FOCUS TOPICS CARDIOLOGY • LEGISLATIVE AGENDAS
Your Middle TN Source for Professional Healthcare News
PHYSICIAN SPOTLIGHT PAGE 4
Ashish S. Shah, MD ON ROUNDS
New Rules in Heart Disease Area cardiologists discuss recent changes to treat America’s #1 killer ... 3
A Conversation with LHC Director Molly Vice Leadership Health Care plays a key role in preparing the next generation of healthcare leaders ... 10
February 2019 >> $5
The 2019 Legislative Agenda THA, TMA, TNA Outline Priorities for the Year By CINDY SANDERS
It’s that time of year when Tennessee lawmakers have returned to the Capitol, elected new leadership and gotten down to the business of governing. The first session of the 111th Tennessee General Assembly convened at noon on Jan. 8, 2019, and the state’s largest healthcare associations have greeted that return with priority agendas to address practice and patient safety issues. The Tennessee Hospital Association (THA), Tennessee Medical Association (TMA), and Tennessee Nurses Association (TNA) all shared key legislative agenda items for this year. While many of those priorities align across hospitals, physi-
cians and nurses, some issues continue to be areas of contention among the otherwise collegial groups. No matter what the points of difference, however, the state’s three large provider organizations are all working to improve high quality access to effective, efficient care for Tennesseans from Mountain City to Memphis. The Tennessee Hospital Association looks to address several key priorities during the current session. The organization will bring legislation to continue to fund the shortfall in the TennCare budget through the voluntary hospital assessment as has happened for the last several years. The
As 2018 drew to a close, area nurses gathered to celebrate the ninth annual March of Dimes Nurse of the Year Awards ... 13
ONLINE: NASHVILLE MEDICAL NEWS.COM
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Updated Cholesterol Guidelines Take a Personalized Approach By CINDY SANDERS
MOD Honors Area Nurses
The American Heart Association (AHA) and American College of Cardiology (ACC) recently released an update to the 2013 cholesterol guidelines, calling for more personalized risk assessments to guide primary and secondary cardiovascular disease prevention throughout a patient’s lifetime. “Both guidelines were very much based on the evidence that has developed in terms of what can benefit patients,” said Neil Stone, MD, MACP, FAHA, FACC, who worked on the 2018 guideline update and served as vice chair of the writing committee. Stone, a Chicago-based cardiologist and AHA national spokesperson added, “Both begin with emphasizing that lifestyle change is most important.”
Women 20 19 TO WATC H
Dr. Neil Stone
In fact, he continued, the new guidelines focus on adopting a heart-healthy lifestyle from a young age and build upon the 2013 emphasis on identifying and addressing lifetime risks to prevent cardiovascular disease (CVD). The update also provides additional guidance for physicians to help them drill down for a more robust and personalized risk assessment that considers multiple factors and treatment paths. The need for personalized risk stratification and intervention is great in the United States. Stone pointed out we live in a country where one of every three people dies of heart disease or stroke annually and nearly six in 10 people develop heart disease during their lifetime. Additionally, he said, one-third of American adults have high levels of low-density lipo(CONTINUED ON PAGE 8)
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TriStar Centennial Heart and Vascular Center Adopts Cerebral Protection During TAVR as Emerging Standard of Care. More than a million people in the United States have aortic stenosis, a condition in which the aortic valve does not open fully because of a thickening of the valve leaflets. Degenerative aortic stenosis is the most frequently encountered valvular heart disorder, as its incidence approaches 2.5â€“7 percent in elderly patients. Approximately 300,000 people in the U.S. each year are diagnosed with severe aortic stenosis. Aortic stenosis carries a poor prognosis if left untreated. For those by Samuel patients, treatment options may include surgical aortic valve replacement (SAVR) Horr, MD or transcatheter aortic valve replacement Interventional (TAVR). Cardiology Surgical aortic valve replacement (SAVR) has been the standard treatment Structural Heart for symptomatic aortic Specialist stenosis; however, many Centennial Heart patients were considered too high risk for SAVR and TriStar Centennial were left untreated. Over the Medical Center last few years, transcatheter aortic valve replacement (TAVR) emerged as an alternative to SAVR and the procedure of choice for patients who have a prohibitive surgical risk and more recently found to be equivalent to SAVR for intermediate risk patients. TAVR, a minimally invasive, catheter-based procedure, has now become the first-line therapy for severe aortic stenosis in this patient population. Several clinical trials are soon to be reported comparing TAVR to SAVR in even the lowest risk patients. More than 200,000 TAVR procedures have been performed worldwide since 2002. For the first time, from 2015-2016, the number (35,000) of TAVR procedures performed surpassed the number of SAVR procedures. The advantages of minimally invasive TAVR are significant; however, no procedure is without risk. Periprocedural stroke is one of the most devastating and feared complications because of its associated severe disability and higher mortality. The risk of stroke is confined mainly in the periprocedural and 30-day period following TAVR. Early stroke is mainly due to debris embolization during the procedure, whereas later events are associated with patient specific factors. While newer generation TAVR devices and improved implant techniques are associated with a lower risk of stroke after TAVR, the incidence is estimated to be between 2-4 percent. The risk for postprocedure stroke underscores the need for patients to be treated at an experienced TAVR center, where studies show stroke rates are lower. TriStar Centennial Heart & Vascular is a large structural heart referral center led by a team of specialists who have significant experience in treating even the most complex heart disorders. Despite the fact that the rate of clinical stroke has been constantly decreasing compared to initial TAVR experience, recent post-TAVR MRI studies suggest that new ischemic lesions may occur in as many as 80
percent of patients. These lesions are associated with a reduction in neurocognitive function. Stroke prevention strategies during and after TAVR becomes all the more important as TAVR expands its indication to lower surgicalrisk patients. One such strategy was the development of innovative embolic protection devices designed to block the debris from migrating to brain during the procedure. The US Food and Drug Administration (FDA) recently approved the Sentinel Cerebral Embolic Protection System, which is the first FDA approved device specifically designed to address the concern of stroke during TAVR. TriStar Centennial Heart and Vascular Center is the first TAVR center in Nashville to adopt the new device commercially as an emerging standard of care in the U.S. to protect patients from the risk of stroke during and immediately after a TAVR procedure. The Sentinel system consists of two filters that are positioned in the innominate and left carotid arteries through a catheter inserted in the right wrist. The filters are deployed prior to the TAVR procedure to capture any debris, calcium or thrombus before they can go to the brain and cause a stroke, and then removed after the procedure. In the over 2,900 patients randomized in clinical trials, the Sentinel Cerebral Protection System has been shown to reduce the risk of stroke in the first three days after TAVR by more than 60 percent. Overall, the device was associated with a 70 percent relative risk reduction in stroke and death. Analysis of the filters demonstrated that debris, including â€˜tissue elements, artery wall calcification, valve tissue and other foreign materialsâ€™ was found in filters in 99 percent of patients. MRI studies found a 44 percent decrease in new, post-TAVR ischemic lesions. TriStar Centennial Heart and Vascular Center has adopted the use of the Sentinel Cerebral Embolic Protection device as a standard of care in those deemed high risk for stroke during TAVR. The risk of stroke is a reality of the TAVR procedure and the SENTINEL System has been shown to help reduce that risk. We are proud to be the first program in the region offering this therapy to our patients, which advances our mission of offering patients the latest medical technologies and the highest quality care. We will continue to participate in the development of this and other like technology by sharing our data and outcomes with a national registry, and expect it to result in further improvements to our neurological outcomes for TAVR. For more information and to refer a patient for an appointment, please call 615-342-7310.
New Rules in Heart Disease Recent Guideline Changes Warrant More Education By MELANIE KILGORE-HILL
Heart disease is the number one killer of both men and women in the United States. Nashville Medical News reached out to several area cardiologists and asked them to weigh in on recent guidelines revisions for cholesterol (see page 1) and blood pressure.
A Better Understanding
Walter Clair, MD, MPH, executive medical director of the Vanderbilt Heart and Vascular Institute and president of the Greater Nashville American Heart Association, said guidelines changes reflect a deeper clinical understanding. â€œThere are philosophical overlays to both issues,â€? Clair said. â€œIn cardiology, we try to offer our best Dr. Walter Clair understanding of the evidence, but providers get frustrated about guidelines because in the process of developing them, we identify areas for which we donâ€™t have recommendations. Weâ€™re also identifying avenues for future areas of research.â€? In rolling out new guidelines, Clair said organizations like the American Heart Association and American College of Cardiology attempt to simplify presentation of clinical findings for the public in order to create awareness of guidelines prior to seeing the doctor. â€œWe were happy to have guideline updates over two consecutive years on both hypertension and cholesterol, because itâ€™s notable in both cases that we recognize the foundation of lifestyle changes is necessary along with medication,â€? Clair said. â€œAll of these lifestyle factors cross over and are risk factors for stroke and heart disease, and both guidelines emphasized we need to think about lifestyle issues from a preventative point of view and as our first line of treatment.â€?
New BP Guidelines
Stricter blood pressure guidelines issued at the end of 2017 mean half of Americans are now classified as hypertensive. Blood pressure categories in the new guideline are: â€˘ Normal: Less than 120/80 mm Hg; â€˘ Elevated: Systolic between 120-129 and diastolic less than 80; â€˘ Stage 1: Systolic between 130-139 or diastolic between 80-89; â€˘ Stage 2: Systolic at least 140 or diastolic at least 90 mm Hg; â€˘ Hypertensive crisis: Systolic over 180 and/or diastolic over 120, with patients needing prompt changes in medication if there are no other indications of problems, or immediate hospitalization if there are signs of organ damage. However, guidelines emphasize the large percentage of Americans now classified as â€œelevatedâ€? donâ€™t necessarily need medication â€“ and those who do start may not need them for life. The goal, Clair said, nashvillemedicalnews
should be to get blood pressure in a healthy range through lifestyle changes and, if necessary, medication. New guidelines emphasize the importance of regular monitoring, and Clair urges providers to refuse to accept excuses. â€œWe canâ€™t give patients a pass on white coat hypertension,â€? he said. â€œWe have to document that itâ€™s low in other settings, because patients arenâ€™t being clear about the fact that theyâ€™re not actually checking it at other times, so they donâ€™t really know if itâ€™s white coat hypertension or not.â€?
Thomas Johnston, MD, cardiologist at Centennial Heart - Nashville, said the most important thing the new guidelines brought to the forefront was the importance of monitoring blood pressure at home, in addition to the office. â€œThey really emphasized the importance of accurate blood pressure measurements â€“ and went through the proDr. Thomas Johnston cess of how to get an accurate reading in the office and how to teach patients to do it at home,â€? Johnston said. Prior to pharmacological treatment, providers should be certain that pressures are consistently high across multiple readings at home and in the office. â€œThis emphasized how important non-pharmacologic interventions are, not just low salt diets but those rich in potassium. Weâ€™re learning that small changes can lower pressure 10 to 12 mm of mercury, which is more than what a lot of medications can do. No other disease is as greatly impacted by lifestyle changes and exercise as heart disease.â€? For otherwise healthy patients with borderline blood pressure, Johnston urges providers to double check cuff size and to schedule a follow-up in one month. Ask patients to purchase a quality home cuff and make sure they know how to use it. He also encourages providers to educate staff about the American Heart Associationâ€™s Target: BP initiative, which encourages a team approach to blood pressure management. â€œThe most important thing is not making light of elevated blood pressure in the office, because the worst thing to happen is that it isnâ€™t acted on,â€? he said. â€œThe new guidelines do make it more difficult to get patients where they need to be, but we do need to be more aggressive in keeping numbers in the normal range while minimizing side effects to reduce the number of strokes and heart attacks.â€?
Revised Cholesterol Guidelines
Cholesterol guidelines also call for more stringent monitoring, and new statin studies are calling for increased usage of the drug, which has been shown to improve outcomes in a broader spectrum of patients. â€œThe benefits of statins far outweigh the risk, but patients hear conflicting information on TV and become fearful,â€? said
cardiologist Stacy Davis, MD, of Saint Thomas Heart. â€œIn reality, statins have had more impact on reducing cardiac mortality than most medications we use.â€? The problem, she Dr. Stacy Davis said, is that patients often stop medication after experiencing side effects like muscle aches, when they simply needed a lower dose or a different statin. â€œNot all statins are the same, and if youâ€™re intolerant of one, you may well tolerate another,â€? she noted. She added she also urges patients to adopt aggressive dietary and exercise changes. The updated guidelines specify physicians should run labs on patients four to 12 weeks after starting statin therapy.Â Davis said she checks labs six weeksÂ after initiating statin therapy,Â after changes in statin dosing, and then annually. New guidelines also stress the danger of drug interactions since certain medications, including antibiotics, can boost the side effects of statins, leading patients to ditch their prescription altogether. Davis said she urges providers to have a discussion with patients explaining potential side effects but keeping it in context of lowered cardiac risk. â€œThe new guidelines do a really impor-
tant job of specifying documented coronary artery disease risk factors, and theyâ€™re broadening statin use to include those with risk enhancing factors for coronary artery disease,â€? she said. Those enhancing risk factors for patients range from chronic kidney disease and inflammatory disorders to premature menopause or a history of preeclampsia. The South Asian population also has been classified as a high-risk ethnic group. â€œPrimary care providers, OBs, cardiologists and nephrologists all need to realize that if we can prevent coronary artery disease, weâ€™ll be doing a good job of preventing mortality as well as morbidity,â€? Davis stated.
Clair said todayâ€™s patients are more educated about heart disease and increasingly aware of risk factors, which helps providers take a more preventative stance in addressing cardiovascular disease. â€œTheyâ€™re now coming to us saying, â€˜What about this?â€™â€? he said. Clair continued, â€œI also believe providers are becoming less complacent about borderline numbers and realizing theyâ€™ve got to push those lower. So many of our providers are becoming part of larger systems of care, which are pushing for improved population statistics, as well. As physicians, weâ€™re getting appropriate pressure externally to help us do these things.â€?
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Dr. Ashish Shah: A Heart for Transplant Patients Shah the Driving Force Behind Growth, Innovation at VUMC By MELANIE KILGORE-HILL
planting 100 hearts in 2017 alone. Their success has opened doors for the team, allowing them to participate in even more cutting-edge research.
“The first time I watched a heart transplant, I said, ‘This is it.’” More than 200 hearts transplants later, Ashish S. Shah, MD, chair of the Department of Cardiac Surgery and director of Heart Transplant and Mechanical Circulatory Support at Vanderbilt, is the driving force behind one of the nation’s busiest heart transplant programs.
Thinking Outside the Box
Finding his Place
Raised in Connecticut, Shah received his bachelor of science in biomedical engineering from Duke University before earning his medical degree from the University of Pittsburg School of Medicine. Following an internship at Duke University Medical Center, Shah remained onsite for residencies in general and thoracic surgery. “I had committed to being a heart surgeon … and at the time, there were just a few credible places to go if you wanted to be a leader in the field,” Shah said of his time in North Carolina. “Duke was a
Hep C Hearts VUMC also is revolutionizing transplantation through “Hep C Hearts” – those harvested from patients with Hepatitis C. “We were approached by liver experts at Vanderbilt who said, ‘We have these drugs that now cure people of Hepatitis C, and our liver surgeons are using organs from people with the disease. A lot of these donors have really strong hearts that aren’t being used,’” Shah said. VUMC initially offered the Hep C hearts to patients at imminent risk of dying. Those who tested positive for Hep C following transplantation received the FDA-approved 12-week drug therapy to eliminate the disease. Three years later, VUMC has performed more than 70 Hep C heart transplants – more than anyone else in the nation. “We’ve learned a lot about the biology of Hep C in these organs, and other teams are looking to us to understand the long-term consequences,” Shah said. While most recipients test positive for the virus within one week, Shah is especially interested to study the biology behind those who never become infected. “It’s remarkable to see the quality of organs available, and we’re able to get them quickly because no one else is using them,” he added.
Dr. Ashish Shah (right) leads VUMC’s growing heart transplantation program.
mecca for the training of heart surgeons, and it was demanding; but it helped me understand how to be the best physician and academic surgeon I could be. They taught work, endurance and excellence that I’ve carried with me.” Shah also was exposed to the school’s heart and lung transplant programs, which led to his first job performing aortic surgery, heart and lung transplants at Johns Hopkins University in Baltimore. It was trial by fire for the young surgeon, who diversified his skill set while working with medically complex patients from across the world. He also established a successful academic career focused on end stage heart and lungs and investigated ways to improve organ function. “Being surrounded by great scientists pushed me to perform better and ask the big questions,” Shah noted of his 10 years at Johns Hopkins.
Coming to Nashville
In 2015, Shah relocated to Nashville to serve as medical director of the heart transplant program at Vanderbilt University Medical Center. “My family and I were looking for a change, but I didn’t want to give up an academic environment,” said Shah, who continues to perform transplants and teach. “That academic enterprise helps you figure out how to do things better, and Vanderbilt had a long history of excellence with a credible and aggressive transplant program. Their work in mechanical support devices and left ventricular assist devices also was a sign that the organization and people were ambitious and hungry to do bold things.” Since his arrival, Shah has been focused on establishing VUMC’s heart
transplant program as an international destination for patients with complicated diagnoses. And it’s working. By increasing the complexity of surgeries, the program has tripled in size since Shah’s arrival, trans-
Recent accomplishments for Shah’s team include VUMC’s trial involvement with novel “heart in a box” technology (see sidebar), which allows organ profusion during transport. Shah is already working to establish a program for the promising technology, currently undergoing FDA approval. He’s also growing VUMC’s aortic surgery program, building partnerships and broadening capabilities for patients with rare vascular and aortic conditions. It’s a passion that stems from his work with at Johns Hopkins, where he cared for patients that other programs weren’t comfortable treating. Shah also has been instrumental in reestablishing the CORE Research Laboratory for cardiac surgery, which has helped attract those pursuing careers in academic medicine. “We’ve established some pretty fertile areas of research, and we’re bringing ideas and post-doctoral fellows together to (CONTINUED ON PAGE 8)
VUMC Raises the Bar for Heart Transplantation Vanderbilt University Medical Center set a new record for total transplants among its five organ specialties in 2018 with more than 500 transplants – of which, more than 20 percent were hearts. The program saw a record 109 adult and pediatric transplants, making VUMC the second largest heart transplant program in the nation by volume for three consecutive years. So what’s next for the thriving program?
Heart-in-a-Box VUMC recently participated in a clinical trial for technology expected to redefine organ transplantation. The TransMedics Organ Care System’s living organ transplant technology allows warm blood perfusion of harvested organs for days or even weeks, giving physicians more time to ensure a perfect match. The “heart-in-a-box” also relieves the time sensitive component to organ transplant – a particular challenge in rural areas worldwide. “The way we traditionally preserve organs is to pack them in an iced cooler for transport, but that six-hour period without blood supply is a time of vulnerability and a lot of metabolic things can happen,” said Ashish Shah, MD, medical director of VUMC’s heart transplant program. “Why not pump blood into the organ to maintain blood supply?” While the idea isn’t new, the technology is: Hearts beat, lungs breathe, kidneys produce urine and livers produce bile. In anticipation of the system’s pending FDA approval, Shah is assembling a team of advanced heart failure cardiologists in hopes of using the technology as a gateway for repairing damaged organs. “We’re working in partnership to produce a collaborative model involving multiple disciples and perspectives,” Shah said. “When you remove the time and distance constraints from transplantation, you can clean it, give it antibiotics, or deliver genes. It becomes a platform to manipulate or repair and prepare it. Vanderbilt has an opportunity because we can ask the big questions and make an impact on the ability to recondition a patient’s own organs.”
I N T R O D U CI N G
Lisa Morgan, MD Rhonda Halcomb, MD Kimberly Hunt, MD Carol McCullough, MD Jennifer Bell, MD Hannah M. Dudney, MD Stephen M. Staggs, MD Nicole Heidemann, MD Sa Cara Shaw, MD Katherine Haney, MD Jeﬀrey Draughn, MD
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Heart Monitor Cardiovascular News of Note Mark Your Calendars
AHA Women of Color Breakfast Feb. 23 • 9 am; Cal Turner Family Center, Meharry Meharry Medical College is hosting the American Heart Association and American Stroke Association Women of Color Breakfast on Feb. 23 at the Cal Turner Family Center at 1011 21st Ave. N. The annual event features medical experts sharing information on how to prevent heart disease and stroke. In addition to a heart healthy breakfast, there will be door prizes and activities. Admission is free (donations are encouraged), however registration is required. To register, go online to bit.ly/wocbreakfast.
Harrison Nationally Recognized for Research
As last year wound down, the American Heart Association recognized 13 distinguished colleagues from across the country for their contributions to the field during the AHA’s Scientific Sessions 2018 in Chicago. David G. Harrison, MD, FACC, FAHA, of Vanderbilt University School of Medicine, was awarded the 2018 Basic Research Prize for “lasting contributions that changed the direction of research in hypertension and its complications.” Dr. David Harrison AHA President Ivor Benjamin, MD, of the Medical College of Wisconsin in Milwaukee, said Harrison “has made two enduring contributions that profoundly changed research in the fields of hypertension and related cardiovascular diseases.” He added Harrison and his colleagues have shown specialized molecules known as reactive oxygen species contribute to elevated blood pressure and its complications. “This led to an entirely new understanding of hypertension – that is, that oxidative signaling in the blood vessel, the kidney and the brain contribute to blood pressure elevation and the organ damage associated with it,” Benjamin continued. Harrison’s team reported seminal findings that T cells play a key role in the development of hypertension. Benjamin noted, “These original discoveries led to an explosion of investigations around the world into oxidative signaling and innate and adaptive immunity in hypertension.” The AHA president added Harrison and his team continue to lead this field of study and seek ways to avoid vessel damage and normalize blood pressure. Harrison joined Vanderbilt’s medical faculty in 2011. He is the Betty and Jack Bailey Chair in Cardiology and serves as director of both the Division of Clinical Pharmacology and of the Center for Vascular Biology. Before relocating to Nashville, Harrison served as director of 6
Cardiology for Emory University. He earned his medical degree from Oklahoma University School of Medicine.
Saint Thomas Heart Celebrates Milestones
Last spring, Saint Thomas Heart launched the state’s first Total Artificial Heart (TAH) program. In January, the hospital announced completion of their first TAH surgery. The procedure was performed on a 28-year-old male patient who arrived at Saint Thomas with severe heart failure in late December 2018. Due to the severity of the patient’s condition, the Saint Thomas Heart team determined the only chance of survival was to receive a total artificial heart transplant. The TAH device was implanted Jan. 10, and the patient continues to recover steadily and become increasingly active. “The Total Artificial Heart technology gives individuals who are too ill to wait for a heart transplant a second chance at life. As the first heart transplant program in Tennessee, we are proud to provide this valuable technology to patients,” said transDr. Ashok Babu plant surgeon Ashok N. Babu, MD, who serves as medical director for the program. “This device allows our patients improved mobility and a more active, higher quality of life.” SynCardia TAH is a life-saving treatment option provided to individuals eligible for heart transplant surgery who have end-stage, biventricular heart failure. It is provided to patients for which a heart transplant is not immediately available. The artificial heart replaces both lower chambers of the heart and the four heart valves and occupies the space of the removed heart. It is connected to an external driver, which pumps and monitors the TAH. The TAH increases chances of survival, allows an enhanced quality of life, including discharge home, and prepares those eligible for transplant by restoring blood flow and optimizing organ function. In other milestone celebrated, the Saint Thomas Heart Team recently completed the 1,000th TAVR procedure since the program’s launch in 2012. According to Ascension Saint Thomas officials, less than 20 heart programs in the country have achieved this level of success with TAVR, which is a minimally invasive heart procedure that replaces the aortic valve through catheters and wires. Because the procedure is minimally invasive, patients experience rapid healing and are often able to return home the day following their procedure. As one of the top TAVR sites in the country, Saint Thomas Heart is currently
the only health system in the state to offer continued access to the Partner 3 Trial evaluating the use of TAVR for low-risk patients with aortic stenosis as a less invasive therapeutic option.
A Record-Breaking Heart Gala
The Greater Nashville American Heart Association held the 45th Annual Middle Tennessee Heart Gala on Jan. 26 at Nashville’s Schermerhorn Symphony Center and raised a record-breaking $1.3 million to fight heart disease and stroke. Chaired by physician leader Herman Williams, MD, and his wife, Jeannie, more than 800 supporters and volunteers attended the 2019 event. The mission of the organization is highly personal to the Williams family. Dr. Williams suffered cardiac arrest at age 31 during his orthopedic surgery residency while playing in a basketball game with his co-residents. He was resuscitated by his colleague using bystander CPR and ultimately had an internal defibrillator implanted. Some years later in 2013, he also suffered a stroke and fully recovered. In 2017, he had a second cardiac arrest at the Nashville International Airport and was saved, once again, by bystander CPR. “Because of our personal connection as a family to heart disease and stroke, we know how important it is to bring more attention to this worthy cause. My husband is alive today because of what the American Heart and American Stroke Association has done in our community,” stated Jeannie Williams. During the event, Becky and Dick Cowart were presented the Martin E. Simmons Award to honor their impact on the mission of the AHA through tireless giving. Additionally, pediatric heart survivor Caleb Aslinger and his family were honored during the evening’s Open Your Heart moment as the crowd happily celebrated Caleb’s one-year “heart-iversary,” marking one year since he received a new heart via transplant.
Expanded Cardiovascular Services at TriStar
TriStar Horizon Medical Center recently began offering coronary CTA, a non-invasive imaging test using advanced CT technology to obtain a high-resolution picture of the heart and vessels. In the past year, the hospital has significantly invested in new technology, including installing a new imaging suite specifically for interventional radiology. In addition to coronary CTA, the hospital has also recently begun offering CT perfusion for stroke patients. Also, as part of an initiative around the management of Congestive Heart Failure patients, TriStar Horizon now offers the CardioMEMS. The small, pressure-sensing device is implanted directly into the pulmonary artery and sends information wirelessly to a patient’s physician to inform
decisions about medication or treatment plan adjustments as needed. Additionally, the hospital also recently introduced the Impella Ventricular Support System, partially or fully bypassing the left ventricle to pump blood into the aorta. At TriStar Hendersonville Medical Center, the hospital and community are celebrating the new Heart & Vascular Center with an open house on Feb. 21. With robust technology, the hospital has made screening and treatment for heart and vascular disease more accessible to residents of Sumner County. TriStar Hendersonville is also adding cardiac MRI to its screening capabilities. Rick Koch, MD, a new cardiologist who joined the team on Feb. 1, has deep expertise in reviewing imaging studies related to heart and vascular care. The hospital has also recently added cardiac rehab to its offerings to expand programming for patients recovering from heart attacks. Last summer, TriStar Centennial Heart and Vascular Center implanted the first MEMO 4D semi-rigid mitral annuloplasty ring in the world. The implant now comes in larger ring sizes, allowing surgeons to treat a broader range of patients who suffer from mitral valve regurgitation.
Vanderbilt Transplant Center Debuts New Mobile App
Patients and providers now have instant access to the Vanderbilt Transplant Center on their smartphones and mobile devices with the debut of a new, free app available for iOS and Android devices. Simply search for “VUMC transplant” in the respective app store. Designed to be a resource for transplant information at Vanderbilt University Medical Center for both patients and providers, the app helps patients find information about transplant programs, as well as educational links about transplantation. Patients can customize what organ they are interested in learning more about, meet the transplant team and find provider locations. Living donor information is also available as well as a living donor referral form. For providers, the app offers improved access in the referring process for both adult and pediatric referrals through mobilefriendly REDcap referral forms. The app gives referring physicians a secure and vetted process to contact the on-call VUMC transplant physicians to enable better communication. The app also has a direct link to call the VUMC Transfer Center for urgent transfers of patients to VUMC facilities. Providers also have access to outcome data. “The Vanderbilt Transplant app is a significant addition for our referring providers to access the transplant center,” said Transplant Center Administrator Edward Zavala. “Additionally, the patient education component of the app provides patients ready access to transplant-specific education.” nashvillemedicalnews
ECMO Program Thriving at TriStar Centennial
Innovation Brings More Chances for Critically Ill Patients By MELANIE KILGORE-HILL
Caring for the sickest patients is a balancing act requiring the sharpest minds and latest technology. At TriStar Centennial Medical Center, a multidisciplinary team is working to give patients on extracorporeal membrane oxygenation (ECMO) a second chance. ECMO provides prolonged cardiac and respiratory support to patients whose hearts and lungs are unable to sustain life. Once considered an attempt to prolong life by a few hours, ECMO is now being used to help critically ill patients reach full recovery.
Bridge to Recovery
“ECMO can be used for any type of acute pulmonary failure, isolated cardiac failure, isolated respiratory failure or combination of the three,” explained Elliott Cohen, MD, who serves as ECMO medical director for TriStar Centennial. “That can stem from respiratory failure from the inability to exchange oxygen Dr. Elliott Cohen in the lungs, as with pneumonia, or the inability to get rid of carbon dioxide, as with severe asthma patients.” ECMO has proven a welcome alternative to the ventilator, which can be especially problematic for patients with pneumonia. “While the ventilator can keep patients alive, it’s also likely contributing to their lung injury,” Cohen said. “We see patients with severe enough injury that may get enough oxygen from the vent, but the vent itself is too injurious, so we add ECMO.” By using ECMO for cardiac failure, doctors are able to restore perfusion and keep blood flowing to organs until the heart heals. “ECMO offers a bridge to recovery to more definitive treatment,” Cohen noted. While 14 days is the average time for a respiratory patient on ECMO, some have utilized the technology for up to a year while lungs recover. Cardiac patients rarely exceed seven days on ECMO, since patients have typically suffered damage or decreased blood flow to multiple organs.
While ECMO technology has been around for nearly 40 years, its use was nashvillemedicalnews
typically limited to neonatal care. It wasn’t until 2008’s H1N1 outbreak that ECMO’s potential was fully realized in adult care. “We saw then how well viral pneumonia patients did with ECMO, thanks to significant technology improvement,” said Cohen. Despite ECMO’s proven track record, Cohen said misconceptions still abound in the medical community. “There’s still this idea around a lot of physicians that ECMO is a last ditch effort for dying people,” he said. “In order for this to really work, we have to get patients on it very early, before cardiac failure leads to a lack of perfusion and keeps patients from recovering. We have a window where organs start to fail, but we can still re-establish blood flow to get them back.”
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Duc Nguyen, MD, a cardiothoracic surgeon with deep experience in LVAD, heart transplantation and ECMO, joined TriStar Cardiovascular Surgery last year. He credits TriStar’s unique, multidisciplinary team approach for the program’s success. Dr. Duc Nguyen Their formal ECMO program celebrated its one-year anniversary in January and continues to thrive thanks to a team of cardiologists, cardiac surgeons, critical care specialists, pulmonologists, cardiac nurses and ECMO coordinators working together for best outcomes. “Our team effort involves a lot of providers with a plan, and we have the infrastructure to be able to treat the sickest patients,” Nguyen said. “We do a lot of heart surgeries, and ECMO allows us to take care of the sickest patients up to the point of heart transplantation instead of having to send them elsewhere while they’re already critically ill.” The team also has established a 24/7 call line (1-833-TN-SHOCK) to allow any community providers to speak to an ECMO physician for consultation or referral. As TriStar’s ECMO program grows, Nguyen said plans are also underway to build infrastructure and invest in capital equipment to support a mobile ECMO team. “Some patients can’t be transferred and a lot of hospitals can’t provide ECMO, so this will allow us to reach out to the community,” he said.
Tiffany Feltman Meals, DO
Matthew L. Sarb, DO
Christopher M. Jones, MD
Hughston Clinic Orthopaedics at TriStar Skyline Medical Center 3443 Dickerson Pike, Suite 190 Nashville, TN 37207 | 615-860-1580 www.hughston.com/tn Other locations: Nashville at TriStar Centennial and at Harding Place, Dickson at TriStar Horizon, Hendersonville, Hermitage at TriStar Summit, Smyrna at TriStar Stonecrest, Lebanon FEBRUARY 2019
Updated Cholesterol Guidelines, continued from page 1 protein cholesterol (LDL-C), known as the ‘bad’ cholesterol that contributes to plaque buildup and narrowed arteries. Key highlights from the updated cholesterol clinical practice guidelines statement, which was released this past November during the AHA’s 2018 Scientific Sessions conference in Chicago, include: High cholesterol, at any age, can increase a person’s lifetime risk for heart disease and stroke. A healthy lifestyle is the first step in prevention and treatment to lower that risk. The 2018 guidelines recommend more detailed risk assessments, called risk enhancing factors, to help healthcare providers better determine a person’s individualized risk and treatment options. In some cases, a coronary artery calcium score can help determine a person’s need for cholesterol-lowering treatment, if their risk status is uncertain or if the treatment decision isn’t clear. While statins are still the first choice of medication for lowering cholesterol, new drug options are available for people who have already had a heart attack or stroke and are at highest risk of having another. For those people, medication should be prescribed in a stepped approach, first with a maximum intensity statin treatment, adding ezetimibe if desired LDL cholesterol levels aren’t met and then adding a PCSK9 inhibitor if further cholesterol reduction is needed. Stone, who is a professor of medicine at
Northwestern University’s Feinberg School of Medicine and the medical director of the Vascular Center of the Bluhm Cardiovascular Institute of Northwestern Memorial Hospital, noted that for those trying to prevent a first heart attack or stroke, personalized risk stratification informs next steps for primary prevention. For those trying to prevent another heart attack or stroke, the guidelines provide additional treatment options for those at very high risk.
For those who have not yet had a heart attack or stroke, Stone said the updated guidelines call for patients with a very high LDL – 190 or more – to be on a high intensity statin. For those with diabetes between the ages of 40 and 75, no matter what the LDL number, the updated guidelines continue the 2013 recommendation for them to be on a statin, as well. He added, “Those who have long-standing diabetes or are older than 50 may do better on a higher intensity of statin.” The new guidelines call for a more nuanced approach to statin use in the largest group – those 40 to 75 without diabetes or the highest LDL-C. Stone said by virtue of four different clinical trials assessing 10-year risk, individuals with a score of 7.519.9 percent should at least be considered for statin therapy. He added, those with a score of 5 percent or less typically don’t need statins, and those with a score of 20 percent or higher on the risk calculator
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should automatically be on statin therapy. “The previous guidelines recommended a clinician-patient risk discussion before a statin was given,” he said of the borderline group. “The new guidelines also recommend a clinician-patient discussion, but they give more details of what that should be. The idea is to provide a way for doctors to give patients, who aren’t sure whether to take a statin, factors to show a patient what their personal risks are.” In addition to traditional risk factors like smoking and high blood pressure, the new guidelines outline a number of other risk-enhancing factors to consider, including: family history and ethnicity, LDL ≥ 160, triglycerides persistently above 175, premature menopause or pre-eclampsia, chronic inflammatory conditions such as rheumatoid arthritis, metabolic syndrome, and chronic kidney disease. A coronary artery calcium (CAC) score can also help tip the scale on whether or not to start statin treatment immediately. A CAC of zero has typically indicated a low risk of CVD, which has been borne out by two large-scale studies. “We are not recommending calcium scores as a screening test,” Stone stressed. “We’re using it as a tiebreaker … it can be the decider,” he added. “Someone with a (risk assessment) score of 9 percent, few other risk factors, and a coronary calcium score of zero may wish to postpone statin use for five to 10 years because their risk is relatively low,” Stone continued of using the personalized approach at the heart of the new guidelines. For everyone, no matter where their risk assessment percentage falls, he stressed the importance of lifestyle modification to either delay or prevent the need for statins or to enhance the work of statins in maintaining heart health. “We point out even if you’re on a statin, you need to focus on lifestyle because the lower you can get your number on a statin, the lower your risk,” stated Stone.
For individuals who have already suffered a heart attack or stroke, the new guidelines call for additional intervention when LDL-C is not well controlled. “We have three trials showing if the LDL is above 70 in people who are very high risk, they might benefit from not just a maximally tolerated statin but also the nonstatin ezetimibe or PCSK9 injection or shot,” explained Stone. He added the recommendation is for a stepwise approach. Stone said the addition of ezetimibe would get a significant portion of high-risk patients under the 70 LDL benchmark. Available as a generic, ezetimibe is typically affordable and well tolerated by patients. For those who cannot achieve the desired goals with a combination of statin and ezetimibe, a PCSK9 inhibitor could be added. The new guidelines also note a PCSK9 inhibitor might be added as a primary prevention tool for individuals who have a genetic condition that causes high LDL-C. However, Stone noted, the shot is considerably more expensive. Some insur-
ers have been slow to cover the treatment, although there has been movement in recent months to lower the cost. The AHA and ACC are bringing together stakeholders to further discuss financial barriers to achieving optimal primary and secondary prevention of heart disease and stroke.
Once treatment has started, whether lifestyle modification only or modification with medication, physicians should schedule a follow-up appointment within four to 12 weeks to assess adherence and effectiveness with a fasting lipid test. The guidelines then call for retesting every three to 12 months, depending on determined needs. Stone said the new guidelines recognize and address the cumulative effects of high cholesterol over a lifetime. In most children, an initial test could be administered between the ages of 9 and 11. For some children with a strong family history of heart disease and high cholesterol, selective cholesterol testing might be appropriate as young as age two. While most children won’t need medication, physicians should use the test to discuss the positive impact healthy behaviors have on lifetime CVD risk. The updated guidelines offer a more individualized method to controlling cholesterol. “Before, it wasn’t a one-size-fits-all approach, but everybody thought if you had a score of 7.5 percent or more, you automatically go on statin therapy. The new guidelines really make it clear how to use enhancers to personalize the risk discussion,” Stone concluded. For a link to the new guidelines, please go online to NashvilleMedicalNews.com.
Dr. Ashish Shah, continued from page 4 fill in the gaps,” he said. Building on his experience performing more than 230 lung transplants in Baltimore, Shah also plans to re-launch a combined heart and lung program at VUMC. It’s a rare, complicated procedure that involves transplantation of two connected organs. “My vision is to be a destination center and to be able to offer everything the most desperately ill people need,” said Shah, noting the program would make the university one of a few places in the country to offer the combined surgery.
Training the Next Generation
Despite his continued success, the world-class surgeon is quick to give credit where it’s due: his mentors. “The longer I’m in cardiac medicine, the more I’ve appreciated the people who’ve been examples of excellence and took a personal interest in teaching me to do very tough surgeries,” Shah said. “My mission here is to do that for others and help young physicians feel as comfortable tackling difficult problems as I do now. Being a program our size makes you better, and being around smart people who push you and make sure you’re at your best is the secret sauce of how programs like this do right by our patients.” nashvillemedicalnews
CMS Utilizes Dartboard Approach to Modernizing the Medicare Drug Beneﬁt By JOHN OTROMPKE
Controlling pharmaceutical prices remains a hot topic, judging from the 6,415 comments received in response to the CMS proposed rule: “Modernizing Part D and Medicare Advantage to Lower Drug Prices and Reduce Out-of-Pocket Expenses.” The comments were posted to the online docket, notwithstanding the federal government shutdown. (The notice-and-comment period ended Jan. 25). As part of the Trump administration’s evolving healthcare strategy (which also includes the ’Five-Part Plan for Medicare Part D’), the nearly 200-page long proposed rule would use several strategies to control drug prices ranging from getting rid of gag clauses in pharmacy contracts and mandating new point-of-service formulary software be available to prescribers to the controversial measure of allowing health plans to restrict access to six previously-protected categories of drugs. “The administration has thrown a lot of darts at the wall, to see which ones are going to stick,” said Juliette Cubanski, PhD, associate director of the Kaiser Family Foundation’s Program on Medicare Policy in Washington, DC. “There are 29 stand-alone Part D plans in Tennessee, and this regulation would have a great impact,” added Sheila Burke, RN, MPA, chair of government relations and public policy at Baker Donelson, a national law firm with 22 offices including locations in Nashville and Washington, DC. “This is one area where there is the potential for bipartisan action,” she continued. “Congress members on both sides of the aisle … and the administration … are strongly interested, so one can assume there will be action.”
Fear of the Backroom Deal
The proposed regulation appears to take a suspicious view of undisclosed discounts, even defining the terms “negotiated price” and “price concessions” in order to counter “so-called PBM spread.” “Pricing for pharmaceuticals is done in a way that is kind of complicated. What a pharma company offers as a list price is not always the price that is actually paid,” said Leah Binder, MA, MGA, president and CEO of The Leapfrog Group, a D.C.based organization focused on healthcare transparency to foster informed purchasing decisions. Some of the fear on the part of regulators and other stakeholders stems from the concern that pharmacy benefits managers (PBMs) could be using their massive buying power to negotiate discounts with pharmaceutical manufacturers but not sharing those discounts with Medicare or with beneficiaries. PBMs are also supposed to serve other functions beyond negotiating discounts to improve cost effectiveness, noted James Manfred, executive director at Vanderbilt Health Pharmacy Group. “Fees for medication therapy management would be separate,” said Manfred. NASHVILLEMEDICALNEWS
“If the patient doesn’t take her medication right, the PBM will come back and take money from the pharmacy she goes to … for example, if my mom isn’t compliant, or she is supposed to get a 30-day supply of a drug every 30 days, they’re supposed to do outreach to get the patient to pick up the medication when they are due to get it,” he explained. “There must be 200 to 300 PBMs in that space at least, although large ones make up 90 percent of the market,” he continued. Manfred also noted some PBMs use a transparent model, such as Vanderbilt’s PBM of more than five years, Navitus, which manages more than four million covered lives and is licensed in all 50 states. Navitus uses a pass-through approach so that 100 percent of discounts or rebates go back to the client. Their business model generates revenue through a set per member per month administrative fee.
Buyer beware … a lack of pricing transparency can sometimes lead to beneficiaries paying more than needed. “In addition to advocating for quality, we are also big proponents of transparency,” said Leapfrog’s Binder. “One thing we like about the proposed rule for Part D is that it is moving us down that road. We don’t want the pharmacist to not tell you the truth. For example, there are sometimes clauses between, say, a PBM or a health plan and the pharmacy called ‘claw-back provisions’ that forbid doctors from telling you that there’s a lower-cost alternative
for the same drug you’re getting, perhaps where the copay for a medication may be more than cost of the medication.” Such situations typically arise in the case where generic versions of a drug are available, Binder explained. In those cases, she added, “The policy should just say just sell it to me as if I wasn’t insured, because it could cost much less money.”
Access to Medications
A controversial aspect of the proposed regulation is that it would also allow health plans and plan sponsors to have greater flexibility in restricting access to medications in six classes of previously-protected drugs. Currently, Part D formularies must include any drug in the six protected classes: antidepressants, antipsychotics, anticonvulsants, immunosuppressants for organ transplant rejection drugs, antiretrovirals, and antineoplastics. The intent of the current policy has been to ensure high-cost beneficiaries aren’t discriminated against in seeking treatment. According to Vanderbilt’s Manfred, access to a new biological drug as first-line therapy could possibly save a cancer patient’s life. Such drugs, however, are typically more expensive than older options available. “They picked these six categories because patients are very sensitive to individual medications. Take anti-psychotics, for example – sometimes only one drug works for a given individual,” he explained of the currently protected classes. “However, in the commercial world, this is pretty normal. One would very rarely find every drug covered on the formulary, so it didn’t surprise
me,” he added of the proposed change. Regulators made a previous proposal to put a limiting construction on the six protected classes of drugs in 2014. “It was found that the proposal would have a negative effect on patients’ access to medications, so the Obama administration decided not to move forward with it,” said Cubanski of the Kaiser Family Foundation. The current proposed rule includes three exceptions to automatic universal coverage of all drugs within the protected classes. To help control costs, the proposed rule calls for using measures like prior authorization or step therapy for Part D drugs; the ability to exclude a specific drug from its designated protected class if the current drug doesn’t provide a unique route of administration and is instead a newer version of an already existing single-source drug or biologic; and the option to exclude a specific drug if certain price increase provisions are triggered. In a letter sent to CMS Administrator Seema Verma, the American Hospital Association signified general agreement with this three-pronged approach, believing it will dissuade manufacturers from engaging in practices that falsely inflate pricing. However, the AHA cautioned it would require “rigorous oversight to ensure protection from abuse.” With all comments now filed, it remains to be seen what changes are made to the final rule and how it will impact providers and patients. To view remarks sent by a number of key stakeholders, go online to NashvilleMedicalNews.com.
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Last year’s LHC Delegation to D.C. gathered for a group shot during a brief break in their busy schedule. After 16 years of traveling to the nation’s capital, LHC will lead this year’s delegation to Boston, the center of biotechnology.
A Conversation with LHC Director Molly Vice By CINDY SANDERS
involvement. In addition, we launched the LHC Women’s Meetups focused on Every company should have a well bringing together emerging female leaders thought out succession plan to strategiin the industry for an intentional time to cally, seamlessly implement a change network with one another. in executive oversight when the time is • In 2018, LHC launched the LHC right. Mentoring Cohort Program as a way to Leadership Health Care plays a key provide members with peer-to-peer menrole in serving as a ‘suctoring opportunities. We also cession plan’ for an entire launched a new Lunch and industry. An initiative of Learn series, which brings the Nashville Health Care together a group of about 50 Council, LHC was formed members to learn about a in 2002 to help prepare the trending healthcare topic in a next generation of execumore interactive environment. tives to lead the city’s robust • This year, LHC is movhealthcare industry by proing its annual delegation to viding education, policy Boston on September 15-17. insights, industry tours, and We also have launched memnetworking opportunities. ber social coffees, providing Nashville Medical News an organic way for members Molly Vice recently had the opportunity to connect with others who to take a deep dive with LHC Director work within the same geographical area Molly Vice to find out more about proof Nashville. gramming and what’s new for 2019. NMN: You mentioned the annual NMN: What was the impetus to delegation. Can you tell us a little create LHC? more about that change for 2019? Molly Vice: LHC grew out of a Molly: After 16 years visiting Washneed within the industry to have a place ington, D.C., LHC’s signature annual where up-and-coming healthcare execdelegation is being revamped for 2019. utives could network with their peers This year, the annual delegation will take while also gaining valuable industry place in Boston, Mass. As a leading city knowledge. in biotechnology and with a healthcare While Council events and programecosystem that looks vastly different than ming are targeted to senior-level leaderNashville’s, LHC hopes to encourage colship, LHC gives middle-management laboration and ignite innovation among professionals an opportunity to take part in LHC members by connecting with Bosprogramming in a smaller, more intimate setting. Today, LHC’s goal is to foster the next generation of healthcare leaders by providing members with ongoing opportunities to develop their knowledge of the healthcare industry through educational events and networking opportunities. NMN: How has the program evolved over the years? Molly: Over the years, LHC has changed and evolved to meet the needs of its members in an everchanging healthcare industry. Today, our focus is on helping our members build a professional network by offering smaller, more interactive events to allow those relationships to develop. Some examples in which the program has evolved over the years include: • In 2017, LHC expanded the number of committees and opportunities for 10
ton’s industry leaders. This year’s delegation to Boston takes place September 15-17, 2019 and is only available to current LHC members. NMN: So being able to attend the delegation is a benefit of membership. What are some of the others? Molly: LHC’s three core values are to provide exceptional educational content, provide a space for members to develop a professional network, and provide an opportunity for members to build personal relationships. LHC offers its members access to an array of programs, from larger Executive Briefings with leading healthcare CEOs, to smaller Lunch and Learns on a trending healthcare topic. Last year alone, LHC hosted more than 20 events for its nearly 800 members. Another component to LHC is the opportunity for leadership development for our members, through both committee and board service. As an initiative of the Council, we are committed to fostering the next generation of healthcare leaders here in Nashville. NMN: How does someone become a member of LHC and what is the criteria to join? Molly: LHC is open to motivated rising healthcare leaders interested in dynamic educational and networking opportunities. Becoming a member of LHC is simple. Just visit our website at LeadershipHealthcare.com, and you can join today!
LHC members visit the Ronald McDonald House to learn more about the nonprofit’s mission and work.
LHC Programming at a Glance Leadership Health Care has a membership of nearly 800 up-andcoming healthcare industry leaders from 300 organizations. The mission of LHC is to nurture the talents of these future leaders and grow their understanding of the complex, ever-changing healthcare industry by offering insights, education and network through year-round programming.
Quarterly • Executive Briefings: Featuring Nashville CEOs • Industry Tours: On-theground views of industry and nonprofit services • Lunch and Learns: Trending healthcare topic with discussion among LHC members in an intimate, conversational setting • Women’s Meetups: Networking reception for female LHC members
Biannually • Networking Receptions: Space to provide camaraderie and build relationships • Mentoring Cohort Program: Facilitates peer mentoring in a small-group setting centered around a common focus area • Member Social Coffees: Organic opportunity for members to engage with each other
Annually • Delegation: Exposes members to thought leaders in leading healthcare cities to encourage innovation and collaboration • Health Care 101: High level overview of the players and stakeholders in healthcare For more information about Leadership Health Care and how to become involved, go online to LeadershipHealthcare.com or reach out to Molly via email at mvice@ healthcarecouncil.com.
The 2019 Legislative Agenda, continued from page 1 assessment helps maintain coverage for physical, speech and occupational therapies, physician office visits and other services, as well as avoidance of a significant provider rate reduction. In 2018, legislators passed Public Chapter 840, often referred to as the ‘Balance Billing’ act. THA President and CEO Craig Becker explained the law made changes to existing requirements for hospitals and ambulatory surgery centers to provide notice to patients regarding billing and coverage for healthcare services. Craig Becker “The intent is to be as transparent as possible to our patients about their healthcare and cost-sharing obligations for services,” he noted. Becker added the revised law requires these facilities to inform patients that even if the hospital or ambulatory surgical center is in-network, certain providers involved in treatment might not be. While THA worked closely with legislators to pass the law, the organization looks to clean up confusing language in the out-of-network notice legislation. Becker said the goal is to simply clarify some elements to ease implementation and ensure patients receive ‘relevant and useful’ information as it relates to coverage benefits and cost-sharing. In 2019, THA also is seeking a specific, narrow modification of the Tennessee Nurse Practice Act to keep hospitals from being cited for violations of what is a longstanding practice. “Hospitals, particularly rural hospitals, were being cited by the Centers for Medicare & Medicaid Services for having trained and certified obstetrical nurses make determinations if a woman was in active labor — a practice that has worked and dates back years,” said Becker. “If the patient was in active labor, the doctor would be called to come to the hospital,” he continued. Becker noted THA staff and representatives from several rural hospitals traveled to D.C. to meet with CMS officials about the issue. “The officials said that although the practice was appropriate clinically, updates to Tennessee’s Nurse Practice Act were needed in order to avoid being cited,” Becker explained. To address EMTALA requirements, Becker said THA looks to clarify in statute what has been consistent practice in hospitals between nurses and physicians. THA is working with TMA and TNA on the issue. Certificate of Need legislation remains a key concern for hospitals. Americans for Prosperity (AFP) Tennessee, the state level arm of the national organization, has identified the elimination of the Certificate of Need (CON) process as one of its top priorities … a move with which THA strongly disagrees. As an organization, THA has firmly maintained that arguments introducing ‘free market principles’ to the healthcare system are deeply flawed
and fail to consider the unique financial model of hospitals and other providers … or the precarious financial situation experienced by many rural hospitals in the state. Hospitals, Becker pointed out, have a mandate to take everyone who shows up at their doors, regardless of that individual’s ability to pay for services. “Once CON laws are gone, entrepreneurs open outpatient services next to hospitals and will only take paying customers, leaving hospitals with the indigent and TennCare patients. Generally, these entities also drive up utilization and, therefore, cost,” said Becker. “The existing CON process ensures the orderly development of healthcare in Tennessee, while minimizing regulatory burdens on healthcare providers,” he added. Becker pointed out THA worked closely with lawmakers in 2016 to significantly modernize Tennessee’s CON process. “Given this action and 2018’s extension of the Health Services and Development Agency (HSDA) for three years, THA believes it is early to reexamine the CON law and elimination would run counter to last year’s action by the General Assembly to extend the HSDA,” he stated.
The Tennessee Medical Association, the state’s largest professional organization for physicians, released its 2019 legislative agenda last month and intentionally limited the list of topics it plans to push in the new-look state legislature. “With a third of the men and women in the General Assembly being brand new this session – along with a new governor – we expect to devote Dr. Matthew Mancini a lot of time building relationships and serving as a resource on important healthcare issues,” said TMA 2018-19 President Matthew L. Mancini, MD. With that in mind, TMA has set its top 2019 legislative priorities as seeking to improve opioid prescribing laws, address MAT parity, defend scope of practice and pursuing a reasonable compromise on payment issues. While TMA was able to make significant tweaks to Gov. Bill Haslam’s “TN Together” legislation in 2018, the organization has found some of the unintended consequences doctors initially feared the new law would create are manifesting across the state. “We were transparent about our concerns last year as the laws were taking shape and even after they passed,” said Mancini. “Putting labels on patients and overly restricting the initial prescription supply has obstructed some patients from getting the care they need.” While new restrictions on prescribing and dispensing are no doubt reducing overall initial supply, TMA said those restrictions could also impede access to legitimate, effective pain management and fuel a rise in illicit drug use.
“Fewer primary care doctors are going to write opioid prescriptions out of misunderstanding and/or fear of the new law, and there are not enough certified pain management specialists in the state to refer their patients,” Mancini said. He continued, “The partial fill provision has been a disaster as some pharmacy chains have chosen to institute their own fill policies that are more restrictive than TN Together. And when their access to prescription pain management goes away, many patients are turning to cheaper and easier-to-find illicit substances like heroin and fentanyl, which are fueling the continued rise in overdose deaths.” TMA has pledged to work with the legislators to amend the law to improve initial prescribing restriction and to focus on alternative treatment therapies and other key aspects to effectively fight the opioid epidemic in Tennessee. Another key issue is MAT parity. TMA has long advocated for more accessible and well-funded treatment options for patients struggling with substance abuse, including using medications in combination with counseling and behavioral therapies. This year, TMA will ask the General Assembly to consider a resolution, rather than a law, encouraging health insurance companies to include Medication-Assisted Treatment (MAT) therapies in patients’ health plans and reimburse specialists who provide MAT services at rates comparable
(CONTINUED ON PAGE 12)
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to other treatments. “In other words,” said Mancini, “we don’t want a lack of health plan coverage to limit the options available to patients who need help.” Scope of practice issues continue to be of concern to the physician organization despite a current moratorium on the subject. TMA has stated its members are “on alert to continue defending against any proposals that would threaten patient safety and quality of care by removing physician oversight for nurses, physician assistants or any other midlevel providers.” In 2016 TMA reached an agreement with the Tennessee Nurses Association that included a three-year moratorium on all independent practice bills. The moratorium expires at the end of the 2019 session, but doctors expect the debate to resurface, particularly around expanding access to care in rural areas. “TMA understands there are access to healthcare issues,” said Mancini. “We are making it our priority to come up with solutions, including telemedicine and increasing the number of doctors being trained in Tennessee, with an emphasis in primary care.” He continued, “We already know that advanced practice clinicians are essential to providing access but also know that Tennesseans get the safest, highest quality care when we collaborate as a team. Giving nurses independent practice without physician collabora-
1/17/19 1:12 PM
The 2019 Legislative Agenda, continued from page 11
Representing more than 110,000 Tennessee registered nurses, TNA is in the midst of its 2018-2020 legislative and health policy agenda. To achieve the mission of improving health and healthcare for all Tennesseans, TNA’s stated focus is on supporting initiatives that improve patient care experience, improve population health and reduce the per capita cost
of healthcare to optimize health system performance. “TNA, along with TMA and others, is a participant in the moratorium on the introduction of any new scope of practice legislation until 2020, so TNA will not be introducing any scope of practice changes in the 111th General Assembly,” said TNA Executive Director Tina Gerardi, MS, RN, CAE. That said, she continued, “TNA will always support efforts to remove antiquated rules and regulations that have no Tina Gerardi impact on patient care outcomes and continue to restrict access to care and provider choice in Tennessee.” Among TNA’s overall key priorities are the: • Provision of a standardized package of essential healthcare services provided and financed by public and private plans with protection against catastrophic costs and impoverishment; • Expansion of primary care capacity by allowing RNs to practice to the full extent of their license to provide chronic care management, care coordination, and preventive care in primary care settings; • Enhanced access to efficient, costeffective, high-quality, equitable, and comprehensive healthcare services by allowing APRNs to practice to the full extent to which their education and train-
Blog Log The Nashville Medical News Blog features additional insights and information from a cross-section of industry leaders. The blog can be accessed directly through NashvilleMedicalNews.Blog or from the homepage of the main website.
NEW IN FEBRUARY George Buck, president emeritus, and Judd Peak, chief compliance officer and general counsel, with Frost-Arnett Company, take a vendor’s perspective to drill down on “Laws and Regulations Continue to Affect Patient Pay.” In part five of this six-part series, the authors look at the Bureau of Consumer Financial Protection.
ing prepare them; • Increased access to MAT by allowing APRNs with appropriate training to prescribe buprenorphine to increase access to combat the state’s opioid crisis; and • Full practice authority and enhanced participation in the delivery of care and policymaking for all professional nurses, including: support for the Tennessee Board of Nursing as the sole regulatory authority over nursing education and practice; adoption of the Consensus Model for APRN Regulation: Licensure, Accreditation, Certification, and Education (2008); elimination of financial, regulatory, organizational, and institutional barriers to the practice of professional nursing; participation of registered nurses on all local, state, and national healthcare advisory, policymaking, and governing boards, committees, and task forces; and inclusion of APRNs as licensed independent providers (LIPs) in hospital licensure rules, health plans, and health care facilities. Although not introducing any scope of practice bills this year, Gerardi said, “(TNA) will monitor and will mobilize nurses across the state to support or oppose
bills that impact nursing practice and healthcare based on the principles outlined in the TNA health policy statements.” She added TNA is also monitoring any legislative outcomes from the buprenorphrine work group recommendations that were released on Jan. 24. “TNA supports APRNs prescribing buprenorphrine in order to meet their patients’ comprehensive healthcare needs,” she said.
Days on the Hill Tennessee Hospital Association Tuesday, Feb. 26 Details at tha.com Tennessee Medical Association Tuesday, March 26 Details at tnmed.org Tennessee Nurses Association Legislative Summit Wednesday, April 3 Details at tnaonline.org
VUSN Ribbon Cutting In late January, officials with Vanderbilt University School of Nursing hosted a grand opening event to celebrate completion of their $23.6 million expansion project that includes technologically advanced classrooms and simulation lab, along with student services offices. Speaking to guests that included healthcare leaders, federal and state officials, donors, university leadership, students, faculty and staff, Vanderbilt University Chancellor Nicholas S. Zeppos noted the ways in which the expansion reflects Vanderbilt’s approach to the field of nursing. “The School of Nursing is deeply committed to improving the quality of healthcare and to educating the professionals who will provide that care in our communities and around the globe,” said Zeppos. “This building captures the cutting-edge and unique interdisciplinary way of teaching and conducting research that has made the Vanderbilt University School of Nursing a national model for education, discovery and advancing human health.” Check out next month’s issue of Nashville Medical News for a deeper dive on how the new facilities support and enhance VUSN’s educational mission. PHOTO: JOE HOWELL/VANDERBILT UNIVERSITY
tion would create more fragmentation in healthcare delivery and threaten quality of care and patient safety. We need more integrated and coordinated healthcare delivery, not more silos.” On the Balanced Billing legislation, Mancini said TMA has attempted to work with stakeholders over the past few years to resolve “surprise bills” for patients. At the heart of the issue is TMA’s dual desire to protect physicians’ rights to be fairly compensated for out-of-network services they provide, while remaining fair to patients who are caught between their health plan and their physician. Mancini noted physicians don’t have control over who the other providers might be when scheduling procedures at a patient’s in-network hospital. He added it’s operationally impractical for physicians to notify every patient in advance about the health plan network status of every provider or service the patient would, or could, encounter. “We are hopeful that we can address the real cause of the problem by working toward more adequate health plan networks,” he added.
Online Bonus Editorial Go online to NashvilleMedicalNews.com for additional editorial in February including: New Vanderbilt University Medical Center and RAND Corporation study linking longterm unemployment to an increase in babies born with drug withdrawal. The study also found counties with shortages of mental health providers had higher levels of neonatal abstinence syndrome. Published in the Jan. 30 edition of the Journal of the American Medical Association, it’s the first study to examine the association between long-term economic conditions, healthcare provider shortage areas and the incidence of NAS. Wall Street’s Perspective on 2019: the Nashville Health Care Council annual program provides insights on prospects for the healthcare industry this coming year. Bass, Berry & Sims has released their Healthcare Fraud and Abuse Review 2018. Regulatory scrutiny from last year is expected to spill over from last year with court rulings and legislative decisions impacting the industry. Read the highlights online and download the full report. The American Institute for Cancer Research launched a new myth-busting campaign regarding cancer risk on Feb. 1 in honor of Cancer Prevention Month. This month (and every month) is a good time to share the facts and debunk the myths with patients to minimize cancer risks. The nation’s leading hospital associations have released a report outlining their agenda to improve interoperability. Learn more about their call to action in Sharing Data, Saving Lives.
(L-R) School of Nursing Dean Linda Norman, Chancellor Nicholas S. Zeppos, Provost and Vice Chancellor for Academic Affairs Susan R. Wente and Board of Trust Chairman Bruce Evans cut the ribbon for the School of Nursing building expansion. nashvillemedicalnews
March of Dimes Honors 17 Area Nurses ALL PHOTOS COURTESY OF MARCH OF DIMES. PHOTOGRAPHY BY MICHELLE HANKES.
Mark Your Calendars
By CINDY SANDERS
As 2018 drew to a close, nurses from throughout Middle Tennessee gathered at Belmont University to celebrate the ninth annual March of Dimes Nurse of the Year Awards. The gala luncheon event honored 17 outstanding professionals across 16 specialty areas ranging from adult critical care, behavioral health and public health to nursing administration, research and student nursing. All of the 2018 nominees and awardees embody leadership, compassion and professional excellence. Emcee Dan Thomas, meteorologist for WSMV, welcomed guests and thanked sponsors, including the platinum plus sponsor Western Governors University (WGU) and platinum sponsors Monroe Carell Jr. Children’s Hospital at Vanderbilt and Vanderbilt University Medical Center. Event Chair Kathie Krause, MSN, RN, NNP-BC, NEA-BC, welcomed guests and noted the exciting response to the annual awards process with 130 nominations and nearly 80 finalists being reviewed before narrowing down to the 18 honorees. “This was not a surprise, however, as our nurses touch so many lives every single day,” said Krause, who serves as chief nursing officer for the Children’s Hospital at Vanderbilt. “The selfless care provided to those in need is what makes you who you are … dedicated and compassionate,” she added, addressing the audience. March of Dimes hosts Nurse of the Year events throughout the country to recognize nurses who live out the organization’s vision for a healthier, stronger generation of babies and families. In Middle Tennessee, a distinguished committee of nursing professionals selected the 2018 honorees through a structured screening and review process. More than a dozen organizations helped sponsor the event, with Nashville Medical News serving as a media sponsor for the sixth year.
ADULT CRITICAL CARE
Deborah Anasky, RN HCA
Bonnie Parker, RN NICU Case Manager Monroe Carell Jr. Children’s Hospital at Vanderbilt
ADVANCED PRACTICE Aaron Scott, MSN, FNP-BC Nurse Practitioner Vanderbilt University Medical Center
BEHAVIORAL HEALTH Rose Vick, PhD, MSN, PHMNP-BC Instructor Vanderbilt University School of Nursing
EMERGENCY Chelsea Carter, RN, BSN, CCRN Monroe Carell Jr. Children’s Hospital at Vanderbilt
PUBLIC & COMMUNITY HEALTH Lisa Holzapfel, RN Medical Services Manager Hope Clinic for Women
QUALITY & RISK MANAGEMENT Susie Lemming-Lee, DNP, MSN, RN, CPHQ Assistant Professor Vanderbilt University School of Nursing
Cori Brown, RN Nurse Leader TriStar Centennial Medical Center
Bethany Rhoten, PhD, RN Assistant Professor Vanderbilt University School of Nursing
GRADUATE STUDENT NURSE
Jaanki Bhakta Belmont University School of Nursing
Lindsay Mann, RN TriStar StoneCrest Medical Center
UNDERGRADUATE STUDENT NURSE
Carolyn McGee Inpatient Utilization Manager Amerigroup
NURSING ADMINISTRATION Pam Jones, DNP, RN, NEA-BC Senior Associate Dean, Clinical & Community Partnerships Vanderbilt University School of Medicine
NURSING EDUCATION Terrah Akard, PhD, RN, CPNP, FAAN Associate Professor of Nursing & Medicine Vanderbilt University School of Nursing
Grace Waters Belmont University School of Nursing
UNDERGRADUATE STUDENT NURSE Carly Gilson Lipscomb University School of Nursing
Our Kids Soup Sunday • Feb. 24 Nissan Stadium Don’t miss the 26th annual event benefitting Our Kids. The event features soups from more than 50 restaurants, silent auction, celebrity and culinary judges, and children’s activities. For details or to purchase tickets, go online to OurKidsCenter.com.
How About Dinner & A Movie? • Feb. 28 Belcourt Theatre This year’s signature fundraising event for Park Center will feature Into the Canyon by Peter McBride and include a silent auction, dinner and movie. Edith McBride Bass is the 2019 honoree. For tickets or more information on the main event or the Patrons Party set for Feb. 14, go online to ParkCenterNashville.org.
Friends & Fashion • April 1 Music City Center Save the date for the annual silent auction, runway show, shopping and luncheon event benefiting the Monroe Carell Jr. Children’s Hospital at Vanderbilt. For more information or to purchase tickets, go online to ChildrensHospitalVanderbilt.org/ friendsandfashion.
Dr. Matthew Walker, Sr. Legacy Breakfast • April 4 Cal Turner Family Center at Meharry Medical College Dr. Stephanie Bailey, educator and public health icon, will be the featured speaker at the second annual breakfast event, which is set for Thursday, April 4 from 7:30-9 am. Benefitting Matthew Walker Comprehensive Health Center, additional information is available go online at mwchc.org.
ACRP 2019 • April 12-15 Music Center Center The Association of Clinical Research Professionals is holding their annual meeting in Nashville. Don’t miss out on this premier education and networking event for clinical research professionals featuring six educational tracks plus the Signature Series. Registration is available online through the NashvilleMedicalNews.com website or at 2019.acrpnet.org.
WOMEN’S HEALTH Leilani Mason, MSN, CNM, FACNM Assistant Professor, Clinical Obstetrics & Gynecology Vanderbilt University Medical Center
Follow us on Twitter @NashMedNews FEBRUARY 2019
GRAND ROUNDS Smith Harris & Carr Now Harris Frazier Government Relations
Nashville’s oldest lobbying firm, Smith Harris & Carr, is now Harris Frazier Government Relations. The firm, originally known as Smith & Johnson, was founded in 1980. “Two of our firm’s named partners retired so it’s time we change our name to better represent our current ownership,” explained Estie Harris, who joined the firm in 1994 and has been a partner since 1996. The firm provides consulting, monitoring, and/or active lobbying services, along with assistance with the state procurement process, in-depth policy Estle Harris research, and issue forecasting. Partners Estle Harris and Meagan Frazier, both of whom have deep experience in hospital and healthcare issues, make up the firm’s leadership and are joined by team mem- Meagan Frazier bers Lou Alsobrooks and Merle Franklin.
TriStar Centennial Welcomes Pantin
Last month, TriStar Centennial Medical Center announced the addition of Jeremy Mark Alexander Pantin,
MD, FACP to Sarah Cannon Center for Blood Cancer at TriStar Centennial. Pantin, who specializes in hematology and blood marrow transplantation, earned his medical degree from Dr. Jeremy Pantin The University of the West Indies in St. Augustine, Trinidad. He completed his residency in internal medicine at Howard University Hospital in Washington, D.C., before completing a fellowship in hematology, medical oncology, and blood and marrow transplantation at the National Heart Lung and Blood Institute in Bethesda, Md.
Care in Denver. Previously, Cuevas practiced with Saint Thomas Medical Group.
Let’s Give Them Something to Talk About! Awards, Honors, Achievements
Saint Thomas Midtown has been recognized by BlueCross BlueShield of Tennessee with a Blue Distinction® Center+ for Bariatric Surgery designation. Blue Distinction Centers are nationally designated healthcare facilities that show expertise in delivering improved patient safety and better health outcomes, based on objective measures that were developed with input from the medical community. PYA, a national management consulting and public accounting firm based in Knoxville but with offices in multiple cities including Nashville, celebrated the company’s 35th anniversary on January 12.
Cuevas Center for Arthritis & Fibromyalgia Opens in Franklin
Last month, Leslie Cuevas, MD is announced the opening of her rheumatology practice, Cuevas Center for Arthritis and Fibromyalgia, in Franklin next to Williamson Medical Center. The new selfpay practice focuses on autoimmune disorders, as well as arthritis and fibromyalgia. Dr. Leslie Cuevas Cuevas is a boardcertified rheumatologist and completed her rheumatology fellowship at Vanderbilt University. She completed her internal medicine residency at the University of Tennessee and then went on to seminary school and studied Soul
TOA Announces Plans for Hendersonville
NAM Installs New Officers
On Jan. 30, the Nashville Academy of Medicine formally installed their new board and president. V. Seenu Reddy, MD, a cardiovascular surgeon with TriStar Centennial Medical Center, has assumed the role of president and Robin Williams, MD, a breast surgeon with Saint Thomas Medical Partners and Tennessee Breast Specialists, will serve as president-elect. M. Kevin Smith, MD, an internal medicine physiDr. Kevin Smith (right) passes the torch to cian at Vanderbilt University Medical CenDr. Seenu Reddy (left), who will serve as NAM’s ter, is the immediate past-president of the 2019 president. Academy and has been named chair of the board of directors for 2019. The complete list of board members is available online at NashvilleMedicalNews.com.
Vanderbilt Discovery Could Advance BP Treatments
PHOTO BY STEVE GREEN
A team of Vanderbilt University Medical Center researchers, working with the U.S. Department of Veteran’s Affairs (VA), has discovered genetic associations with blood pressure that could guide future treatments for patients with hypertension. The study, an international effort using data from sources including the VA Million Veteran Program (MVP) and United Kingdom (UK) Biobank, is published in the January issue of Nature Genetics. Todd Edwards, PhD, and Adriana Hung, MD, MPH served as two senior corresponding authors. Researchers discovered over 250 new genetic variants, and also identified over 400 new genes associated with blood (Back Row L-R) Drs. Adriana Hung & Todd Edwards pressure through changes in (Front Row L-R): Drs. Jacklyn Hellwege, Ayush Giri & Jacob Keaton gene expression. The findings also suggest that several existing drugs not currently used to treat high blood pressure could be used to potentially lower blood pressure.
Last month, Tennessee Orthopaedic Alliance (TOA) unveiled plans to open a new facility in Hendersonville this fall. The groundbreaking ceremony for the facility, which is slated to open in September, was held on Jan. 17 at the site on Saundersville Road. The new state-of-the-art facility will house all physicians and services previously based at the New Shackle Island Road location. The new 23,000-square-foot TOA Indian Lake Clinic will offer the full slate of clinical services previously offered and will add an even more robust catalogue of options including personal training, yoga and fitness classes, advanced imaging, a larger physical therapy facility and an orthopedic urgent care. TriStar Health Hospitals Add Secure WebStreaming Cameras to NICUs TriStar Health is adding 75 NICVIEW web-streaming cameras to the Neonatal Intensive Care Units (NICUs) at five of its Nashville-area hospitals, which include TriStar Centennial, TriStar StoneCrest, TriStar Summit, TriStar Hendersonville and TriStar Horizon medical centers. Each NICVIEW camera will be mounted on the wall near the infant’s bed and will allow families to view their babies 24/7 through a password protected livestream. “NICVIEW cameras will give families the opportunity to connect with their infant and feel close to them no matter where they are” said Heather J. Rohan, president of TriStar Health. “The installation of these cameras will provide a more personalized approach to medicine and ensure the best possible experience for our patients and their families.” Many NICU families travel long distances from their homes which may limit the amount of time they can spend with their newborns. The new NICVIEW cameras are especially important for those families, allowing them to stay connected and close to their child.
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Expanded Grand Rounds Online NashvilleMedicalNews.com
announces its newest product addition
Vibativ® (telavancin) is an FDA-approved injectable antibiotic used in the treatment of certain serious bacterial infections including hospital-acquired and ventilator-associated bacterial pneumonia (HABP/VABP), as well as complicated skin and skin structure infections (cSSSI). This lifesaving antibiotic is designed for difficult to treat Gram-positive bacterial infections, including those that are classified as MRSA or multidrug-resistant.
IMPORTANT SAFETY INFORMATION CONTRAINDICATIONS Intravenous unfractionated heparin sodium is contraindicated with VIBATIV administration due to artificially prolonged activated partial thromboplastin time (aPTT) test results for up to 18 hours after VIBATIV administration. VIBATIV is contraindicated in patients with a known hypersensitivity to the drug. ADVERSE REACTIONS Most common adverse reaction (≥10% of patients treated with VIBATIV) in the HABP/VABP trials is diarrhea; in the cSSSI trials, the most common adverse reactions (≥10% of patients treated with VIBATIV) include: taste disturbance, nausea, vomiting, and foamy urine.
For more information, including important safety and full prescribing information, please visit www.vibativ.com.
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Nashville Medical News February 2019