. Olmsted Medical Center provides an excellent opportunity to practice quality medicine in a family oriented atmosphere. The Rochester community provides numerous cultural, educational, and recreational opportunities. Olmsted Medical Center offers a competitive salary and comprehensive benefit package.

Dermatology Southeast Clinic

Family Medicine Pine Island Clinic, Plainview Clinic

Hospitalist Rochester Hospital

Internal Medicine Southeast Clinic

Sports Medicine Orthopedic Surgeon Southeast Clinic

Orthopedic SurgeonJoint Replacement Southeast Clinic

Send CV to: Olmsted Medical Center Administration/Clinician Recruitment 102 Elton Hills Drive NW Rochester, MN 55901 email: egarcia@olmmed.org Phone: 507.529.6610 Fax: 507.529.6622

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www.olmstedmedicalcenter.org

With Essentia Essentia He H Health, alth, yyou’ll ou’ll find group more a supportive supportive gr o of mor oup e than 750 medical 7 50 physicians physicians across across 55 55 me dical

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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. 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.

specialties. large spe cialties. Located Located in lar ge and small communities communities across across Minnesota, Minnesota, Wisconsin, North Dakota Idaho, Wis consin, Nort th D akota and Idah o, Essentia Health emerging E ssentia He alth h is emer ging as a leader cost-effective, le ader in high-quality, high-q quality, c ost-effectivve, patient-centered care. p atient-centered c are. EEOE/AA OE//A AA

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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: Lori Martin, Executive Assistant 1500 Curve Crest Blvd, Stillwater MN (651) 275-3305, lmartin@lakeview.org stillwatermedicalgroup.com

We’ll make it all better.

FEBRUARY 2013

MINNESOTA PHYSICIAN

Transplant from page 34 over, subclinical CMV and/or EBV viremia have been associated with deterioration in kidney function in kidney transplant recipients. The greatest risk factor for the detrimental effects of CMV and EBV on transplant patients is a lack of previous exposure and immunity to the virus. This makes children particularly vulnerable since they very often have been unexposed to either virus at time of transplant. BK virus also threatens kidney transplant survival. A benign virus in the healthy general population, BK is ubiquitous, residing in the urogenital tracts of 70 percent of adults. In kidney transplant recipients, it can infect the graft and cause BK nephropathy, possibly leading to graft loss. Successful outcomes

Between Jan. 1, 1984, and Dec. 31, 1999, our pediatric kidney transplant program conducted 321 transplants in children under age 13. Based on those transplants, we separated the children into three groups: under

age 1, ages 1–4, and ages 5–13. Outcomes showed no significant difference among the groups in the success of the kidney transplant. Also noteworthy—all the infants underwent living donor transplant. In addition, incidence of acute rejection in children under age 2 was the same as for older children and adults. Although nationally, patient and kidney graft survival for infants and small children is significantly lower than in older children, we have seen remarkable success, due, in part, to better surgical techniques. To date, our surgeons have performed more than 170 kidney transplants in children under age 2. In addition, between 1987 and 2010, we performed more than 30 percent of all kidney transplants in the U.S. for children under age 1. For both groups we have some of the highest reported success rates in the world. We analyzed growth and development of nine infants, two to seven and a half years after their first transplant. According to our data, the babies in our program improve quickly in

growth, height and weight, and brain development. Pretransplantation head circumference and height standard deviation scores in six infants were less than -2. Five infants had seizures, four had delayed mental development, and six had delayed motor development. The mean increment in height standard-deviation scores for six boys after transplantation was +1.4 (p<0.05), and one achieved complete catch-up growth. All eight surviving children achieved normal head circumference (mean improvement +2.2 SD, p<0.001); no child had further seizures. Of seven infants reassessed with the Bayley Scales after transplantation, mental development was normal in all and motor development was normal in five. Thus, we have seen that successful renal transplantation in young children with chronic renal failure can often be associated with significant improvement in cognitive and psychomotor function, as well as cephalic growth. The post-transplant impact on these children

further emphasizes the importance of timely transplant. Improved immunosuppressive regimens have also played a significant role in successful transplantation. Our outcomes with these young patients validate kidney transplant in infants as young as 6 months. The timing of kidney transplant should be not be dictated by age or size but by the abilities of transplant centers to perform this procedure successfully. Infants and small children with ESRD should be offered the same opportunities available to older children and adults. They should be referred to centers capable of providing outstanding results rather than lingering for years on dialysis with all of its attendant problems. Priya Verghese, MD, heads the Pediatric Transplant Program, University of Minnesota Amplatz Children’s Hospital. Michael Mauer, MD, is a professor in the Division of Nephrology, Department of Pediatrics, University of Minnesota Amplatz Children’s Hospital.

Trinity Health One of the region’s premier healthcare providers.

Currently Seeking BC/BE s Ambulatory Internal Medicine s Emergency Medicine s General Surgery

s Psychiatry s Urology Contact us for a complete list of openings.

Based in Minot, the trade center for Northern and Western North Dakota, Trinity Health offers the opportunity to work within a dramatically growing community that offers more than just a high quality of life. Comprised of a network of nearly 200 physicians in hospitals, clinics and nursing homes, Trinity Health hosts a Level II Trauma Center, Critical Care Helicopter Ambulance, Rehab Center, Open Heart and Lung Program, Joint Replacement Center and Cancer Care Center.

For immediate conﬁdential consideration, or to learn more, please contact

Physicians are offered a generous guaranteed base salary. Beneﬁts also include a health and dental plan, life and disability insurance, 401(k), 401(a), paid vacation, continuing medical education allowance and relocation assistance.

www.trinityhealth.org

MINNESOTA PHYSICIAN FEBRUARY 2013

Shar Grigsby Health Center - East 20 Burdick Expressway Minot ND 58702 Ph: (800) 598-1205, Ext 7860 Pager #0318 Email: shar.grigsby@trinityhealth.org

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

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

is accepting applications for the following full or part-time positions:

• Associate Chief, Primary & Specialty Medicine (Internist-St. Cloud) 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

• Director, Primary and Specialty Medicine (Internal Medicine) (St. Cloud) • ENT (St. Cloud) • Geriatrician/Hospice/ Palliative Care (Nursing Home-St. Cloud)

Family Med/ER Physicians We’re recruiting Family Med physicians with Emergency Room experience for our full-time practice in the western Wisconsin community of Amery. Utilizing a team of five dedicated FM/ER physicians, Amery Regional Medical Center’s ER has an annual volume of 6,000 and provides backup to ARMC’s 12,000 visits/year Urgent Care unit. Our FM/ER physicians work 32 hours per week in a block schedule of 12-hour (weekday) and 24-hour (weekend) shifts. BC/BE Family Med physicians with ER experience and an interest in pursuing alternative EM board certification are preferred; ABEMcertified EM physicians are also welcome to apply. You must have or be eligible for WI medical licensure.

• Psychiatrist (Brainerd, St. Cloud) • Urgent Care Provider (MD: IM/FP/ER) (St. Cloud)

US Citizenship required or candidates must have proper authorization to work in the US. J-1 candidates are now being accepted for the Geriatrician/Hematology/Oncology positions. Physician applicants should be BC/BE. Applicant(s) selected for a position may be eligible for an award up to the maximum limitation under the provision of the Education Debt Reduction Program. Possible recruitment bonus. EEO Employer.

Excellent benefit package including: Favorable lifestyle 26 days vacation CME days Competitive salary 13 days sick leave Liability insurance

Nestled near the WI/MN border, Amery offers abundant outdoor recreation, affordable housing and excellent schools — all just 60 minutes east of Minneapolis/St. Paul, MN. As part of the HealthPartners Medical Group,our Amery FM/ER physicians receive a competitive comp and beneﬁts package, paid malpractice coverage and the security of being part of a successful multi-specialty medical group. Apply online at healthpartners.jobs or email your CV and cover letter to sandy.j.lachman@ healthpartners.com. EO Employer

• Medical DirectorExtended Care & Rehab (IM or Geriatrics) (St. Cloud) • Pain Specialist (St. Cloud)

• Hematology/Oncology (Part Time-St. Cloud)

Small Town, Big Impact!

• Internal Medicine/ Family Practice (Alexandria, Brainerd, St. Cloud, Montevideo)

Interested applicants can mail or email your CV to St. Cloud VAHCS Sharon Schmitz (Sharon.schmitz@va.gov) 4801 Veterans Drive, St. Cloud, MN 56303 Or fax: 320-654-7650 or Telephone: 320-252-1670, extension 6618

healthpartners.com

FEBRUARY 2013

MINNESOTA PHYSICIAN

Disruptive from page 11 However, the theory should be used as a guidepost rather than a definitive method for addressing physician disruptive behavior. The process of acknowledging, addressing, evaluating, and monitoring physician disruptive behavior should be ingrained in the culture of the independent physician group. The medical group’s leadership should clearly communicate that this type of behavior is not acceptable, by means of implementing a sustainable, internal method of reviewing such cases. This will ensure that the expectations are clearly outlined and accountability for the behavior is understood. It will also support leadership to more readily rectify the disruptive situation and promote a healthy organization culture. This type of research is critical for the ongoing success of medical practices. A physician’s disruptive behavior can compromise patient safety when employees are fearful of an outburst. Groups are dealing with many other issues, and the dis-

traction of a disruptive physician can compromise business development and progression of strategic initiatives. A healthy culture and workplace are key components of retention and staff satisfaction. A disruptive physician can quickly dissolve this environment and create a wave of dissatisfaction within the team. In addition, a culture that promotes and supports personal accountability for behavior and acknowledges awareness of the impact of disruptive behaviors is important to ensuring healthy functioning of the group. Limitations

The Physician Disruptive Behavior model did not attempt to identify deeper reasons for physician disruptive behavior, such as drugs, alcohol, or other imbalances. In those cases, it is highly recommended that the group and/or the disruptive physician seek professional assistance. Another limitation is that this study focused on singlespecialty practices, in order to

provide the baseline for this research. Further research would expand on this knowledge and provide more insights into physician disruptive behavior in other environments or settings. Courage and commitment are key

One of the purposes of this research was to provide a forum for health care leaders to talk about the challenges they experience with physician disruptive behavior. The stress that is associated with addressing disruptive individuals is distracting to the business, challenging to the leaders, and overwhelming to the entire group. The action learning model may serve as a catalyst for critical conversations to occur and lend support and tools to the practice leaders in these circumstances. The hope is that as more research on this topic emerges, independent practices can share their successes and failures in dealing with physician disruptive behavior with a broader constituency, so that others can

learn from these experiences. While the research has limitations, the overall intent is to provide physician leaders, administrators, and other leaders within health care organizations a framework for having a different conversation about disruptive physician behavior. It takes courage and a commitment to an organization’s health and well-being for medical group leaders to address disruptive behaviors. However, analysis of this research indicates that the long-term benefits to the group will be worth short-term pain. And in the end, everyone in the organization, as well as the patients it serves, will benefit from a healthier culture. Melanie Sullivan, EdD, MBA, is CEO of St. Croix Orthopaedics.

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