Physician's Practice May 2011

St. Luke’s healthbeat for physicians

Healthcare to go

In this issue A1 Healthcare to go iTriage mobile healthcare app

Developed by two ER physicians, iTriage is a healthcare app that empowers people to make better healthcare decisions, with information such as:

A2 Laparoscopic partial nephrectomy Robotic surgery increases positive outcomes for kidney cancer patients

• Symptoms, diseases and medical procedures.

• Locations of ERs, urgent care clinics, doctor’s offices and pharmacies anywhere.

A5 St. Luke’s Work Well Solutions

• ER wait times and turn-by-turn GPS directions.

New satellite clinic opens at Jones Regional Medical Center

A7 Behavioral health

Download iTriage for your mobile device one of two ways: Use a QR code scanner

• Open your preferred QR code scanner.

• Point your phone camera at the QR code below and scan it.

• Follow the instructions for installation.

Mental health wellness in chronic illness management

Download manually iPhone®, iPod touch®, iPad™: Download at iTunes®.

Android™: Download at the Android Market.

BlackBerry®, Palm and others: Use your phone’s browser to visit iTriageHealth.com/get-mobile to access the app’s mobile version.

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iPhone, iPod Touch, iPad, and iTunes are registered trademarks of Apple Inc. Android is a trademark of Google, Inc. BlackBerry is a registered trademark of Research in Motion Limited.

■ To learn more about iTriage, log on to stlukescr.org or go to iTriageHealth.com

P.O. Box 3026 Cedar Rapids, IA 52406-3026 319/369-7211 stlukesmedstaff.com

St. Luke’s Hospital – A1

At home: desktops and laptops Visit iTriageHealth.com.

Kidney cancer cure:

robotic laparoscopic partial nephrectomy

R

obotic surgery techniques and earlier diagnoses increase positive outcomes for kidney cancer patients.

Kidney cancer represents approximately three percent of all adult cancers in the United States. According to the American Cancer Society, about 58,000 new cases are diagnosed in adults and children each year and it’s estimated that 13,000 people die from the disease annually. Kidney cancer occurs most often in people between the ages of 50 and 70, and affects men almost twice as often as women.

A2

– St. Luke’s Hospital

According to Jon Rippentrop, MD, Physicians’ Clinic of Iowa, P.C., Department of Urology and St. Luke’s medical director of Minimally Invasive Surgery, renal tumors are increasingly being found incidentally. In fact, a study conducted from 1982 until 1997 demonstrated a shift in the reason for diagnosis of renal cancer. In 1982, 13 percent of renal cancers were found incidentally. By 1997, this number had increased to 59 percent (Luciani LG, Cestari R, Tallarigo C. Incidental renal cell carcinoma – age and stage characterization and clinical implications. Urology 2000; 56(1):58-62.)

Rippentrop sees this shift happening in his own practice: “Typically a patient is found to have a renal mass during an evaluation of another problem, although some patients still present with the classic triad of flank pain, hematuria and weight loss.

Thankfully, with an early diagnosis, there exists the possibility of renal preservation,” said Rippentrop.

Surgical removal (nephrectomy) is a curative method for kidney cancer, as the disease does not respond well to chemotherapy or radiation treatments. The trend towards earlier diagnosis when a tumor is smaller makes a partial nephrectomy (removal of only the diseased portion of the kidney) a more viable option than removing the entire kidney (total nephrectomy). This allows better preservation of overall renal function, which is especially important in patients with diabetes or hypertension.

“While there is not a maximum size criteria that determines whether a partial nephrectomy

can be performed as opposed to a total nephrectomy, a partial nephrectomy is usually reserved for smaller masses,” said Rippentrop.

“In addition, the mass must be in a favorable location in the kidney; if it is too close to the center of the kidney (i.e. renal hilum), a partial nephrectomy may not be an option for a patient.”

Along with earlier diagnoses, the increasingly positive outcomes for kidney cancers can also be credited to newer surgical techniques such as robotic surgery. A partial nephrectomy using traditional open surgery methods involves

“ In addition to three-dimensional viewing, another advantage of the da Vinci system is that the surgeon can view both the patient’s ultrasound and anatomy simultaneously on one screen for precise, coordinated information.”

Jon Rippentrop, MD, Physicians’ Clinic of Iowa, P.C. Department of Urology and St. Luke’s medical director of Minimally Invasive Surgery

Open kidney surgery incision

da Vinci surgery incisions

making a large incision across the flank through multiple layers of muscle. This results in persistent pain, a multiple-day stay in the hospital and prolonged recovery at home after discharge.

Rippentrop has been performing robotic laparoscopic partial nephrectomies incorporating the da Vinci® robotic system since 2008. The system has been used in laparoscopic cases for several years, but has recently been applied to renal surgery with an impressive level of success.

“Increasingly, the da Vinci robotic system’s advantages of the threedimensional viewing and precise wristed instruments, is allowing a minimally invasive approach to select renal tumors,” said Rippentrop.

“This has the benefit of less pain, quicker recovery and preservation of a maximum of functional renal tissue.”

In addition to three-dimensional viewing, another advantage of the da Vinci system is the surgeon can view both the patient’s ultrasound and anatomy simultaneously on one screen for precise, coordinated information.

Once the renal mass is indentified, the blood supply to the organ is temporarily stopped so the surgery can be performed with minimal bleeding. The cancer is then removed, along with a margin of normal tissue.

The da Vinci system’s operative controls and three-dimensional

“To be able to perform each phase of the procedure – dissection, excision and reconstruction – with efficiency and precision is remarkable.”

Jon Rippentrop, MD, Physicians’ Clinic of Iowa, P.C. Department of Urology and St. Luke’s medical director of Minimally Invasive Surgery

magnification also create greater precision for the reconstruction portion of the surgery once the diseased tissue has been removed.

Time is a challenge when performing a partial nephrectomy.

Because blood flow is restricted during the procedure, the tumor removal and kidney reconstruction ideally is completed in less than

thirty minutes in order to preserve normal kidney function.

Rippentrop credits the capabilities of the da Vinci robotic system in the rise of positive outcomes for kidney cancer patients. “To be able to perform each phase of the procedure – dissection, excision and reconstruction – with efficiency and precision is remarkable.”

St. Luke’s Hospital – A3

A partial nephrectomy using the da Vinci surgical system begins with four to seven .5 cm to 1 cm incisions through which a small camera and working instruments are placed. The renal mass can generally be seen using the da Vinci’s optical system, however, if the cancer is located deeper in the kidney, a laparoscopic ultrasound device can be used to identify the location and size of tumor. The device can also determine the amount of blood flow to the diseased area and to the entire kidney.

Case Report: A 72-year-old female patient was referred to Jon Rippentrop, MD, Physicians’ Clinic of Iowa, P.C., Department of Urology and St. Luke’s medical director of Minimally Invasive Surgery. She presented with left lower quadrant abdominal pain. A CT scan obtained by her family physician demonstrated diverticulitis, as well as a 2.5 centimeter left solid renal mass. Her symptoms cleared with antibiotics.

A4

– St. Luke’s Hospital

After considering her treatment options: total nephrectomy (either open or laparoscopic) or an open partial nephrectomy, the patient elected to undergo a robotic-assisted laparoscopic partial nephrectomy.

Her tumor was identified and only the affected portion of the kidney was removed, successfully maintaining the vast majority of her renal function and keeping blood loss to a minimum.

Postoperatively, she began a regular diet and ambulating the day of surgery and was discharged home the day after surgery. Final pathology demonstrated a renal cell carcinoma with negative margins and she underwent no further therapy.

Follow up has demonstrated her to remain tumor free in both kidneys.

To learn more about St. Luke’s robotics program, contact Janna Petersen at 319/369-7224.

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St. Luke’s Work Well opens

new clinic at Jones Regional Medical Center S

t. Luke’s Work Well Solutions recently opened a new satellite clinic at Jones Regional Medical Center in Anamosa.

Troy Overholt, director, St. Luke’s Work Well Solutions, said the new clinic opened March 2 and is currently staffed with a boardcertified occupational medicine physician, Mark Taylor and a nurse from the Cedar Rapids Work Well Clinic.

three years. Once the new Jones Regional Medical Center was completed in summer 2010, work to make the clinic operational began to move forward. Overholt said choosing the location was key: “We already do business with some clients in the Monticello and Anamosa areas, and with the new critical access hospital, this was a really good fit for the community and St. Luke’s,” said Overholt.

Being located between St. Luke’s in Cedar Rapids and Finley Hospital in Dubuque has also been a positive factor. “We are able to make services more accessible to more

Mark Taylor, MD Board-certified occupational health physician

According to Overholt, a satellite clinic has been in the plans for

The Work Well Center at Jones Regional Medical Center is open Wednesdays from 12:30 3:30 p.m. for pre-employment physicals.

For more information about Work Well Solutions, contact Troy Overholt at 319/369-8153.

“We are able to make services more accessible to more people with this location.”

Troy Overholt, director St. Luke’s Work Well Solutions

Work Well Solutions partners with more than 400 local companies to serve business health needs. The Work Well Clinic provides services exclusively for work-related injuries such as: • Physicals • Wellness screenings • Workers’ compensation treatment • Drug screenings • Vaccinations

St. Luke’s Hospital – A5

“Currently we offer preemployment physicals and have plans to offer more services such as employee ‘fit for duty’ exams and injury care,” said Overholt.

Employment drug screening is provided through the lab at Jones Regional Medical Center.

“We hope to soon coordinate clinic hours with times that best suit the employers in the area and offer a comprehensive set of services to cover their occupational health needs.”

people with this location,” said Overholt. “And it’s been a real bonus being able to work with the occupational medicine program at Finley.” Finley and St. Luke’s are both affiliates of the Iowa Health System.

Mental health wellness in chronic illness management

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s the largest behavioral health provider in the state, the mental health professionals at St. Luke’s treat hundreds of patients each year, from children to the elderly.

Kent Jackson, director of St. Luke’s Behavioral Health Services, says one of the most important trends he is witnessing in the behavioral health field is the recognition of a co-occurrence of chronic physical and mental health issues.

“Research is uncovering that not only is the mind like the rest of the body, but the wellness of one can impact the wellness of the other,” said Jackson.

A6

– St. Luke’s Hospital

“There was a time when the argument of the chicken or the egg would come up in relation to mental health and physical illness: did hypertension cause the anxiety or did the anxiety cause the hypertension; the mental health side was generally secondary,” said Jackson. “We now know each illness can greatly impact the other, so it’s imperative we look beyond the cause and effect aspect and treat both equally. If a patient was being treated for cancer but not for co-occurring diabetes, it would seem ridiculous; yet that is

happening with patients who have both a mental illness and another chronic condition.”

Jackson highlights depression as a mental illness, which can impact an individual’s physical health.

Because depression has been shown to weaken the immune system, a depressed individual becomes more susceptible to physical disorders. Studies show people with depression are four times as likely to die within six months of a heart attack.

recognizing and treating mental health conditions that co-exist with physical issues can work proactively to rein in healthcare costs.

“Studies indicate patients suffering from depression use healthcare services three times more often than non-depressed patients and make seven times more visits to the Emergency Room,” said Jackson.

The statistics also hold true for those with more severe and persistent mental illness such as schizophrenia: as many as 75 percent of those individuals also have a serious physical illness such as high blood pressure, diabetes, respiratory and heart problems.

In fact, according to the Substance Abuse and Mental Health Services Administration (SAMHSA), a meta-analysis of 91 studies found with active behavioral health treatment, patients diagnosed with a mental disorder had a reduced overall medical cost of 17 percent, while controls who did not receive behavioral treatment increased an average of 12.3 percent.

The cost of care

Insurance concerns

With medical deductibles and co-pays on the rise for many patients, Jackson says it’s possible

Also at issue has been the polarizing of physical healthcare from mental healthcare by medical health insurers, who in the past

“ If a patient was being treated for cancer but not for co-occurring diabetes, it would seem ridiculous; yet that is happening with patients who have both a mental illness and another chronic condition.”

Kent Jackson, director St. Luke’s Behavioral Health Services

Reduced need for medical visits as a result of treatment for depression separated each. Until recently, many health insurance plans failed to provide as much – if any – coverage for mental health or substance abuse services as they did for other healthcare. However, a sweeping law- The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008- mandates parity for mental health and substance abuse services in private health insurance and was enacted into law in January 2010.

Jackson said while the new legislation has numerous loopholes yet to be worked out, it is a move in the right direction. “The parity bill is a start in recognizing mental illness as a disease just as important and as treatable as physical illnesses such as diabetes and hypertension,” said Jackson.

A new path to treatment Jackson believes the movement to coordinate treatment for both physical and mental illness should begin by offering mental health services at general or family practice offices, as that’s where nearly two-thirds of patients go when they have a mental health concern.

9– Number of primary care physician visits over six months

9.2

8– 7–

6.9

6– 5– 4– 3– 2– 1– 0– Six months before depression treatment

Six months after depression treatment

Health Insurance Plan of New York; Business & Health Executive Briefing, 1999

more efficiently when they visit a professional specifically trained in mental health.

Jackson believes the stigma of mental illness is a major reason many people avoid a mental health professional. Many contact family physicians, who treat over half of all behavioral health patients in this country.

With more common disorders this is generally acceptable, but with more complex disorders it may be problematic in terms of clinical outcomes and it may delay treatment with a mental health provider. An ideal model

of care would involve grouping services together, such as placing behavioral health specialists in family practices. “If we begin to bundle services together- general practitioners with mental health professionals, patients would feel comfortable in their choices and could be treated more effectively and efficiently,” said Jackson.

To learn more about Behavioral Health Services at St. Luke’s, contact Kent Jackson at 319/369-8356.

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St. Luke’s Hospital – A7

“A national survey found 32 percent of undiagnosed, asymptomatic adults would likely turn to their primary care physician to help with mental health issues while only four percent would initially approach a mental health professional,” said Jackson. “This is really not ideal.”

He said while general practitioners can be helpful in some behavioral health cases, patients generally are treated for mental health issues

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