J u n e 2 012
Team Approach Among Physicians Distinguishes Carotid Artery Stenting Program at
Cone Health
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Editor’s Note
Brain Power Rather than butting heads, three physicians from different practices and specialties put
Editor Heidi Ketler, APR
his vascular surgeon colleagues Charles Fields and Wells Brabham offer the benefits
Contributing Editors Maryan Binkley Brandon Chandos, M.D. June DeLugas Christine Hagen, M.D. Amanda Kanaan James Osborne, M.D. Jason W.W. Thomason, M.D., F.C.C.P., D.-A.B.S.M.
of their collaborative approach, including improved decision making. Patients who are
Photography - Anna Paschal Photography
theirs together for the carotid stenting program at Cone Health System, the spotlight of this month’s Triad Physician. In the cover story, team leader Dr. Jonathan Berry, an interventional cardiologist, and
well suited for minimally invasive carotid stenting versus endarterectomy also reap the
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2
The Triad Physician
Category
Contents
COVER STORY
4 Cone Health
Team Approach Among Physicians
Distinguishes Carotid Artery Stenting Program at
June 2012
FEATURES
11
Marketing
V ol . 1 , I s s u e 5
DEPARTMENTS 14 Internal Medicine
Understanding Daytime Sleepiness
Physician Outreach Is a Cost-effective Way to Boost Relationships and Referrals
15 Extracurricular
Amanda Kanaan explains the value of a
Carpe Noctem: Identifying and Treating Obstructive Sleep Apnea
physician liaison to specialists, in particular, and some techniques used.
12
Racing Experience Is an Opportunity for Thrills and Group Team Building
16 Sleep Medicine 18 Neurology Exploring Causes of Morning Headaches
19 Practice Management Neurology
Home Sleep Testing Is Not an Alternative for Patients Who Have Co-Morbidities
Rethinking the Electronic Health Record Revolution
20 Caregiving Unexpected Life Changes: What It Is Like to Raise a Child with Juvenile Diabetes
21 News
- Forsyth Cancer Center Awarded for Improving Access to Clinical Trials - MammoPad Provides Kinder, Gentler Mammograms
Dr. Brandon Chandos reviews the pros and cons of home sleep testing versus polysomnogram to diagnose sleep apnea.
On the cover: Interventional cardiologist Jonathan Berry (center) stands with vascular surgeons Wells Brabham (left) and Charles Fields. They work in concert in the Cone Health System’s peripheral vascular suite to deliver an innovative, team-based carotid artery stenting program.
June 2012
3
Category On the Cover
Team Approach Among Physicians
Distinguishes Carotid Artery Stenting Program at
Cone Health
By Vicki L. Friedman
There is more than one way to reopen a
blood flow to the face and brain. The
But Cone Health, whose mission is to
blocked carotid artery.
typical location for a blockage is at the
deliver “exceptional care by exceptional
bifurcation, which is in the neck. A fatty
people,” offers carotid artery stenting with
For many years, a highly invasive surgery
material called plaque can partially or
its beneficial outcomes for select patients.
has been the predominant method of
totally block the area – called carotid artery
During the minimally invasive procedure,
treatment. But another procedure that is
stenosis – thereby reducing the blood
the endovascular specialist inserts a
less invasive for eligible patients is being
supply to the brain. If the brain does not get
slender, metal-mesh stent that expands
performed on a regular basis by the
enough blood or if a piece of this plaque
inside the carotid artery to increase blood
interventional partners at Cone Health,
breaks off, a stroke can occur.
flow to areas blocked by plaque.
comprehensive health networks in the
Carotid artery stenosis has traditionally
For the right patient, carotid artery stenting
Triad.
been treated by carotid endarterectomy,
can be as beneficial as traditional surgery,
one of the largest and most respected
which involves surgically removing the
minus some of the risks and recovery time
The right and left carotid arteries are
inner lining of the artery that contains the
of surgery, according to Jonathan J. Berry,
branches of the aortic arch. They bring
plaque.
M.D., F.A.C.P., F.A.C.C., F.A.H.A., F.S.C.A.I.
From left to right: Stacey Matsuoka, Dr. Jonathan Berry, Stephanie Brown, Dr. Wells Brabham, Jan Johnson and Dr. Charles Fields, stand in the peripheral vascular suite.
4
The Triad Physician
Dr. Jonathan Berry is assisted by Jan Johnson during a carotid artery stent procedure.
An interventional cardiologist with The
Even though carotid artery stenting has
Southeastern Heart & Vascular Center, Dr.
evolved into an effective and emerging tool
About the Team Approach at Cone Health
Berry is chief of the Cardiovascular Section
in the treatment of carotid artery disease,
Carotid artery stenting at Moses Cone
at Cone Health System and medical director
the traditional carotid endarterectomy will
Heart and Vascular Center is distinguished
of the Cone Health Peripheral Vascular
not become extinct, stress Dr. Berry and
by two sets of eyes, two sets of hands and
Invasive Lab, as well as the Coronary Care
his colleagues at Cone Health – Charles E.
two sets of perspectives that stem from
unit. He is among the few interventionalists
Fields, M.D., and V. Wells Brabham IV, M.D.
two diverse professional backgrounds
in the nation who regularly performs
of the two vascular specialists working
carotid stenting and advocates a team
“Insurance
starting
together. The center – among the busiest
approach that integrates his specialty with
to reimburse for the procedure,” Dr.
companies
are
and most advanced cardiac care facilities
that of a vascular surgeon.
Berry says. “Medicare is very strict in
in the state – boasts a national reputation.
reimbursement only for those patients
Carotid artery stenting under the direction
“In most vascular angiographic suites, only
who are older than 65 and meet specific
of an experienced team is at the forefront
one specialist performs the procedure
criteria. Other companies in the past have
of those advances.
known as carotid artery stenting,” Dr. Berry
reimbursed people who are high risk and
says. “That doctor is either a specially
symptomatic.
“We have a very experienced technical
trained interventional cardiologist, like
staff in the peripheral vascular lab,” Dr.
myself, a vascular invasive physician
“As time goes on and more data is analyzed,
Berry says. “I started working with them
or a vascular surgeon. Our situation at
the restrictions on who is eligible will
19 years ago in 1993. We do three to four
Cone Health is unique, as we follow a
likely relax. As this occurs, carotid artery
carotid stents per month, and we’re starting
team-based approach, with the goal of
stenting will become more readily adopted
to ramp up that volume.”
improving patient selection and outcomes
and part of our standard armamentarium.
by incorporating multiple points of view
Patients will be asking for it.”
Dr. Berry performed his first carotid
from multiple specialties.”
stenting procedure 13 years ago. He, Dr.
June 2012
5
Dr. Jonathan Berry (left) reviews a a patient’s carotid angiogram with Dr. Wells Brabham.
Fields and Dr. Brabham teamed up years
is technically challenging, you have two
Traditionally
certain
experts
perform
ago. “Together, we perform every carotid
sets of eyes and two sets of hands working
endarterectomy; others perform stenting.
stent,” Dr. Berry says. “You don’t usually
together. This increases the likelihood of a
“We do both,” Dr. Brabham says. “We
see a surgeon and a vascular specialist
successful outcome. Our margin for error
can evaluate the patient and, based on
standing side by side.”
is extremely small.”
their risk profile, offer them the most
“By working together on multiple cases,
The team approach starts with diagnosis
vascular
we start to learn each other’s habits and
to determine the best treatment. If the
working together is what makes us unique
each other’s skills and expertise,” Dr.
preferred treatment is a carotid stent, Dr.
at Cone Health. Most importantly, I believe
Fields says. “It has become a much more
Berry offers not only the experience but
that our patients benefit the most.”
fluid team concept. As you start to do more
also the specialized expertise that stems
procedures, everybody knows what’s
from his training in coronary health.
Carotid Artery Stenting vs. Endarterectomy
“Dr. Berry gives us his perspective on
Oxygen-rich blood flows easily through
appropriate treatment option. Having
on the next page of the book and what everyone is going to do next.”
surgeons
and
cardiologists
the condition of a patient’s myocardial
the smooth inner walls of healthy
“We aren’t competitors with each other;
function, which is an important indication
carotid arteries. Arterial plaque, which
we’re collaborators,” stresses Dr. Brabham.
of how well the patient may tolerate
accumulates on the inner walls of the
“The way we do it, we have two different
endarterectomy versus a carotid stenting
arteries,
physicians from two completely different
procedure,” Dr. Fields says. “Given Dr.
reducing blood flow or blocking it all
backgrounds, as far as training goes,
Berry does so many coronary procedures,
together. Hence, the condition referred to
coming together. To bring that background
it’s nice to have his expertise when we
as clogged arteries results from this plaque,
to each case is an asset to the patient. We
might need to use a special wire or a
which can be composed of calcium, fat,
question each move to make sure what
catheter that we wouldn’t ordinarily use as
cholesterol, cellular waste or fibrin, a
we’re doing is what’s best for the patient
vascular surgeons.”
material involved in blood clotting.
at that time. When you run into a case that
6
The Triad Physician
can
interrupt
that
process,
When plaque deposits grow, atheroscle-
the artery. The shunt is removed just before
the blood to flow freely. The balloon is
rosis or hardening of the arteries causes
the patch is completed. The incision is
then removed and another catheter guides
the arteries to narrow. Atherosclerosis is
then closed. Generally, a one-night stay in
a compressed stent to the same area as
the leading cause of heart attacks, stroke
the hospital is required.
the blockage. The stent expands to fit the artery, remaining in the carotid artery
and peripheral vascular disease in the United States. If plaque builds up in the
Carotid stenting requires only a needle
permanently. An angiogram confirms that
carotid artery, a stroke can occur. Carotid
stick through the groin and to the artery
the blockage has been corrected.
artery disease causes more than half of
generally under local anesthesia. Patients
the strokes in the United States, accord-
are given antiplatelet medication to prevent
The stent procedure can be performed
ing to the National Heart, Lung and Blood
clots, atropine to reduce the chances of the
in 90 minutes or less and recovery time
Institute.
heart slowing and a numbing agent where
generally involves a one- to two-day stay
the long, thin catheter is inserted. A dye is
in the hospital, which is largely dependent
Sometimes conservative medical therapy
injected into the artery, allowing one of the
on the patient’s overall health. “Patients
is a treatment option for patients diagnosed
physicians on the Cone Health team to take
who come in with overall health problems
with carotid artery stenosis. Hypertension,
real-time X-rays using fluoroscopy. One of
generally need to stay a bit longer, so we
high cholesterol, smoking and diabetes
the physicians then places a filter device
can monitor their overall health,” says Dr.
are additional risk factors for stroke.
to keep debris or clots from going to the
Fields.
Antiplatelet agents, including aspirin,
brain, a safeguard against stroke. Next, the
Plavix or Prasugrel, are pharmacotherapy
narrowed area is pre-dilated with a balloon
First introduced in 1994 as an investigational
options.
(angioplasty), and a stent is deployed
treatment for carotid artery disease and
across the lesion to correct the stenosis.
approved by the United States Food and Drug Administration as a treatment option
Carotid endarterectomy is considered the gold standard treatment for the surgical
“There are essentially three steps,” Dr.
in 2004, carotid artery stenting can be the
removal of plaque from neck arteries.
Brabham says. “Number one is to get your
best option for patients with stenosis. A
Under a general anesthetic, a surgeon
diagnostic images. If we proceed with a
recent, randomized trial called the CREST
makes an incision in the skin over the site
stent, the next step is to put the filter, or
study found no significant outcome in
of the blockage. The common internal
the protection device, in place, and then
major risks between carotid stenting and
and external carotid arteries are then
we put the stent in. Each of us knows how
endarterectomy.
exposed. After heparinization, the arteries
to do all aspects of the procedure, so we
are occluded. An arteriotomy is then
rotate among the three of us.”
“The most important thing people need to remember is that carotid artery stenting is
performed so plaque can be exposed. A temporary shunt is often placed to
At the site of the blockage, the carotid
one solution but not always the solution,”
maintain blood flow to the brain while the
artery stenting team inflates and deflates
Dr. Fields says. “It’s a wonderful option
carotid artery is occluded. Next, the plaque
the angioplasty balloon to compress the
to have available. The beauty of our
is removed. The artery is usually closed
plaque against the artery walls and widen
arrangement at Cone Health is we’re
incorporating a patch, so as not to narrow
the diameter of the blood vessel, allowing
collegial enough with each other that if the
A
B
C
D
A. Angiogram of carotid stenting procedure; B. Distill procation device deployed beyond lesion; C. Positioning of carotid artery stent; D. Final result post stent placement
June 2012
7
Dr. Jonathan Berry (right) and Dr. Charles Fields perform carotid artery stenting together while assisted by Jan Johnson.
best method of treatment for a patient is a
“We are certainly in a much better position
too many twists and turns during the pro-
carotid stent, that’s what we do. If the best
to know they would be better off if we do a
cedure, stenting may not be the preferred
treatment is nothing, that’s what we do, and
carotid stent than a redo operation.”
choice. As an example, the configuration of the aortic arch may pose a problem for
if the best treatment is an endarterectomy, we’re skilled at doing that.”
Patients at high risk for surgery may be
safely navigating the wires and catheters
ideal candidates for carotid artery stenting.
and the protection used in carotid stenting.
Carotid Artery Stenting: Who is a Fit and Who is Not?
However, there are a number of factors that exclude patients as candidates for stenting,
Age is also an important consideration.
Carotid stenting is approved for the
leaving carotid endarterectomy as the best
The CREST study indicates stenting is an
treatment of patients with symptomatic
option.
effective treatment for patients younger than 70 who have symptoms related to
carotid artery disease who are identified
carotid occlusive disease.
as being at too high of a risk for carotid
“There are lesions that are difficult to get
endarterectomy because of concurrent
to surgically,” Dr. Brabham says. In those
medical problems. In addition, patients
cases, stenting is more effective. However,
The biggest risk during carotid artery
who have had recurrent narrowing after
calcified lesions, often found in older
stenting is stroke, a risk that rises when
a carotid endarterectomy or prior neck
patients, may be better treated surgically.
a patient is over 80, says Dr. Fields. “I always look at patients over 80 with a bit
radiation therapy are good candidates. Sometimes, a patient’s anatomy makes tradi-
of a second eye,” he says. “We make a
“Carotid artery stenting is an especially
tional surgery a better option. Patients with
judgment call, particularly if they have
viable option for patients who have
torturous arteries might not do as well with
other debilitating health issues. Sometimes
developed a restenosis,” Dr. Fields says.
a stent. If the physician is forced to navigate
the decision is not to do anything at all.”
8
The Triad Physician
Groin puncture in patient undergoing carotid stenting.
Fresh incision of patient post op Day 1 of right carotid (endarterectomy).
Given that carotid artery stenting is a relatively new procedure,
concludes that experience is a significant factor in determining
insurance reimbursement has been an issue. Initially, the U.S.
outcomes related to carotid artery stenting.
Centers for Medicare and Medicaid Services expanded its coverage of the stenting procedure for patients who did not
Since its beginnings in 1953, Cone Health has emerged as one of
have the specific symptoms of a blockage. But that decision was
the premier healthcare institutions in North Carolina. Active in
subsequently reversed in spite of clinical evidence that seemed to
advancing healthcare outcomes, it has participated in three global
show the procedure is safe and effective, according to Dr. Fields.
studies showing carotid artery stenting is as safe and effective as surgery, with the risk of stroke similar and the risk of heart attack
“Currently, Medicare will not reimburse for asymptomatic carotid
even lower than previously estimated.
lesions unless they are within the context of a trial,” Dr. Fields says.
“Carotid artery stenting has been shown in numerous trials to be as effective as carotid endarterectomy in addition to being as safe,
“These are technically challenging surgically,” says Dr. Berry.
with the benefit of being less invasive,” Dr. Berry says.
“The asymptomatic patients have been done surgically because there has been no mechanism for reimbursement.
“Cone Health’s Heart and Vascular Center has the expertise and the experience to be a major player in carotid stenting and to
Dr. Berry also stresses that patients with atherosclerosis in the
match the capabilities of the nation’s most advanced medical
neck have it in other places. “These patients have vascular
centers,” says Dr. Berry, a leader in the field of carotid stenting
disease,” he says. “So it’s important to screen patients for
and the sole cardiologist at Cone Health who performs it.
heart disease prior to the procedure. You don’t want to have a periprocedural heart attack that could have been prevented. All
“The unique aspect at Cone is we work collaboratively to offer the
patients being considered for a carotid stent are screened with
patient what we deem is the best option for them given their risk
appropriate testing to rule out concomitant heart disease. If these
factors,” Dr. Brabham says.
patients are found to have heart disease as well, we treat the ‘entire patient.’
In addition to being chief of the Cardiovascular Section of the Cone Health System and medical director of the Cone Health
“Most of the patients are elective and asymptotic. Some are semi-
Peripheral Vascular Invasive Lab, as well as the Coronary Care
elective, meaning they have had a stroke or mini-stroke, and it’s
unit, Dr. Berry is chairman of the Cone Health’s Medical Executive
important to be more aggressive and timely. Still, we assure that
Committee. He was certified by the American Board of Internal
the procedures are performed as safely as possible.”
Medicine in 1987 and by the American Board of Medical Specialty, Cardiology in 1989. He has a special interest in cardiac and
Experience Matters
peripheral vascular intervention (carotid stenting), in addition to
A recent study by the Journal of the American Medical Association
vascular and nuclear imaging.
June 2012
9
Dr. Jonathan Berry and Dr. Wells Brabham performing carotid stenting assisted by Jan Johnson. Cone Health has been chosen to be 1 of 100 sites to participate in the Abbott Vascular CANOPY Study, which is a registry for low risk a-symptomatic patients to undergo carotid stenting procedures
Dr. Berry completed
to Greensboro and the surrounding region
partner since 2008. He earned his bache-
his bachelor’s in bio-
for more than 30 years.
lor’s degree at the University of North Carolina in 1994 and his master’s degree from
chemistry/biophysics from Dartmouth Col-
Dr. Fields, certified by
the University of North Carolina in 1996.
lege in 1979 and gradu-
the American Board of
He graduated from the Medical College of
ated from the University
Surgery in 2003 and in
South Carolina in Charleston in 2001. Dr.
of Pennsylvania School of Medicine in 1983.
vascular surgery since
Brabham performed his internships and
He completed his residency at the Duke
2005, has been a VVS
residencies in general surgery and vascu-
partner
2004.
lar surgery at UNC. He is the medical di-
ogy fellowship there as well. He completed
He is a fellow in the American College
rector of the Noninvasive Vascular Lab at
an interventional cardiovascular fellowship
of Surgeons. He earned his bachelor’s
Cone Hospital.
at the University of Michigan in Ann Arbor.
degree from Wake Forest University in
He is a clinical professor of medicine at the
1991 and medical degree from the Medical
In addition to the extensive knowledge and
University of North Carolina Chapel Hill
College of Virginia in 1995. He performed
experience each of the physicians offers,
School of Medicine.
internships and residencies in general
Dr. Brabham and his partners are proud of
surgery at the Medical College of Virginia
how well the teamwork concept works for
and in vascular surgery at the Mayo Clinic.
the patient.
University Medical Center and his cardiol-
For referrals please call (336) 273-7900
since
(Southeastern Heart and Vascular Center). Dr. Brabham, certified
“Our collaboration allows us to stand
Drs. Fields and Brabham are partners at
by the American Board
apart,” Dr. Brabham says. “We get along
Vascular and Vein Specialists of Greens-
of Surgery in 2007 and
and we work together to ensure that the
boro (VVS), a comprehensive surgical
in vascular surgery in
best patient outcome is our focal point.”
group that has provided vascular services
2010, has been a VVS
10
The Triad Physician
Marketing
Physician Outreach Is Cost-Effective Way to Boost Relationships and Referrals By Amanda Kanaan
As a physician, you can’t be everywhere
As a physician, you can relate to the fact
at once. From a clinical perspective, you
that referring doctors prefer to send patients
help ease this burden by hiring nurse
to practices they have relationships with.
practitioners or physician assistants as an
In some ways when you refer a patient to
extension of your care. From a marketing
another doctor, you are putting your own
perspective, hiring a physician liaison helps
reputation at stake by endorsing that doctor’s
expand your outreach in the community by
skills and services. Patients will either thank
building and maintaining relationships with
you or complain to you for doing so. By
referring doctors on your behalf.
referring to practices you already have an established relationship with, you reduce the
From private practices to major hospital
chances these patients will come back in the
systems, health care providers have long
form of a complaint.
Amanda Kanaan is a medical marketing specialist whose company, WhiteCoat Designs, provides Physician Outreach services, Medical Website Design, Search Engine Optimization (SEO), Social Media Management and Marketing Consulting to private practices and healthcare organizations. Ms. Kanaan
relied on the assistance of a physician liaison
can be reached by e-mail to amanda@
to strengthen their practice’s reputation,
Hiring a physician liaison isn’t for everyone.
uncover opportunities, collect valuable
It primarily benefits specialists and sub-
feedback and ultimately increase new patient
specialists who heavily rely on referrals to
referrals.
fuel their practice.
For smaller practices, this concept may seem
It is an ongoing commitment that takes time
easier (such as script pads that can be faxed
daunting considering the costs involved with
to achieve results. Much like dating, you won’t
in for scheduling) and using your liaison to
hiring another full-time employee. However,
be in a relationship with someone after just
uncover and fix internal issues.
many medical marketing agencies now offer
one or two dates. It may take multiple visits to
physician liaison services on a contract
convince a practice to try your services, and
The key to a successful physician outreach
basis, making it feasible and much more
when they do, it has to be a good experience
program is listening. Liaisons shouldn’t just
affordable for specialists to pursue this
in order for the referrals to continue.
walk into offices, tell the staff about your
marketing strategy.
whitecoat-designs.com, phone at (919)714-9885 or on the web at www.whitecoat-designs.com.
practice, drop off some brochures and walk Physician liaisons help build new referring
out. Their role is to listen, find opportunities to
In marketing, if you’re not saying it then
relationships. They also are essential in
strengthen relationships and then nurture those
you’re not doing it. That means that if you are
maintaining those relationships by ensuring
relationships into consistent referral patterns.
not out communicating the benefits of your
the referring office has a smooth experience
practice to the referring community, then it’s
and by rectifying any negative feedback on
Although many doctors hesitate hiring a liai-
safe to assume no one knows. I work with
behalf of either the referring office and/or
son, because they feel the concept of sales
many physicians who think because their
the patient.
has no place in their practice, the truth is
practice has been in existence for more than
liaisons act more as customer service repre-
15 years their reputation speaks for itself.
The key to a successful physician outreach
sentatives. When used effectively, liaisons are
While reputation is important, doctors are
strategy is to bring value to your relationship
the furthest thing from a traditional sales rep.
often astonished when liaisons report back
with referring physicians. Ways to legitimately
that many referring physicians are not only
add value include offering a monthly or
Overall, physician liaisons are often an afford-
unfamiliar with their services, but don’t even
quarterly newsletter containing ongoing
able and valuable tool in winning over your
know they exist.
education about your specialty, creating
peers and gaining valuable new patient refer-
tools that make referral coordinators’ lives
rals to fuel your practice.
June 2012
11
Neurology
Home Sleep Testing Is Not an Alternative for Patients Who Have Co-Morbidities By Brandon Chandos, M.D.
Home testing for sleep apnea is an
sleep medicine physician. Acceptable
gram to assess sleep stage (light, deep or
alternative to the traditional in-facility
compliance is defined as using the
rapid eye movement, or REM). This infor-
monitored polysomnogram.
equipment more than four hours per day,
mation is used to assess patterns of “sleep
at least 70 percent of the time.
architecture.” Electrodes on the legs record limb movements for the diagnosis of sleep-
Until a few years ago, home sleep testing (HST) was not considered a valid or accu-
Other useful data include mask leak and
related movement disorder. The electrocar-
rate test by the Centers for Medicare and
estimated apnea index on therapy. Based
diogram channel is a monitor for abnormal
Medicaid Services (CMS). The American
on these data, adjustments to mask or
rhythms. Complex respiratory patterns can
Academy of Sleep Medicine was of the
pressure settings can be made to improve
be assessed, such as combined central and
same opinion. This changed in 2007. There
comfort and efficacy.
obstructive apneas. The data is monitored in real time by a trained technician and re-
A home sleep study can be used for an uncomplicated patient with a clinical suspicion of moderate or high-severity sleep apnea. Period.
viewed by a sleep medicine physician. Sleep apnea is common. Like its comorbidity
obesity,
the
incidence
is
increasing. During a recent 10-year period, the number of sleep studies performed increased 350 percent.
was a paradigm shift. CMS began placing
There are major differences in the technical
more emphasis on outcomes measures,
aspects and clinical utility of HST versus
and somewhat paradoxically, less empha-
polysomnogram (PSG). HST is indicated
Treating sleep apnea can improve quality
sis on the relative accuracy of the testing
when a clinical assessment indicates a
of life and reduce morbidity. This is
used. In other words, the test used became
moderate or high suspicion of sleep apnea.
associated with reduced health care costs over the long term. We are, however,
less relevant, and the documentation of the benefit of treatment became the primary is-
An HST records less data. It typically
confronted with the upfront cost – initial
sue and outcome measure.
includes: pulse oximetry, nasal airflow and
diagnosis and treatment – now. A home
respiratory effort.
sleep test is less expensive than a standard polysomnogram: $245 versus $931.
If a patient is diagnosed with sleep apnea and is treated with a form of positive
HST is not recommended when there are
airway pressure support (PAP), they must
significant co-morbidities, such as cardiac
However, home sleep testing remains
have a face-to-face evaluation with a sleep
or pulmonary disease. These morbidities
controversial
in
medicine physician within 31 to 90 days of
are associated with a more complex
community.
From
beginning treatment. The sleep medicine
pattern of sleep-disordered breathing. An
standpoint, the data is simply not as
physician must review compliance with
unmonitored study with less data than
good with an unmonitored home test
treatment and benefit of treatment.
a PSG is not considered adequate. This
compared to a monitored polysomnogram.
excludes many patients from HST.
Unmonitored studies are liable to have data
Most PAP devices have either a memory
loss
and
the
sleep a
medicine
quality-of-care
false-negative
results.
card or a wireless modem. Compliance and
A polysomnogram is required to assess
An inadequate study can result in an
other data are transferred to the respiratory
other sleep disorders. Additional channels
inaccurate diagnosis or require a follow-up
equipment provider for review by the
of data recorded include electroencephalo-
polysomnogram. Nevertheless, economic
12
The Triad Physician
Dr. Brandon Chandos is a neurologist and sleep medicine specialist with Forsyth Comprehensive Neurology, an outpatient practice he helped establish six years ago. He now serves as its medical director, caring for patients with a variety of sleep issues. Originally from Chicago, Dr. Chandos completed his undergraduate training at Texas Christian University in Fort Worth and then attended Texas Tech Health Sciences Center in Lubbock for his medical training. His fellowship training in neurology was completed at The University of Washington in Seattle. Dr. Chandos is a diplomat of the American Board of Psychiatry and Neurology, with subspecialty certification in sleep medicine. Forsyth Comprehensive Neurology is located at 2025 Frontis Plaza Blvd., Suite 120, Winston-Salem, N.C. For more information or for patient referrals, call (336) 277-2200 or visit www. forsythcomprehensiveneurology.com.
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forces are pushing us in the direction of home sleep testing.
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There are several factors I use in deciding
• Urticaria
what study, if any, I will use in assessing a sleep disorder. First, a sleep study is not indicated for the assessment of insomnia. Insomnia is a clinical diagnosis. A home sleep study can be used for an uncomplicated patient with a clinical suspicion of moderate or high-severity sleep apnea. Period. The assessment of sleep apnea as a legal requirement for truck drivers and pilots requires a monitored study. Medically complicated patients or patients with
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another suspected sleep disorder deserve a monitored polysomnogram. Though it has its limitations, I appreciate having the tool of home sleep testing as a
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more affordable and convenient test option for our uncomplicated sleep apnea patient.
June 2012
13
Internal Medicine
Understanding Daytime Sleepiness By James Osborne, M.D.
Everyone has a bad night sleeping from
If the airway closes completely, no air
time to time and knows how one feels the
moves at all. In the case of a person with
next day – kind of foggy-headed, feeling a
sleep apnea, the situation won’t improve
step behind all day, sometimes even achy,
until he awakens slightly. This slight awak-
like you have a mild case of the flu. But
ening, called an arousal, lasts only a few
what if you felt that way every day?
seconds. When the person snoring does arouse and start breathing again, it can be
Daytime sleepiness can make working,
with such a loud snort that it is noticeable
thinking and driving a problem. Exces-
to all those in the vicinity, except the one
sive sleepiness is a major cause of motor
snoring.
vehicle crashes in the United States. In addition, many major man-made catastro-
If the patient slows down or stops breath-
phes, including the Three Mile Island and
ing often enough, sleep is disrupted and
Chernobyl disasters, the Exxon Valdez
fragmented, and the person will be sleepy
oil spill and the Space Shuttle Challenger
the next day. In addition, the oxygen level
disaster, have been attributed to the poor
can fall surprisingly low during the night in
judgment of sleep-deprived workers. The
people with sleep apnea.
Dr. Jim Osborne has been with Eagle Internal Medicine since 1986. He earned his medical degree from the University of North Carolina-Chapel Hill and his post-graduate training at the University of Iowa. He has been board certified in internal medicine since 1986 and in sleep medicine since 2011. Dr. Osborne also is medical director of Advanced Home Care and is heavily involved in leading Triad Health Care Network. He is active in his church, where he even preaches from time to time, and he enjoys ballroom dancing with his wife, Nanette. Dr. Osborne can be reached at Eagle’s Tannenbaum office at (336) 274-3241.
cost of sleep-related incidents each year is This process leads to the well-known symp-
staggering.
toms of sleep apnea: daytime sleepiness,
the morning and is sleepy through the day,
The two most common causes of excessive
morning headaches, witnessed episodes
then she is not getting enough sleep. Also,
sleepiness are sleep apnea and “voluntary”
of absent breathing and awakening with
if a person tends to sleep one-and-a-half to
sleep deprivation.
the feeling of being chocked. In addition,
two hours more on weekends when she
sleep apnea is a risk factor, like high blood
gets the chance, then she is probably sleep
pressure and high cholesterol, for heart
deprived.
Sleep Apnea
disease and stroke. Fortunately, sleep apnea is treatable by a physician.
How do you prove the problem is voluntary sleep deprivation? That is pretty sim-
“Voluntary” sleep deprivation, which often
ple, as well.
is not very voluntary, simply means not spending enough time sleeping. The result
A person can plan to get an hour more
is daytime sleepiness.
sleep every night for four or five days, which may require giving up something in
Sleep apnea is a condition in which a
There is a lot of misunderstanding about
one’s life. If he finds he feels better the next
person’s airway narrows in his sleep. This
how much sleep a person needs. You may
day, it proves he is sleep deprived.
narrowing most commonly occurs in the
have heard people say that six or seven
throat, so those with sleep apnea tend to
hours are enough, or even that sleeping
In addition, those who get sufficient sleep
snore. When the airway narrows, it can get
eight or more hours per night is needed.
are better able to be productive, make wiser decisions and drive more safely. And
to a point at which it is much like sucking air through a straw. The person tries harder
To determine how much sleep an individ-
recent research indicates being well rested
and harder to breathe and gets no addi-
ual needs, simply ask him or her how she
reduces the risk of heart attack. All makes
tional air.
feels every day. If she doesn’t feel rested in
getting a good night’s sleep well worth it.
14
The Triad Physician
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June 2012
15
Sleep Medicine
Carpe Noctem: Identifying and Treating
Obstructive Sleep Apnea By Jason W.W. Thomason, M.D., F.C.C.P., D.-A.B.S.M.
Are you tired even after sleeping eight
STOP-BANG also can help screen popula-
reduction have dramatically enhanced
hours? Does your spouse complain about
tions at special risk, such as commercial
tolerance. Recent Medicare guidelines that
loud snoring or “gasping” during sleep?
drivers (OSA patients have a two-to-three-
require durable medical equipment (DME)
Any problems with hypertension? Diabe-
times greater relative risk for motor vehicle
companies to track CPAP data for each pa-
tes? Atrial fibrillation? Heart failure? All of
accidents) and patients planning surgery
tient and insist that patients have a follow-
these can be associated with a diagnosis
who will require general anesthesia. For
up visit in the sleep clinic have helped pro-
of obstructive sleep apnea (OSA). Fortu-
example, we screened 1,043 orthopedic
mote compliance, as well.
nately, proper therapy for OSA can improve
patients recently, identifying 41 percent to
them all, as well.
be at risk and 16 percent to have significant
Alternative treatment options can include
OSA. Screening such patients clearly has
oral appliances, surgery or weight loss,
The fact is that OSA affects millions of
been shown to reduce complications, both
plus positional therapy. Current clinical tri-
people, most of whom remain unaware of
on a national level and within the Triad.
als are testing implanted hypoglossal nerve
their illness. When defined as an apneahypopnea index (AHI) of greater than five events per hour of sleep, the estimated prevalence in the general population is
OSA affects millions of people, most of whom remain unaware of their illness.
around 20 percent. The two most important findings on physi-
stimulators, which advance the tongue and
A few short questions and findings on
cal examination of suspected OSA are an
elevate the soft palate with each inspira-
physical examination can enhance the
increased body mass index (BMI) and
tion during sleep. Preliminary data look
screening process. I would suggest hav-
neck circumference. Male patients with
promising, and similar devices have been
ing your staff include at least one question
a BMI that is greater or equal to 28 and a
approved in Europe and Australia.
about sleep into each patient encounter,
neck circumference that is greater or equal
similar to the role of vital signs and inqui-
to 17 inches are at higher risk. In females,
Patients’ reward for persistence with treat-
ries about tobacco.
look for a neck circumference of greater
ment includes reduction in health risks,
or equal to 16 inches. Other factors to con-
in particular with regard to cardiovascular
In terms of specific screening tools, I prefer
sider include tonsillar hypertrophy and mi-
disease, better memory and mood, im-
the STOP-BANG (snoring, tiredness, wit-
crognathia/retrognathia.
proved metabolism and weight loss and even increased libido. Studies also have
nessed obstructed breathing, high blood pressure, body mass index, age, neck
Today’s treatment options vary depending
shown an improvement in the quality of life
circumference,
of the patient’s bed partner.
questionnaire.
on the patient, comorbidities and severity
Though brief, it has been shown to be
of illness. In general, some form of positive
nearly 100 percent sensitive for identifying
airway pressure, such as continuous posi-
Studies regarding OSA patients with hyper-
patients with severe disease. Coupling this
tive air pressure (CPAP) or variable/bi-level
tension show a reduction in both systolic
to the Epworth Sleepiness Scale and physi-
continuous air pressure (BiPAP), remains
and mean arterial pressure to be similar to
cal examination, no patient with significant
the gold standard. Recent technological in-
that seen with ACE (angiotensin-convert-
OSA should be missed.
novations in terms of mask style, humidifi-
ing enzyme) inhibitors. Other data show
cation, pressure-release options and noise
significant improvements in ejection frac-
16
gender)
The Triad Physician
Dr. Jason Thomason is board certified in pulmonary, critical care and sleep medicine. After completing fellowship training at Vanderbilt University in 2004, he helped found and remains the medical director of the American Academy of Sleep Medicine-accredited Southeastern Sleep Disorders Center of Salem Chest Specialists in Winston-Salem. For more information and referring patients, call (336) 765-0383 or visit www. salemchest.com.
Legal Expertise, Health Care Knowledge Principal Karen McKeithen Schaede, a registered nurse for 10 years, brings in-depth understanding of health care to the practice of law. Our staff can assist you with: • Medical Practice Formation • Physician Employment • Medical Practice Sale, Acquisition or Consolidation • Medical Joint Ventures • Medical Staff Disputes • HIPAA Issues • Corporate Compliance • Contract Disputes • Employment and Labor Law
tion after one and three months of CPAP for patients with systolic heart failure. For patients with atrial fibrillation and who undergo cardioversion, a recurrence rate of 82 percent can be reduced to 42 percent with proper treatment of their OSA. In summary, do not allow yourself or your patients to consider feeling tired each day as a “normal.” Those who snore loudly, have a large neck, have an elevated BMI, experience frequent morning headaches and suffer from any of a number of cardio-
1175 Revolution Mill Drive Studio 7A Greensboro, NC 27405 Fax: (888) 392-2707 karen@shadylaw.net www.shadylaw.net
vascular conditions, consider the possibility of OSA. The positive effects of treatment for OSA can be remarkable.
Carpe noctem.
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June 2012
17
Neurology
Exploring Causes of
Morning Headaches By Christine Hagen, M.D.
Morning headaches are seen quite frequently in a headache clinic setting. Many headaches are associated with pain on awakening. These include primary headache disorders, such as migraine, cluster and hypnic headaches. It is also important to consider secondary causes for headache, including cervical spinal disease, infection or neoplasm. Sleep disorders, such as insomnia, circadian rhythm disorders, movement disorders, parasomnias and obstructive sleep apnea can also present with morning headaches.
Dr. Christine “Lollie” Hagen is a board-certified neurologist with subspecialization in sleep medicine. Dr. Hagen’s interests include headache medicine, the impact of sleep disorders on headache disability and women’s health issues. She is currently practicing at the Headache Wellness Center in Greensboro. For information visit www.headachewellnesscenter.com or contact Dr. Hagen by phone at (336) 574-8000 or e-mail to chagen@headachewellnesscenter.com.
So what is the best way to evaluate a patient with morning headache?
Treatment for sleep apnea varies tremendously. Weight loss may
First, a thorough history should be obtained. Does the patient have
improve or resolve obstructive sleep apnea, but the gold standard for
a history of headaches? Is there a family history of headaches? What
treatment is continuous positive airway pressure (CPAP). If a patient
time is the headache occurring? What is the duration of the headache?
cannot tolerate CPAP therapy, alternatives include use of a mandibular
Are there secondary symptoms (phonophobia, photophobia, nausea,
advancement devices while sleeping or referral for surgery. It may be
autonomic symptoms)?
worth noting that a patient may be more receptive to, and compliant with, treatment when they understand there may be a possible link to
Second, the physician should perform a thorough exam. If there are
apnea and headaches.
any neurological abnormalities, an imaging study should be obtained. Other things to think about during the exam include an enlarged uvula,
So the next time you see a patient complaining of morning headache,
large tonsils, retrognathia, a broad tongue and/or a full neck. If these
consider obstructive sleep apnea as a possibility.
are present it may be worth ordering a polysomnogram to rule out a sleep disorder. Sleep difficulties may present as a primary cause or as a secondary cause, which may be making a primary headache syndrome worse, particularly in patients that are at high risk for sleep apnea. We know that our chronic headache patients may share some of the same risk factors for sleep apnea, including obesity. Also, untreated sleep apnea or poor sleep may contribute to transformation and progression of migraine disability.
YOU DON’T HAVE TO STOP DICTATING TO USE YOUR EMR.
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So why is it important to identify and treat sleep apnea? For many patients, treatment of obstructive sleep apnea may improve quality of life. We know that untreated sleep apnea can lead to excessive daytime sleepiness that can affect work and family life. It can also be extremely dangerous to have people drive when they are excessively sleepy. New Jersey has even put laws into place to charge sleep-deprived individuals with vehicular manslaughter. Also important are the health risks associated with untreated sleep apnea. These include uncontrolled hypertension, risk of cardiovascular disease, depression, concentration and memory difficulties, nocturia, and erectile dysfunction.
18
The Triad Physician
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Practice Management
Rethinking the
EHR Revolution By Maryan Binkley
For years, experts have pointed to electronic health records as a cure for many of the problems hindering our health care system, including the inability of physicians to quickly access a patient’s history.
Maryan Binkley is the owner and president of WebChart Inc. WebChart specializes in providing webbased, total medical data documentation solutions for physician practices, surgery centers and hospitals. Ms. Binkley graduated from nursing school in 1968 and began her career in a physician practice in the Washington, D.C., area. In 1974 she earned a bachelor’s degree in business administration. Ms. Binkley has worked in health care since 1968 in both clinical and administrative positions, providing her working knowledge of the challenges facing physicians and staff in today’s rapidly changing environment.
In terms of making information more readily
of checkboxes for each patient they see.
available, new federal incentives to subsidize
The required computer interaction limits
the upfront costs of electronic health records
their mobility, and if the computer is in
(EHRs) are a welcome development. A
the exam room, their interaction with the
recent report projects a robust 12 percent
patient, causing dissatisfaction from both
growth rate for such systems over the next
parties. Physicians who use front-end voice
few years. After a notoriously slow start for
recognition fare only marginally better, as
the technology, four of every 10 physicians
they’re required to immediately correct
now utilize EHRs at their hospital or office.
anything the software misinterpreted.
Of course, adopting electronic records is only
The quality of the document can also suffer.
When the transcriptionist types the note
step one. The real key to improving patient
The physician becomes the only set of
into the system, the software automatically
outcomes and gaining efficiencies lies in how
eyes looking at information going into the
parses the document for discrete data,
EHRs are implemented. Clearly, the industry
record, making it harder to detect crucial
which is automatically uploaded to the
is still finding its way in this regard. Last year,
mistakes. When it comes to reviewing patient
appropriate field of the EHR. The provider
a study of more than 2,700 family physicians
information, because the information was
receives all of the structured data needed
found that only 49 percent were satisfied in
entered into a one-size-fits-all template,
to meet Meaningful Use requirements, but
whole with their system.
practitioners no longer have a narrative note
also retains access to the note in narrative
they can look to for a clear understanding of
form. Further enhancing the documentation
what previous medical personnel observed.
process, mobile applications are becoming
While there’s no silver bullet to improving
increasingly robust and look to be a viable
the EHR experience, providers often benefit
means to simplifying a clinician’s workflow.
from taking a clear-eyed look at what these
EHR users do well by playing to the
systems can deliver. Many facilities discover,
technology’s strengths. For a number
only after an expensive rollout, that electron-
of forward-thinking facilities around the
Efforts to improve interoperability within the
ic charts aren’t actually a panacea for their re-
country, this has meant integrating their EHR
industry continue to advance, suggesting
cord-keeping challenges. For instance, while
with other software programs and building
a bright future for such interfacing. What’s
physicians appreciate the ability to call up
synergies between them. One promising
becoming more apparent is that EHRs are not
patient data instantaneously, many are unen-
trend involves hospitals and clinics linking
the solution to inefficiencies in health care,
thused about not only how that information is
transcription management software with their
but rather part of the solution. The sooner
initially captured, but also how it’s presented.
EHR system, creating a “hybrid” solution.
providers realize this, the quicker we’ll see the real information revolution we’ve been waiting for.
Doctors who were previously able to quickly
With the help of a software technology known
dictate their exam notes into a phone system
as “discrete reportable transcription,” doctors
or digital recorder now have to log into a
can realize the benefits of EHRs without
For more information call 866-953-2828 or
computer and scroll through extensive lists
giving up their ability to dictate patient notes.
visit online at webchart.biz.
June 2012
19
Caregiving
Unexpected Life Changes
What It Is Like to Raise a Child with Juvenile Diabetes By June DeLugas
It all began in November 1993 when I
endocrinologist. We spent four days at
noticed my daughter exhibiting strange
Brenner Children’s Hospital where we
behaviors. The normally happy child
were educated on how to take care of our
had become agitated and was crying and
baby. They also educated us on nutrition
not sleeping. Other signs that something
and the importance of avoiding low blood
was wrong were losing weight, profuse
sugars.
bedwetting, and low energy. We had just relocated to Winston-Salem a few months
My husband and I checked our daughter’s
earlier. I took her to the doctor but
blood sugar interchangeably at night. He
because we had just moved here, they did
would check her at 2 a.m. and I would
not have a record to compare her weight,
check her blood sugar at 4 a.m.. She was
etc. Another week passed and things got
on NPH and regular insulin. The main
worse, and I knew there was something
issue with this combination of insulin was
going on really bad as she was very
the low blood sugars.
June DeLugas is a well-known designer who owns a firm located in Clemmons, N.C. She is known for creating awardwinning homes that reflect the special relationship she develops with each client. Her retail showroom and design firm is open Monday through Friday between 10 a.m. and 5:30 p.m. or on Saturdays by appointment. You also can visit her website or blog online at junedelugasinteriors.com.
sick now and throwing up. My daughter began drinking more fluids than me, and
Just like any child, my daughter would
thankful for our wonderful daughter as
at a fast pace. I looked at her and I just
often get sick. Whether it was the flu
some struggles continue. She aced high
knew what was wrong with her. You know
or a cold, we had to find a way to keep
school, even playing varsity basketball and
what they say about a mother’s intuition.
her diabetes in control. One night in
volleyball. She is in college now at UNC
I remembered my great aunt as a child
particular, she woke up vomiting. With
Chapel Hill and wants to go to medical
drinking orange juice and giving herself
the combination of vomiting and NPH
school. This has been her dream since
shots. My grandmother would say “her
insulin, her blood sugar dropped to a low
she was young and she owes this dream
sugar is off.” That was my only exposure
reading on the glucometer. I squeezed
to her diabetes. However, she refuses to
to diabetes and I kept thinking, “I have
glucose gel in the sides of her mouth and
let her school know that having diabetes
never heard of a baby with diabetes.”
checked her blood sugar every few hours.
falls under the Americans with Disabilities
Her blood sugar would easily drop to 20
Act. She doesn’t want special treatment
Once we arrived at the doctor, he sent
with a stomach virus. There were several
(even though she is very special to us).
us directly to Forsyth Hospital where
instances where she ended up in the
they drew blood. My daughter’s blood
hospital due to viruses.
Working outside the home did not seem like an option to me, so I started June
sugar was 700, which is considered extremely high. They told us that when
When our daughter turned 9, the insulin
DeLugas Interiors and the rest is history.
most undiagnosed diabetic children are
pump became available and we started
I was able to help folks with their homes
brought to the hospital, they are almost
the journey to convert to a pump to
as well as take care of my daughter. I
comatose because the parents think they
disperse insulin. She is now 21 years old
would work my schedule around her
have the flu. However, it is the direct result
and has been wearing the insulin pump
needs. My design business is successful
of prolonged high blood sugars. Forsyth
for 12 years. The pump changed all of
and after l0 years of working from home, I
Hospital sent her directly to NC Baptist
our lives. She is able to sleep late and eat
opened a retail store and design center in
Hospital where they had a pediatric
foods her friends are eating. We are very
Clemmons, N.C..
20
The Triad Physician
News
Forsyth Cancer Center Awarded for Improving Access to Clinical Trials The Derrick L. Davis Forsyth Regional
represented populations enrolled and inno-
cal piece of the cancer care delivery system
Cancer Center is one of six cancer centers
vative techniques used to overcome barriers
and ultimately lead to improved patient out-
nationwide, and the only center in North
to participation in clinical trials.
comes and progress in cancer treatments.”
The research staff at Forsyth Regional Can-
According to Novant Health, the Derrick L.
Carolina, to earn an award for its work in improving access to clinical trials.
cer Center takes a collaborative approach
Davis Forsyth Regional Cancer Center partic-
Given by the Conquer Cancer Foundation of
to identifying potential patients for trials, ac-
ipates in nearly 100 research trials of preven-
the American Society of Clinical Oncology
cording to a Novant Health press advisory.
tive and clinical medications and methods,
(ASCO), the award recognizes practices that
Also, an emphasis is placed on educating
as well as National Cancer Institute-spon-
have established high quality clinical cancer
physicians about new clinical trials and pro-
sored cancer prevention studies.
research programs.
tocols, and a team of oncology nurse navigators actively works with research coordina-
“Throughout 2011, we enrolled about 10 per-
tors to identify patients for trials.
cent of new cancer diagnoses, or about 300 patients, in clinical trials. That number far
“We also recognize the importance of edu-
exceeds the national average of two to three
cating patients and their families about clini-
percent,” said Tom Grote, M.D., an oncolo-
cal trials and establishing a certain level of
gist with Forsyth Regional Cancer Center.
trust. Without that trust, research consent simply does not happen,” said Dr. Grote.
The Conquer Cancer Foundation selects centers based on several factors, including
According to Martin J. Murphy, Ph.D., D.Med.
the total number of patients enrolled in clini-
Sc., chair of the Conquer Cancer Foundation
cal trials, the number of minority and under-
Board of Directors, “Clinical trials are a criti-
Members of the research team accepted the Clinical Trials Participation Award June 3 at the American Society of Clinical Oncology’s annual meeting in Chicago. They are (left to right) Dr. Eugene Paschold, oncologist; Dr. Judy Hopkins, oncologist; and Elizabeth White, research supervisor,
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June 2012
21
CLEVELAND CLINIC
FORSYTH MEDICAL CENTER
Forsyth Medical Center is now affiliated with #1 ranked Cleveland Clinic. Forsyth Medical Center has been selected as the Triad region’s only affiliate heart hospital for the Cleveland Clinic — ranked #1 in the nation by U.S. News & World Report, 17 years in a row. This transforms our healthcare landscape forever. With Forsyth Medical Center and Cleveland Clinic working together, you have the best of the best on your side, with access to the most advanced research, programs, technologies and techniques in the world of cardiovascular medicine and surgery. Now there’s no need for you or your loved ones to travel for most cardiac care. Or to compromise. The #1 choice in cardiovascular care is right here for you.
www.forsythmedicalcenter.org/heart www.clevelandclinic.org/heart