CHESAPEAKE
Physician YOUR PRACTICE. YOUR LIFE.
EVOLUTION IN ORTHOPAEDIC TREATMENTS THE STATE OF TRANSPLANTS PATIENT-CENTERED SPECIALTY PRACTICES DEVELOPING PHYSICIAN LEADERS
chesphysician.com VOLUME 5: ISSUE 4 JULY/AUGUST 2015
Maryland/DC/Virginia
Contents 8
VOLUME 5: ISSUE 4 JULY/AUGUST 2015
10
F E AT U R E S
10 Evolution in Orthopaedic Treatment 16 The State of Transplants:
Advances & New Approaches D E PA R T M E N T S
Cases
| 7 | Collagenase Injection: An Alternative to Surgery for Dupuytren’s Contracture
Solutions HIT
| 8 | Developing Physician Leaders for Tomorrow
| 20 | The Medical Home Gets a New Neighborhood
Policy
| 28 | Today’s Skilled Nursing Facility: Not Your Parents’ Nursing Home
Our Bay
| 30 | Celebration of the Chesapeake Bay
On the Cover: Michael Barr, MD, MBA, FACP, executive vice president of the NCQA
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Physician YOUR PRACTICE. YOUR LIFE.
Maryland/DC/Virginia www.chesphysician.com
JACQUIE COHEN ROTH FOUNDER/PUBLISHER/EXECUTIVE EDITOR jroth@chesphysician.com
“Q” is for quality patient care. At a photo shoot with NCQA Executive Vice President Michael Barr, MD, for this issue’s Healthcare IT feature (see page 20), I zoomed in on a gift he’d received, a brightly lit letter “Q.” The “Q” recognizes Dr. Barr’s national leadership in promoting the foundations of quality patient care and making it part of a national agenda. Similarly, I’ve made a focus on quality patient care a cornerstone of the Chesapeake Physician brand. The Chesapeake Physician mission, dedicated to building a regional physician and healthcare stakeholder network with a commitment to achieving the highest standards of quality patient care, is deeply rooted in me, embedded in my earliest memories. My dad, Nathan A. Cohen, MD, was the one who lit that light for me. Each and every day of his professional career, his commitment to delivering quality care was part of every decision he made as the director of a community hospital medical lab, and part of his mentoring, from his medical school students to lab techs. Sadly, as this issue was in development, my family and I lost him to Alzheimer’s. His disease actually gave me a gift, allowing me to connect with him on an issue he had been focused on 20 to 30 years earlier, at a time when he and I did not share a professional commonality. On Father’s Day 2012, I had a long telephone chat with my dad when, because of his disease, he was reliving a moment in 1980 and he was distraught that hospital leadership was failing to recognize the incredible work of his teams, which kept that medical lab humming 24 hours a day, saving patients’ lives. Thanks to the hundreds of folks I’ve had the privilege of speaking with as part of our editorial development, I was able to have a conversation with my dad where I could help to gently guide him through some ideas for conflict resolution. It was a remarkable experience. My mind was in 2012 and his was somewhere around 1980. What better way to honor my dad’s memory than by going outside our leading-edge regional providers for subject-matter expertise to another physician who is driven by a commitment to quality, and who was equally inspired by my dad. My sister and board-certified orthopaedic surgeon, Jessica Brown, MD, is this issue’s contributor to our Cases department, discussing advances in treating Dupuytren’s contractures (see Cases page 7). That topic is part of our clinical focus this issue on advances in various aspects of orthopaedics, from zero profile cervical devices to advanced PT treatments and healthier bones in children. My team and I have heard from many of you that you are interested in hearing each other’s stories. What led you to become a physician? What are your personal challenges as a physician? What do you love about being a physician and what do you hate about it? Please, share your story like I often share mine. Help us to build the Chesapeakebased regional network I’m passionate about. Every page of this magazine is an integral part of that mission. To life!
Jacquie Cohen Roth Founder/Publisher/Executive Editor jroth@chesphysician.com @chesphysician 4 | CHESPHYSICIAN.COM
If you would prefer to read Chesapeake Physician online instead of print, please email jroth@chesphysician.com or tweet @chesphysician
LINDA HARDER, MANAGING EDITOR lharder@chesphysician.com PRODUCTION MANAGER Stefanie L. Jenkins sjenkins@mojomedia.biz MANAGER SOCIAL & DIGITAL MEDIA Jackie Kinsella jkinsella@mojomedia.biz CONTRIBUTING WRITER Anne K. Sessions COPY EDITOR Ellen Kinsella BUSINESS DEVELOPMENT Pat Klug pklug@mojomedia.biz PHOTOGRAPHY Tracey Brown, Papercamera Photography
Chesapeake Physician – Your Practice. Your Life.™ is published bimonthly by Mojo Media, LLC, a certified Minority Business Enterprise (MBE). Mojo Media, LLC PO Box 949 Annapolis, MD 21404 443.837.6948 mojomedia.biz Subscription information: Chesapeake Physician is mailed free to licensed and practicing physicians and a select group of healthcare executives and stakeholders throughout Maryland, Northern Virginia and Washington, DC. Subscriptions are available for the annual cost of $52. To be added to the circulation list, call 443.837.6948. Reprints: Reproduction of any content is strictly prohibited and protected by copyright laws. To order reprints of articles or back issues, please call 443.837.6948 or email sjenkins@ mojomedia.biz. Chesapeake Physician Magazine Advisory Board: An advisory board comprised of medical practitioners and business leaders in diverse practice, business and geographic scopes provides editorial counsel to Chesapeake Physician. Advisory Board members include: PATRICIA CZAPP, MD Anne Arundel Medical Center HOLLY DAHLMAN, MD Green Spring Internal Medicine, LLC MICHAEL EPSTEIN, MD Digestive Disorders Associates STACY D. FISHER, MD University of Maryland Medical Center DANILO ESPINOLA, MD Advanced Radiology GENE RANSOM, JD, CEO Maryland Medical Society (MedChi) CHRISTOPHER L. RUNZ, DO Shore Health Comprehensive Urology VINAY SATWAH, DO, FACOI Center for Vascular Medicine THU TRAN, MD, FACOG Capital Women’s Care Although every precaution is taken to ensure accuracy of published materials, Chesapeake Physician and Mojo Media, LLC cannot be held responsible for opinions expressed or facts supplied by authors and resources. Printed on FSC certified, 100% PCW, chlorine-free paper
CASES
Collagenase Injection: An Alternative to Surgery for Dupuytren’s Contracture By Jessica Brown, MD
CASE: A 49-year-old woman with blue eyes and fair skin presented with severe Dupuytren’s contracture of her little finger. She first noted thickening of her palmar fascia and a nodule in her 30s. She had a positive family history of Dupuytren’s that included her father, brother and several cousins. At the time of onset of palmar fascia thickening, she had consulted with her primary care physician, who referred her to a hand surgeon. However, due to the fact that her family members had experienced poor outcomes after receiving surgical treatment for their contractures, she had refused surgery. Her palm gradually developed contractures, and she was seeking an alternative to surgery. Dupuytren’s diagnosis was confirmed upon physical examination. Treatment alternatives, including open fasciectomy and needle fasciotomy, were discussed. The patient rejected all surgical options, not only because of the poor results of family members’ surgeries, but also because she knew surgery carried other risks, such as stiffness and infection. Because diseased tissue may attach to the skin, surgical removal can be difficult and may require skin grafting. Fat pads may also have to be removed during surgery. Physical therapy is typically required, and recovery generally takes several weeks to months. Instead, the patient received a single injection, in the office, of collagenase, isolated from clostridium histolyticum (Xiaflex) into the contracted collagen cord. The following day, she returned to the office where the cord was popped and her hand was straightened. Two weeks post injection, her results were superior to typical surgical results. Results are expected to last for approximately five years, when a repeat injection can be given if appropriate.
DISCUSSION: Dupuytren’s contracture is created by excessive collagen deposition that typically causes contracture in the metacarpophalangeal and/or proximal interphalangeal joints. Progressive fibromatosis typically leads to the formation of nodules and painless tissue contraction, generally progressing slowly. The cause is unknown, but may be associated with an autoimmune reaction. It may also cause contractures of the penis (Peyronie’s disease) or feet (lederhosen disease). Dupuytren’s affects seven times as many males as females, typically after 50 years of age. Other risk factors include northern European descent like this patient, a family history of the disease, smoking, alcohol use and diabetes. It is an autosomal dominant condition, requiring that only one parent have the abnormal gene. Diagnosis is typically made through a thorough history and physical examination of the hands, including strength, range of motion, presence and location of any nodules. An X-ray may be ordered, but no additional testing is required. While fine motor coordination is usually not affected since the thumb, index and middle fingers are not affected, patients often present complaining of difficulty with activities such as grasping objects, putting on gloves or shaking hands. Studies of Xiaflex found that the average patient required 1.7 injections to eliminate the contracture and create a ‘tabletop’ flat hand. Some 30 to 50% of patients require re-treatment within five years. After completion of
Phase-3 clinical trials, Xiaflex was approved by the FDA in February 2010 for treating Dupuytren's. Treatment Approaches
Mild Dupuytren’s contracture may be treated conservatively with heat, massage and by using padded, built-up handles during daily activities that involve grasping. Stretching and splinting are contraindicated. When conservative measures are insufficient, surgery used to be the primary treatment option, but minimally invasive options, such as needle aponeurotomy and collagenase injection to disrupt the cords and restore range of motion, have become more widespread. This case reflects the growing trend to move toward chemical treatment of medical problems in place of surgical treatment. Needle aponeurotomy uses a hypodermic needle under local anesthetic to ‘break’ the cord of tissue that causes the contractures. The procedure can be repeated when contractures recur. The procedure can be performed on more than one finger at the same time, and requires little or no physical therapy post-procedure. Its use, however, is usually restricted to the palm, as nerve and tendon damage can occur in the finger. Collagenase injections into the collagen cord can soften the contracture to allow the physician to manipulate the hand and straighten the fingers. The injection needs to be given by a trained physician to avoid risk of tendon rupture. Jessica Brown, MD, is an orthopaedic surgeon who is fellowship-trained in hand surgery. She can be reached at jbrown@sansumclinic.org.
JULY/AUGUST 2015
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SOLUTIONS
Developing Physician Leaders for Tomorrow By Linda Harder • Photography by Tracey Brown
A
S HEALTHCARE delivery models become more complex, and reimbursement transitions from fee-for-service to population healthbased approaches, strong physician leadership is more essential than ever. Yet few programs exist to help physicians develop the skills they need to go beyond managing organizations to effectively leading them. That’s why Mark Rulle, EdD, president, Maryland Healthcare Education Institute (MHEI), is so passionate about a new program his organization launched last fall called the Physician Leadership Initiative. Designed specifically to meet the needs of tomorrow’s physician leaders, the initiative offers a four-day program in the fall that includes discussions, readings and onsite experiences at companies that are at the forefront of leadership development, followed by three breakfast meetings in the spring. Rulle describes the rationale for this program. “I see physicians getting into more formalized leadership positions now – we’ve really come full circle. Physicians used to lead hospitals, but in the 1970s, lots of professional administrators came out of school to manage increasingly complex jobs. Today, clinical care has become so important again that it’s incumbent on physicians to develop into leaders. The role of chief of staff still exists, but it’s more important than ever, and doctors find themselves ill prepared for these roles. “We only accept 15 people into our leadership program, and most are leaders under age 40. Most of our participants are just starting and wondering how leadership works. They often have no peers or mentors they can count on. First we discuss changes at the 30,000-foot level. Then 8|
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we talk them through a particular situation, such as how to have constructive conversations with other caregiving staff or how to balance their clinical duties with their administrative responsibilities.
Being the boss is not the same as being a good leader. – Mark Rulle, EdD
“They can discuss what they have tried in their own workplaces, then get input from the others in the group,” he adds. “Experienced physicians facilitate the discussions. Our goal is not to give them an answer, but to arm them with some skills to develop potential solutions to their problems. Our attempt is a first step in formalizing the leadership process and starting to connect them with peers and older physicians for support. Mark Rulle, EdD, president, Maryland Healthcare Education Institute (MHEI)
“The sessions cover critical leadership topics such as how to build trust and how to engage people, even when you have no direct reports. Physicians are encouraged to develop their listening skills and their ability to understand other people’s viewpoints, characteristics that are critical to effective leadership. We concentrate on getting results and discuss how you hold everyone accountable within the current culture, which likely is not ideal. We also talk about whether you take an incremental approach or try to change the culture in one fell swoop.” Leadership Requires Emotional Intelligence
“Leadership is not the same as administrative work or paperwork,” Rulle remarks. “An MBA can provide financial and business skills, strategic planning and the like, but you aren’t necessarily trained in how to change the culture, how to engage employees, and other leadership skills. Being the boss
is not the same as being a good leader.” He reminds physicians that being a leader is less about your title and more about who you are and how you act in a given situation. Drewry White, MD, MBA, FACEP, chief of Emergency Medicine at Carroll Hospital Center in Westminster, Md., and the regional medical director of Emergency Medical Associates (EMA), a large group of about 250 physicians and 100 PAs that staffs 16 ED sites, concurs with Rulle. He says, “The key leadership criterion is emotional intelligence. It’s less and less about your IQ – everyone who graduated from medical school is smart. The keys are skills such as how you react to other people, and how you get buy-in for something when it’s not popular.” Leadership Academy for Emergency Physicians
Having received his own MBA in the early 2000s, Dr. White co-chairs the group’s Leadership Academy, which provides administrative and leadership training to potential leaders within EMA. “Medicine is becoming an increasingly complex profession,” Dr. White observes. “Medicine self-selects for people who like to continue learning throughout their lives. All of our doctors practice good medicine, but we take one to two with leadership potential from each site and provide half-day sessions every other month for one year, plus assignments. All doctors can benefit from good leadership skills, whether leading the medical staff or a team of nurses, or meeting C-Suite leaders in the hallway.” He outlines some of the content his group’s Leadership Academy covers. “We teach promising leaders a variety of skills, including how to have difficult conversations, such as during an annual evaluation, how to conduct meetings and how to survive office politics. We also cover accounting, finance and human resources skills. I use real emails I’ve received to demonstrate email etiquette, and inappropriate social media posts to show what not to do. We walk attendees through politically charged situations and talk about how to handle them.” Leadership Resources
Rulle recommends several resources for physicians interested in honing their leadership skills. The first is The Leadership Challenge by James Kouzes
and Barry Posner, first published 25 years ago. The 25th anniversary edition of the book features over 100 new case studies and examples, and describes the five practices of exemplary leadership. Other resources used in the course include components of Stephen Covey’s work, from his popular books, The 7 Habits of Highly Effective People, The 8th Habit: From Effectiveness to Greatness and Principle-Centered Leadership. And the course includes some TED talks by Simon Sinek, a leadership expert and author. MHEI also offers an annual leadership conference each fall that can serve as a resource for area physicians in leadership positions, and the 2015 conference will feature Sinek as a keynoter.
Drewry White, MD, MBA, FACEP, chief of Emergency Medicine at Carroll Hospital Center in Westminster, Md.
The key leadership criterion is emotional intelligence. – Drewry White, MD, MBA, FACEP
Dr. White contributes, “The Emerging Leaders Program in Montgomery County, Md., is another great leadership training program.” It involves eight monthly interactive sessions for leaders under age 35 who live or work in the county, and is not limited to healthcare leaders. Rulle also notes that a servant leadership approach, a term coined by Robert K. Greenleaf in The Servant as Leader, an essay first published in 1970, can help physicians become more effective leaders. He explains, “The servant leader recognizes that he is not there to give orders but to serve other people. That allows you to engage with those you work with, and hear them on their terms. I’m also a proponent of
recognizing that the people reporting to you know what they’re doing. Engagement works better than getting it done by decree. Healthcare has many educated, talented people, and you’re wasting talent if you don’t engage them and allow them to speak up.” Mark Rulle, EdD, president, Maryland Healthcare Education Institute Drewry White, MD, MBA, FACEP, regional medical director of Emergency Medical Associates and chief of Emergency Medicine at Carroll Hospital Center
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EVOLUTION IN
ORTHOPAEDIC TREATMENT BY LI NDA H A RD ER • PHOTOGRA PHS BY TRAC EY B ROW N
In this issue, experts explain the advantages of zero profile devices for cervical fusion, discuss new challenges and therapies in pediatric bone health and describe how to get the most from physical therapy referrals.
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NEWER TECHNIQUES FOR CERVICAL FUSION The cliché ‘pain in the neck’ has its roots in a common orthopaedic problem, with about one-third of spine problems related to cervical pain. For patients suffering pain without compression of the cervical nerve roots or spinal cord, conservative treatments generally suffice. But when stenosis or herniated discs impinge on these structures, some patients will require surgery. Ira Fedder, MD, a fellowship-trained spine surgeon with Towson Orthopaedic Associates, describes how to differentiate patients with radiculopathy from those with myelopathy. “Radiculopathy involves compression of a nerve, while myelopathy involves compression of the spinal cord. Radiculopathy often presents with arm pain, weakness and
numbness and abnormally low reflexes – lower motor neuron issues. In contrast, patients with cervical myelopathy will have abnormally ‘brisk’ reflexes – positive Hoffman’s and Babinski’s, clonus and positive scapular humeral reflex above C3.” Dr. Fedder notes that radiculopathy can be treated conservatively, with progression to surgery only if conservative measures fail. However, he recommends that patients with myelopathy be referred to a spine surgeon immediately. Myelopathy Symptoms May Be Overlooked
“The thing that confuses people about spinal stenosis is that the neck pain is unimportant, but problems with fine motor skills, such as putting on jewelry
or makeup, are significant for myelopathy,” he continues. “Patients often say they’re fine, but they may have stopped wearing jewelry or may have progressed to having their spouse do their buttons for them without realizing this is cervical stenosis. Instead, they often attribute their issues to carpal tunnel or arthritis. I advise people to go home and take inventory of the daily activities they’ve stopped doing.”
With zero profile devices, I can visualize one level at a time because there’s no plate running the entire length of the repair. – Ira Fedder, MD
He adds, “Surprisingly, myelopathy can affect people of all ages. It’s not unusual to find it in people in their 30s and 40s, and genetics can play a role. I had one mother and son with myelopathy, and the son had a more severe case at an earlier onset than his mother. Even older patients in good health with myelopathy can benefit from surgery – I had a 91-year-old patient who had surgery and can now walk and do his activities of daily living independently again.” Surgery is generally a way to prevent disease progression, not a cure. “A lack of progression of symptoms constitutes a good outcome for surgical treatment of myelopathy – it’s important to get them referred early to keep them from progressing,” Dr. Fedder notes.
allograft or autograft, then screwing on a titanium plate to increase stability. A problem with these plates is that they require larger exposure and may displace the esophagus, frequently causing dysphagia. Zero Profile Cervical Devices
To address the problems associated with titanium plates, Dr. Fedder and his partners started using a new approach called ‘zero profile’ devices in 2010. He explains, “With the titanium plates, patients frequently couldn’t swallow or eat normally. With zero profile devices, the surgical technique is segmental, and even when we include more levels the severity of dysphagia is dramatically improved. With some exceptions, patients can eat and drink right after surgery, compared with a typical wait of two to four days following the conventional approach.” Using a zero profile device, surgeons drill pins into the cervical bone, retracting one level at a time to view the spinal cord, rather than having to retract the entire esophagus as is necessary in a traditional approach. The device can be used on up to four levels. “A zero profile device is easier to put in,” Dr. Fedder notes. “When using a plate, I can’t see one level when viewing another – I have to go back and forth constantly from top to bottom. With
zero profile devices, I can visualize one level at a time because there’s no plate running the entire length of the repair.” If only one or two cervical levels are involved, Dr. Fedder and colleagues can create a tiny incision in the front of the neck. With three or more levels, he used to make a vertical incision, but was persuaded to try a horizontal incision. “These incisions heal beautifully,” he exclaims. Dr. Fedder describes the following advantages of the zero profile approach: z z z z z z z z z
Shorter operative time Ability to perform segmental insertion Narrow footprint Lower intra-esophageal pressure Reduced esophageal retraction Less dysphagia Fewer revisions Bone healing visible sooner in some patients No protrusion of a plate to displace soft tissues
Impressive Results
While acknowledging that the zero profile devices still have many skeptics, he notes, “Our results have been impressive. In four years, we’ve put 1,539 of these devices in 788 patients, and at two years out, we’ve had only eight levels that required reoperation,
Anterior Cervical Discectomy
Surgery for radiculopathy and myelopathy involves anterior cervical discectomy and fusion (ACDF), which was developed at Johns Hopkins more than 50 years ago. The anterior approach creates better access to the cervical spine and causes less pain than a posterior approach. Traditionally, this procedure involved removing the affected disc(s), and distracting the spine to permit the insertion of a bone
Laura Tosi, MD, director of the Children’s National Health System Bone Health Program in Washington, DC
plus five documented screw fractures. The company we use is very responsive and very engineering-driven. I haven’t used a traditional plate since 2010, and personally haven’t had to revise a single patient.”
PEDIATRIC BONE HEALTH Laura Tosi, MD, brings her extraordinary enthusiasm and joie de vivre to her work as director of the Children’s National Health System Bone Health Program in Washington, DC, one of the few such programs in the country. “When I started out in pediatric orthopaedics, the expectation was that many children with birth defects or severe illnesses such as cancer would not survive to adulthood. Well, things have changed! The new paradigm is that MOST children will survive, and a significant number will have a normal life expectancy. The challenge is that frequently the disorders and/or their treatments damage the skeleton, leaving children vulnerable to painful and disabling fractures,” she says. The Bone Health Program addresses this growing challenge. Dr. Tosi notes, “Making sure that survivors of childhood-onset conditions don’t fracture is one of the best things I can do to improve the quality of life and independence of this rapidly expanding population. We initiated the program in 2004 and it has grown beyond our wildest expectations. We now treat the full spectrum of metabolic, treatmentinduced and genetic conditions that impact bone quality in children.” Clinicians and families must remember that bone is a “use it or lose it” proposition, she argues, and weightbearing exercise is critical to building and maintaining a strong skeleton. A Resurgence of Rickets
A big surprise has been the number of young children who present with oldfashioned rickets. “The pendulum has swung back to breastfeeding infants and avoiding formula. Overall that is a very positive change. But breast milk doesn’t transmit much Vitamin D to the infant. Without adequate Vitamin D, an infant cannot absorb the calcium needed to build a strong skeleton.” Dr. Tosi explains, “One of my great joys is when a young toddler presents looking like an elderly citizen – and then returns in a few weeks as a running and jumping normal child. I am thrilled 12 |
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when parents ‘accuse’ me of giving their children a personality transplant!” She imparts an important reminder to pediatricians: All breastfed babies need Vitamin D supplementation. “Just a few weeks ago, a colleague referred a one-year-old breastfed fellow who was being evaluated for developmental delay. I found that the child had an almost undetectable Vitamin D level. I am pleased to report that after just six weeks of treatment with Vitamin D, the child is walking and developing normally.”
“Bone is fabulous, as long as you provide adequate nutrition and build it in slow increments,” notes Dr. Tosi. “If someone starts playing competitive tennis at a very young age, at puberty his or her serving forearm can be as much as one-third larger than a ‘normal’ forearm. The bone ‘remodels’ to accommodate the demands being placed on it. But too much demand, applied too quickly, can lead to these slow-healing and painful injuries.” Exciting New Therapies
…breast milk doesn’t transmit much Vitamin D to the infant. Without adequate Vitamin D, an infant cannot absorb the calcium needed to build a strong skeleton. – Laura Tosi, MD
The clinic serves as the training site for the NIH’s Skeletal Clinical Studies Unit (NIDCR). The trainees are able to learn to care for children with a wide variety of metabolic problems, as well as other bone disorders such as skeletal dysplasia. Overuse Injuries in Young Athletes
Dr. Tosi also sees young athletes with overuse injuries that are failing to heal. “Most fractures heal in about six weeks. However, children who participate in only one sport, don’t cross-train, have low Vitamin D and avoid milk or other calcium-rich food-stuffs can develop what is commonly called a stress fracture or overuse injury.” In this injury, the bone fails to remodel quickly enough to accommodate the significant workload imposed by vigorous sports participation. As a result, bone can break, crush or even collapse, causing extreme pain. The X-ray is often normal early on, and the diagnosis may require an MRI.
For some bone disorders, new therapies offer considerable promise. That’s the case for osteogenesis imperfecta (OI), also called ‘brittle bone disease,’ which is caused by one or more of over 1,500 genetic variants. Dr. Tosi comments, “The genetic defect in OI typically leads to the development of an inadequate meshwork to support the calcium critical to making the bone strong. Imagine building the foundation of a skyscraper. You begin by using stainless steel cables to support the cement used in the foundation. In severe cases of OI, it is as though the stainless steel was replaced by toothpicks. Thus the foundation of the skeleton is very weak and prone to injury. There is no cure for this disorder yet. However, the Bone Health Program is one of a handful of pediatric programs nationally to offer specialized bonealtering medications to these children. We offer pamidronate infusions, a bisphosphonate drug that helps strengthen OI bone by slowing bone resorption, an important step in bone remodeling.” Dr. Tosi adds, “Pamidronate can also interrupt the vicious cycle of repeated fractures in other children with disabilities. We are carefully exploring the impact of medical treatment for children with other disorders that can lead to bone fragility, as well.” “Bone formation is time-limited – you have to make the strongest possible skeleton when you’re young,” Dr. Tosi concludes. “Unfortunately, the closer a child is to puberty when she or he becomes ill, the less time they have to repair their bone health. We are eager to meet and evaluate all children with disorders that are impairing normal bone formation as early as possible, so that we will have the maximum possible time to help them improve their bone health and achieve their full genetic potential.”
check the patients’ insurance benefits first, and then we can prescribe PT directly without a physician referral. We refer appropriate patients to an orthopaedist, and we send an initial evaluation and monthly progress notes to the primary care physician and orthopaedist as appropriate.” Among the most common issues Perone treats are shoulder and knee injuries in active middle-age populations and in high school athletes. Studies have shown that a frequent cause of knee pain is imbalanced structures in the hip. “A lot of knee pain comes from the hip, with weak hip abductors and external rotators, which increase the stress on the knee,” Perone explains. “We use a variety of techniques for pain relief, including icing and electrical stimulation, as well as strengthening and stretching. Often, manually loosening the lateral quads in the iliotibial band area can help.” Graston Technique
The Graston Technique® is a form of instrument-assisted soft-tissue mobilization that allows PTs and chiropractors to effectively break down scar tissue and fascial restrictions. It employs a set of stainless steel instruments to identify and treat areas that are chronically inflamed or fibrotic. “It breaks up fibrotic soft tissue and promotes healing,” notes Perone. “We use lotion along with one or more of the metal tools in the kit to loosen the myofascial tissue.” The Graston Technique can treat both chronic and acute post-surgical problems, offering advantages that include: z Tom Perone, DPT, director of Physical Therapy at Mid Atlantic Sports Therapy and Rehab
PROMPT PT REFERRALS Getting the most out of physical therapy (PT) may depend in large part on a timely referral. Tom Perone, DPT, director of Physical Therapy at Mid Atlantic Sports Therapy and Rehab, urges physicians to refer patients who are not getting significant improvement in pain and function two weeks after an injury to an orthopaedist and/or directly to a PT. “Rest, ice and anti-inflammatories are appropriate treatment for the first two
weeks,” he says, “but then patients who aren’t improving by at least 50 to 80% need to be referred out for further differential diagnosis. As long as there’s no suspicion of a serious traumatic injury such as a rotator cuff, ACL or meniscal tear, you can refer basic strains and sprains directly to a PT rather than an orthopaedist. Patients also can refer themselves directly to a PT, in most cases without risking the loss of insurance coverage.” Perone describes the process. “We
z z z
Decreasing overall time of treatment Promoting faster recovery Reducing the need for antiinflammatory medication Resolving chronic conditions thought to be permanent
Providers must attend a 12-hour M1-Basic Training course before being qualified to treat patients with this technique. Trigger Point Dry Needling (TDN)
Appropriate for patients who are not responding to less-invasive approaches, TDN generates a twitch response from fibrotic tissues that releases the JULY/AUGUST 2015
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superficial muscles and allows therapists to access the injured joint more effectively. The technique uses the same microfilament needles found in acupuncture, but involves a different approach based on Western medical research and principles, not traditional Chinese medicine. Called dry needling because it does not involve injecting a solution, TDN is useful for reducing muscle tension and spasm resulting from arthritis, nerve irritation, muscle or ligament strain, or herniated discs. Injured muscles typically go into a protective contracture and inflamed state that becomes hypoxic and results in fibroblast buildup. “Because it is more invasive and can be uncomfortable, I usually try other techniques first,” Perone explains, “and I discuss using TDN with the referring physicians before using it. It works well in conjunction with other techniques, and data has proven its success in short-term pain relief and increased mobility. It can take six to eight sessions to get the maximum results.” PTs Now Need Doctorate
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For the last decade, PTs have been required to get a doctorate degree that involves a science-related undergraduate degree plus seven semesters of PT training. The curriculum typically includes biology, exercise physiology, kinesiology, anatomy, joint mobilization/manipulation, and also basic training in imaging, pharmacology and differential diagnosis. PTs in practice prior to the new requirements could be grand-fathered in without additional training. PT assistants must get an associate degree that involves a five-semester program. They can perform daily treatments but not evaluations or reassessments, and they cannot independently make changes to the plan of care.
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Ira Fedder, MD, a fellowship-trained spine surgeon with Towson Orthopaedic Associates Laura Tosi, MD, director of the Bone Health Program at Children’s National Health System Tom Perone, DPT, director of Physical Therapy at Mid Atlantic Sports Therapy and Rehab
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The state of transplants BY LI N DA HA RD ER
Medical experts from the Chesapeake region discuss how pre-clinical trials are benefiting a wide range of transplants, and what’s new and exciting in liver transplantation.
Rolf Barth, MD, associate professor of Surgery at the University of Maryland School of Medicine and director of Liver Transplantation at the University of Maryland Medical Center
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IMMUNOSUPPRESSION RESEARCH ADVANCES COMPLEX TRANSPLANTS Transplanting several genetically distinct types of cells, as is required to transplant a face or hand, was once deemed impossible. The development of a new field, vascularized composite allograft (VCA), was critical for enabling these complex transplants involving multiple cell types, including skin, bone, muscles, blood vessels, nerves and connective tissue. Results from pre-clinical transplant models conducted over the past 10 years at the University of Maryland in Baltimore are now paving the way not only for the long-term success of face and hand transplants, but also to improve more typical organ transplants such as liver, pancreas and kidneys. Rolf Barth, MD, associate professor of Surgery at the University of Maryland School of Medicine and director of Liver Transplantation at the University of Maryland Medical Center, completed a post-doctoral fellowship in Transplantation Immunology and has special expertise in pre-clinical transplantation models. Pre-Clinical Trials Pay Off
He recalls, “When I arrived at the University of Maryland in 2006, Dr. Stephen Bartlett had initiated pre-clinical studies in face transplantation, that I
joined, along with Dr. Eduardo Rodriguez, a reconstructive surgeon. Our goal was to understand as much as possible about transplants via pre-clinical models first, before we undertook clinical transplants. We received over $10 million in funding to set up a rigorous program for preclinical hand and face transplants. We spent the first four years in the lab to understand the unique challenges and pitfalls of these transplants.” The first successful hand transplant was performed in 1999, and the first of over 25 face transplants took place in 2005. However, these transplants were controversial, sporadic and the long-term outcomes were unknown. Most of the face transplants also were partial. The research at University of Maryland is helping to change that. Dr. Barth explains, “We explored the potential for long-term success before undertaking any clinical trials, and reached a series of findings that led to our initial clinical trial. Short-term results had been encouraging in experimental transplants elsewhere, but we resolved to demonstrate that a long-term approach was viable.” He adds, “Some pre-clinical trials have demonstrated that infusing bone marrow at the time of transplant can be beneficial. That motivated us to conduct clinical trials. Getting through the review board process took over a year, and we had to also work with the donor side, but we’re used to long wait times in the transplant field. We also learned that some immunosuppression drugs could be predicted not to work with the face, and we identified some new types of infection.” One of their more encouraging findings was that transplants containing bone and bone marrow might protect skin cells, despite the fact that these cells are highly subject to rejection. While some 90 to 100% of results showed early rejection, Dr. Barth and his colleagues found that, as long as the transplant contained bone marrow, the results were reversible. And if they could successfully use FDA-approved and tolerable levels of immunosuppression drugs to get patients through the short term, they could be more successful in the long term. Research Results in a World-Famous Face Transplant
The research that Dr. Barth and his colleagues performed paved the way for
the highly publicized face transplant for Richard Norris in 2012. Norris, who had accidentally shot himself in the face 15 years prior, was a rare full-face transplant, and was considered the most ambitious to date. He received upper and lower jaw, tongue, blood vessels, skin, nerves, and bone from a deceased organ donor. Dr. Barth notes with a laugh, “This was the first time our work had been published in the likes of GQ Magazine, rather than strictly in medical journals.” However, being able to successfully perform face and hand transplants has less to do with cosmetic outcomes for a handful of civilians like Norris, and more to do with the growing number of military personnel who survive blasts from improvised explosive devices and similar catastrophic events. “We’re awaiting final approval from the Department of Defense to perform a second face transplant, which helps fund our research,” states Dr. Barth.
Vascularized Bone Marrow
Dr. Barth explains, “We’re seeking to better understand the role that vascularized bone marrow plays in protecting transplanted cells. It appears to be far better to transplant a piece of bone marrow than to infuse marrow into the blood. For organ transplants, we can separately transplant a piece of bone to provide that protection. It’s like transplanting a whole ‘factory’ of immune cell development.” In a 2015 letter to the editor of the American Journal of Transplantation, Dr. Barth wrote, “We have previously shown in a nonhuman primate (NHP) a facial transplantation model that co-transplanted vascularized bone marrow (VBM) in the allograft improved outcomes when compared to VCA without VBM… No animal with infused BMC [bone marrow cells] demonstrated any evidence of chimerism, in contrast to three of four VCA+VBM animals that
It appears to be far better to transplant a piece of bone marrow than to infuse marrow into the blood. – Rolf Barth, MD
“We think we’ll have approval to enroll our second patient within the next month, but then we still have to find the right blood type and physical match for this patient. We ideally match size, coloration, gender, immunology and blood compatibility. The ideal patient is someone with complicated injuries that can’t be restored with a traditional approach.” He adds, “The advantage of VCA is that we can fix function as well as appearance in only one operation. However, patients still need lifelong medications at a higher level than that needed for organ transplants. And immunosuppression creates a higher risk of malignancies, infections and other medical problems. We’re seeking to decrease the level of immunosuppression needed, but we’re happy with achieving stable graft function. It’s an exciting development for the field.” This immunosuppression research also has exciting implications for other organ transplants, which are far more common. There are over 100,000 people in the US waiting for transplants, and 18,000 of those are waiting for livers. Half of those patients won’t survive over a year.
demonstrated transient chimerism… These data suggest that compared to infused bone marrow, VBM may improve VCA outcomes by minimizing pretransplant conditioning and chronic immunosuppression, thus reducing rejection episodes.” Dr. Barth underscores the importance of pre-clinical research. “While much of transplantation is focused on sewing things into people, the future is in the lab,” he concludes. “That lets us make possible things that were never possible before.” NEW APPROACHES FOR LIVER TRANSPLANTS MedStar Georgetown Transplant Institute is a busy place, where 116 liver transplants and some 350 total transplants were performed in 2014. Thomas Fishbein, MD, executive director of the Institute, discusses the evolution of liver transplant approaches that are allowing more people to benefit, and describes the shift in medical issues that necessitate this major procedure. First, Dr. Fishbein notes that the oneyear survival rates after liver transplant have increased to about 95%, thanks in large part to the new medications that JULY/AUGUST 2015
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PHOTO COURTESY OF MEDSTAR GEORGETOWN TRANSPLANT INSTITUTE
Thomas Fishbein, MD, executive director of the MedStar Georgetown Transplant Institute
cure hepatitis C – currently the most prevalent indication for liver transplantation in adults. “Many baby boomers have hepatitis C. Three to six months post transplant, if their virus reappears, we can treat them with one of the new medications to cure their underlying hepatitis. We’ve virtually eliminated the main cause of death post transplant,” he says. Medications for hepatitis B also have improved significantly, preventing recurrence of this disease in patients post transplant. Early Consult and Treatment Are Critical
According to Dr. Fishbein, some primary care physicians mistakenly believe that patients with large liver tumors or advanced cirrhosis are ineligible for anything except palliative care. “Get a consult early,” he strongly recommends. “Scarring of the liver is often reversible and we can often treat tumors if we see them in time.” Non-alcoholic liver disease (‘fatty liver’) is increasing rapidly in the US at the same time that new hepatitis C curative medications are available. “It takes 20 to 30 years for hepatitis C to cause cirrhosis,” Dr. Fishbein notes. “But many patients with acute liver failure from drugs, such as treatment for high cholesterol, can create an urgent situation where patients must receive a transplant within weeks. These are a higher priority for a transplant.” Liver Tumors Benefit from Transplant
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transplantation. “We can cure cancer with transplants by resecting the liver when there is only one tumor affecting a small area, or removing the entire liver when the patient has multiple tumors,” explains Dr. Fishbein. “Today, some 30 to 40% of transplants are performed to cure liver cancer. Adenomas will turn malignant if not removed, and we’re seeing growing numbers of patients with as many as 10 adenomas. They ideally should be referred before they get to this stage.” Even patients with tumors over five centimeters may be eventual transplant candidates when radiation therapy administered prior to surgery can shrink the tumor. Dr. Fishbein states, “People often assume nothing can be done for these patients, but we can take tumors that wouldn’t be candidates and downstage them using radiation oncology or other methods. For example, we can shrink a six-centimeter tumor to four, then perform a transplant.” The center also treats patients with any kind of bile duct or hepatobiliary tumors. Pediatric Liver Disease
Congenital anomalies are the primary indication for pediatric liver transplants, such as biliary atresia, where the bile ducts don’t form during embryogenesis. The second-largest cause is acute liver failure, typically from an autoimmune disease or a virus. “These children typically present as confused and with jaundice,” Dr. Fishbein explains. “The third-greatest cause – but the fastest growing – is metabolic liver diseases, which includes maple syrup urine disease
(MSUD) and nearly 30 other such diseases in which an enzyme is missing. “In MSUD, children don’t get cirrhosis, but the missing enzyme creates a buildup of toxins that leads to an elevated ammonia level and brain damage,” he continues. “Working with Children’s National Medical Center in Washington, DC, we stabilize these children medically, then send them for a transplant. Consanguineous marriages, such as those in the Mennonite or Amish populations, put children at higher risk for these disorders.” These defects can be addressed with ‘domino transplants,’ in which the child gets a cadaveric liver and passes their liver on to an adult. While the metabolic defect in the liver is fatal to the child because the same defect is present in his or her muscle cells, the defect is harmless in someone without the congenital disorder. Opt-Out System Would Increase Available Livers
“We need major changes in the system to address the limited supply of available livers to transplant,” Dr. Fishbein states. “We perform about 6,000 transplants a year in the US, a number that has been steady for decades. If there were a sufficient supply of livers, the demand would vastly increase the number of transplants performed.” He continues, “We need to remove the disincentives to donation and provide reimbursement for living donors, who lose productivity. Also, in our current system, getting permission for cadaveric livers can delay the funeral and increase costs for the family. Some nonprofit groups, such as the Donor Alliance, are working to establish limited trials to provide this support. “We also need an opt-out system, not an opt-in system,” concludes Dr. Fishbein. “In Europe, they presume consent as a donor until proven otherwise. I’m an advocate for having to check off a box when filling out your tax form to help increase supply.”
Rolf Barth, MD, associate professor of Surgery at the University of Maryland School of Medicine in Baltimore, and director of Liver Transplantation at the University of Maryland Medical Center Thomas Fishbein, MD, executive director of the MedStar Georgetown Transplant Institute
Clinical Features In each issue, Chesapeake Physician interviews some of the region’s top specialists to spotlight the latest clinical developments, including leading-edge diagnostic and treatment options.
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HEALTHCARE IT
The Medical hoMe geTs a new neighborhood PATIENT-CENTERED SPECIALTY PRACTICES BY LI NDA H A RDER • PH OTO GRA PH BY TRAC EY BROW N
The Patient Centered Medical Home (PCMH) concept is now part of a burgeoning neighborhood that includes specialists and urgent care centers. In March 2013, The National Committee for Quality Assurance (NCQA) launched the Patient-Centered Specialty Practice™ (PCSP), a program that allows specialists to receive similar recognition to primary care physicians. And in March 2015, they added a new program to complement the existing PCMH recognition program that includes retail clinics, urgent care centers and other ambulatory care sites in the PatientCentered Connected Care™ (PCCC) recognition program. Today there are nearly 50,000 clinicians in over 10,000 sites across the country that have achieved PCMH recognition. The far newer PCSP program has nearly 600 clinicians in 65 sites, which are presently concentrated in New York, Oregon, Kansas and Pennsylvania. The brandnew PCCC program is currently available in about 50 sites, the first four of which are in the mid-Atlantic states. Patient-Centered Specialty Practice
Michael Barr, MD, MBA, FACP, executive vice president of the NCQA, 20 |
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Michael Barr, MD, MBA, FACP, executive vice president of the NCQA
leads the nonprofit’s efforts to promote delivery system reform and performance measurement, research, analysis and consulting work. He was formerly a senior vice president at the American College of Physicians (ACP). He notes, “PCMH evolved from the medical professional societies’ efforts to create a better environment for patient care
and to make primary care more attractive to young doctors. But about half of ACP’s members are subspecialized and they felt left out. We asked ourselves, ‘What would be a good model of care for these specialists?’” Answering that question led to the development of a policy paper by the ACP about the medical home
“neighborhood” and the PCSP by NCQA. All medical specialties or subspecialties are eligible, along with nurse practitioners, physician assistants, certified nurse midwives and many behavioral health professionals. PCSP is geared to specialty practices that are playing a larger role in coordinating patient care, including cardiologists, oncologists, endocrinologists and rheumatologists. It is less appropriate for more procedure-oriented physicians, such as gastroenterologists. Dr. Barr explains, “The spectrum of care by specialists falls into three categories – those who are chiefly providing an opinion to a primary care physician or co-managing patient care, those who provide the dominant level of care – as in treating HIV – and those who provide the vast majority of care, such as medical oncologists for patients in active treatment of a malignancy.” NCQA consulted with medical specialty societies before developing the following criteria for PCSP: z z
z
z
z
z
Track and coordinate referrals with other specialists and PCPs. Provide enhanced access and communication that includes timely appointments, after-hour communications, and patientcentered training for employees that allows them to practice to the full extent of their license or role. Identify and coordinate patient populations by capturing key clinical and administrative data and by using evidence-based tools to manage their care. Plan and manage patient care, including creating a patient-centered care plan and managing medications and referrals to community services as appropriate. Track and coordinate care, including lab and imaging data, from the point of request through receipt and patient notification, and track patients through care transitions. Measure and improve performance on a number of clinical processes or outcomes, as well as patients’ experiences, and share data within and beyond the practice.
A PCSP Specialist’s Perspective
Harry Bigham, MD, is a cardiologist
with Johns Hopkins Community Physicians in Bethesda, Md. An early adopter of electronic medical records, he switched from NextGen to an Epic EHR when his group merged with Hopkins several years ago. Today, he is again in the forefront of medical care as one of the first recognized PCSP specialists. He states, “PCSP is good because it forces us to look at everything we’re doing. You think you’re sending
the incentive payment. It is likely that PCMH and PCSP will qualify. “It’s a lot of work to go through the PCSP recognition process, and it costs money,” Dr. Barr acknowledges. “However, there are many aspects that don’t cost a lot of dollars but that help practices operate more efficiently. Specialists can look at their access issues and address them even if they don’t become credentialed, using selected
…there are many aspects [of recognition] that don’t cost a lot of dollars but that help practices operate more efficiently. – Michael Barr, MD, MBA, FACP
information and reminders to all of your patients and referring physicians, but when you measure it, you realize you’re not doing it as well as you thought, and you clean up existing systems. We benefited from being part of a larger organization that had the resources to help us. “The PCSP credentialing process is worth it in the end,” Dr. Bigham adds. “However, it’s a lot of work and someone has to be a champion to drive the process. It’s better for patients, and can create a tighter relationship with referring physicians. It’s also helping us reinvigorate a team approach to caring for patients.” MACRA Likely to Incentivize PCSP
PCSP is likely to grow more slowly than PCMH, in part because specialists currently have less of a financial incentive to participate in this program than primary care physicians have for PCMH. Yet specialists that adopt some PCSP concepts may find that they boost their efficiency, as well as their enjoyment of practicing medicine. The new Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) established the Merit-Based Incentive Payment System (MIPS), which will give credit to recognized practices for the practice-improvement component of
criteria as a guide for their practice.” He continues, “When people have access to care, studies have found that health disparities melt away. We’re looking at new ways to increase access, including non face-to-face encounters, such as through telehealth and patient portals. However, specialists that are ‘too booked’ to see patients within a reasonable timeframe remain an issue.” While it’s too early to have seen results yet from the PCSP program, Dr. Barr believes that it will foster practices that are better organized, more efficient, and that have more complete patient records because they communicate more effectively with primary care practitioners – ordinarily a common problem for specialists. PCSP also promotes bidirectional conversations, and more conversations with patients and their families. Patient-Centered Connected Care
Dr. Barr notes that Patient-Centered Connected Care, the latest program developed by the NCQA, was developed because, “People are increasingly using retail clinics and urgent care centers for their healthcare, and we’re concerned that they don’t have a primary care physician or that these centers aren’t coordinating with primary care doctors.” JULY/AUGUST 2015
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The goals of this recognition program are to: z Support the use of evidence-based guidelines in treating patients. z Provide a consensus-driven framework for including non-PCMH and non-specialty sites within the medical home neighborhood, and connecting them to primary care. z Help providers become a part of the medical home neighborhood, resulting in better outcomes and improved patient experience. z Improve trust among providers. z Help reduce waste in the healthcare system, such as duplication of procedures and unnecessary readmissions or hospitalizations. Updating the PCMH Program
The NCQA, established a quarter of a century ago, is working hard to be responsive to physician concerns with the original PCMH requirements. Originally launched in 2008, the program has been revised in both 2011 and 2014. “There were critiques of the program that it was more checkbox-oriented
than outcome-oriented,� Dr. Barr concedes. “We heard that practices felt there was insufficient guidance and engagement from NCQA. After talking to lots of people involved with the program, we announced our redesign strategy in March 2015. In the future, instead of having applicants work through the process on their own and submit their documentation, we will assign a member of our team to work with practices over the course of their preparation.� After conducting extensive research that included focus groups, NCQA will also lessen the documentation requirements for new practices and employ more web-based tools. “Many small practices have achieved PCMH recognition, even though offices of five to 15 clinicians might have more internal resources to support the recognition process,� Dr. Barr remarks. The recognition process typically takes between six and 18 months, depending on how quickly the practice wants to convert. “We’re also planning to use data already generated by practices, such as that for the PQRS
program, to support their recognition for PCMH,� says Dr. Barr. “And in place of the current requirement that practices go through the process every three years, we are considering a transition to a more streamlined annual process for practices that have already achieved recognition.� He adds, “Additionally, the online platform is getting a complete overhaul with the help of usability experts. We’ll have some pilot projects in the second half of 2015 and will introduce some of the new concepts then, and we’ll probably roll out the fully redesigned platform in 2017, though you’ll see some changes sooner than that. We’re working to become more customer-friendly and to have an attractive, useful model.�
Michael S. Barr, MD, MBA, FACP, executive vice president of the NCQA Harry Bigham, MD, a cardiologist with Johns Hopkins Community Physicians in Bethesda, Md.
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INCIRCULATION SUMMER 2015
The Official Publication for Center For Vascular Medicine™ VOLUME 1
Sanjiv Lakhanpal, MD
ISSUE 3
THE CENTER FOR VASCULAR MEDICINE MEETS THE TRIPLE AIM OF THE AFFORDABLE CARE ACT JEANNE SANDERS, RN, FACHE VICE PRESIDENT, CENTER FOR VASCULAR MEDICINE
Vinay Satwah, DO
Mike Malone, MD
Gaurav Lakhanpal, MD
Shekeeb Sufian, MD
T
he Affordable Care Act (ACA) was created with the goals to expand healthcare access, control costs and improve quality. Signed by President Obama in 2010, it introduced the possibility of unprecedented access to healthcare for patients throughout the United States. This legislation, which contains over a thousand pages of provisions and requirements, represents the largest overhaul of the US healthcare system since the introduction of Medicare in 1965, 45 years earlier. Of the ACA’s numerous requirements of employers, patients and insurance companies, one of the most important is the requirement that insurers provide coverage regardless of pre-existing medical conditions. For the first time, patients must be offered coverage despite previous disease diagnoses. This is vitally important to the tens of thousands of Americans who suffer with chronic conditions such as vascular and kidney disease. Although there is continuing debate regarding the ACA, it is clear that more patients today have healthcare insurance coverage than ever before. An extensive study by the Rand Corporation (Modern Healthcare, May 6, 2015) reports that 17 million more Americans have health insurance coverage since the launch of the ACA. This tremendous increase in patients with coverage has resulted in the demand for enhanced access to both primary care and specialty services. The ACA also encourages the use of safe and costeffective healthcare delivery models. The goal is to reduce the growth of healthcare spending that accounts
for 17.4% of the Gross Domestic Product (Congressional Budget Office, December 2014). It appears that the emphasis on cost effectiveness is working. The 2013 rate of growth was only 3.6%, the lowest increase ever recorded (Health Affairs, December 2014). The Center for Vascular Medicine (CVM) is committed to the ACA goals of expanding access to coverage, controlling costs and improving quality. Our clinical offices in Greenbelt, Annapolis, Prince Frederick, Glen Burnie and, Silver Spring, Md., offer patients from a wide geographic region convenient access to board-certified vascular specialists. Patients requiring treatment for venous and/or arterial disorders can typically be treated in our state-of-the-art minimally invasive outpatient angiography suites in Greenbelt, Annapolis and Prince Frederick. eHealthcare costs in outpatient office-based suites are lower than inpatient facilities due to the tighter control of staffing, supplies and scheduling (Becker’s ASC Review, January 2015). Our commitment to improved eHealthcare quality is consistently demonstrated by our participation in the Physician Quality Reporting System (PQRS) and our Intersocietal Accreditation Commission (IAC) accreditation. CVM also submits quality data to Medicare to demonstrate our performance. The Affordable Care Act contains additional provisions that will be introduced in the future. The physicians and providers at the Center for Vascular Medicine will continue to be leaders in demonstrating our commitment to the goals of enhanced access, controlled costs and improved quality. For us the future is now!
Tom Militano, MD
C E N T E R
F O R
Pelvic Pain Krutiben Patel, PA-C
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POST-THROMBOTIC SYNDROME: A COSTLY COMPLICATION OF DVT BY GAURAV LAKHANPAL, MD, FACC, RPVI
P
ost-thrombotic syndrome is the development of symptoms and signs of chronic venous insufficiency following deep vein thrombosis (DVT). It is a common, burdensome and costly complication. The term “post-thrombotic” replaces the prior terminology “postphlebitic” syndrome. Pathophysiology: Post-thrombotic syndrome develops as a consequence of long-standing venous hypertension. A combination of reflux due to valvular incompetence, and venous hypertension due to thrombotic obstruction, is thought to contribute to post-thrombotic syndrome. Acute DVT causes obstruction of venous outflow, which can be partial or complete. The inflammatory response to acute thrombosis and the process of recanalization directly damages venous valves. Reflux occurs early, progressively increasing from 17% of patients at one week to 69% at one year following the diagnosis of DVT. Epidemiology: The reported incidence of post-thrombotic syndrome varies widely. Among studies that use validated diagnostic criteria, the incidence is approximately 50% in the first year in spite of anticoagulation. Severe post-thrombotic syndrome occurs in 5 to 10% of patients. Risk Factors: Patient-specific factors that may increase the risk for post-thrombotic syndrome include pre-existing
primary venous insufficiency, older age, obesity and varicose veins. There does not appear to be a consistent relationship between gender and the development of post-thrombotic syndrome. The development of recurrent ipsilateral DVT is strongly associated with the risk for the post-thrombotic syndrome. Proximal DVT increased the risk for postthrombotic syndrome twofold compared with distal DVT. The risk of post-thrombotic syndrome is greater in patients who do not maintain adequate anticoagulation during initial treatment for their DVT. The use of thrombolytic therapy to treat acute proximal DVT may decrease the risk of post-thrombotic syndrome by reducing clot burden or possibly preventing proximal vein valve dysfunction; however, it is not clear whether the benefits outweigh the risks involved. Clinical Features: Symptoms and signs can include extremity pain, venous dilation, edema, pigmentation, skin change, and venous ulcers. Edema occurs in approximately two-thirds of patients with post-thrombotic syndrome, skin pigmentation in about one-third, and venous ulceration in less than 5%. Diagnosis: The diagnosis of postthrombotic syndrome is predominantly clinical. Venous imaging, typically duplex ultrasound, may be useful for patients in whom the clinical signs of chronic venous insufficiency are not obvious, those with
a clinical history that suggests DVT but that did not undergo studies, and those with severe symptoms. Treatment: Conservative management includes exercise, limb elevation, compression therapy, and possibly pharmacologic therapy. Venous intervention: Endovascular or surgical interventions in appropriately selected patients with venous obstruction or reflux may decrease the incidence of recurrent ulceration and skin changes and improve quality-of-life in patients with chronic venous disease. Occluded or stenotic iliac vein segments can be treated using percutaneous angioplasty, with or without stenting, venous bypass or endophlebectomy. Surgical vein bypass is an option for selected patients with severe proximal venous reflux, but only if percutaneous intervention has failed to restore flow; however, it is limited to certain highvolume referral centers. Patients with focal symptoms and venous ulceration may benefit from treatment of incompetent superficial veins. Quality of Life: Post-thrombotic syndrome causes significant disability and economic burden for patients and the healthcare system. In a study of patients two years after DVT treatmens, quality of life measures of patients with postthrombotic syndrome were comparable to published norms for those with angina, cancer, or congestive heart failure.
REFERENCES: Kahn SR, Partsch H, Vedantham S, et al. Definition of post-thrombotic syndrome of the leg for use in clinical investigations: a recommendation for standardization. J Thromb Haemost 2009; 7:879. Porter JM, Moneta GL. Reporting standards in venous disease: an update. International Consensus Committee on Chronic Venous Disease. J Vasc Surg 1995; 21:635. Franzeck UK, Schalch I, Jäger KA, et al. Prospective 12-year follow-up study of clinical and hemodynamic sequelae after deep vein thrombosis in low-risk patients (Zürich study). Circulation 1996; 93:74. Bergan JJ, Schmid-Schönbein GW, Smith PD, et al. Chronic venous disease. N Engl J Med 2006; 355:488. Prandoni P, Kahn SR. Post-thrombotic syndrome: prevalence, prognostication and need for progress. Br J Haematol 2009; 145:286. Yamaki T, Nozaki M, Sakurai H, et al. High peak reflux velocity in the proximal deep veins is a strong predictor of advanced post-thrombotic sequelae. J Thromb Haemost 2007; 5:305. Nicolaides AN, Hussein MK, Szendro G, et al. The relation of venous ulceration with ambu-
latory venous pressure measurements. J Vasc Surg 1993; 17:414. Araki CT, Back TL, Padberg FT, et al. The significance of calf muscle pump function in venous ulceration. J Vasc Surg 1994; 20:872. Welkie JF, Comerota AJ, Katz ML, et al. Hemodynamic deterioration in chronic venous disease. J Vasc Surg 1992; 16:733. Roumen-Klappe EM, Janssen MC, Van Rossum J, et al. Inflammation in deep vein thrombosis and the development of post-thrombotic syndrome: a prospective study. J Thromb Haemost 2009; 7:582. Shbaklo H, Holcroft CA, Kahn SR. Levels of inflammatory markers and the development of the post-thrombotic syndrome. Thromb Haemost 2009; 101:505. Kahn SR, Shbaklo H, Shapiro S, et al. Effectiveness of compression stockings to prevent the postthrombotic syndrome (the SOX Trial and Bio-SOX biomarker substudy): a randomized controlled trial. BMC Cardiovasc Disord 2007; 7:21. Markel A, Manzo RA, Bergelin RO, Strandness DE Jr. Valvular reflux after deep vein thrombosis: incidence and time of occurrence. J Vasc Surg 1992; 15:377.
Prandoni P, Frulla M, Sartor D, et al. Vein abnormalities and the post-thrombotic syndrome. J Thromb Haemost 2005; 3:401. Meissner MH, Zierler BK, Bergelin RO, et al. Coagulation, fibrinolysis, and recanalization after acute deep venous thrombosis. J Vasc Surg 2002; 35:278. Bergqvist D, Jendteg S, Johansen L, et al. Cost of long-term complications of deep venous thrombosis of the lower extremities: an analysis of a defined patient population in Sweden. Ann Intern Med 1997; 126:454. Bergqvist D, Jendteg S, Johansen L, et al. Cost of long-term complications of deep venous thrombosis of the lower extremities: an analysis of a defined patient population in Sweden. Ann Intern Med 1997; 126:454. Kahn SR, Shbaklo H, Lamping DL, et al. Determinants of health-related quality of life during the 2 years following deep vein thrombosis. J Thromb Haemost 2008; 6:1105. Ashrani AA, Silverstein MD, Rooke TW, et al. Impact of venous thromboembolism, venous stasis syndrome, venous outflow obstruction and venous valvular incompetence on quality of life and activities of daily living: a nested case-control study. Vasc Med 2010; 15:387.
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CURRENT STRATEGIES FOR MANAGING HEMODIALYSIS PATIENTS IN THE OUTPATIENT SETTING MICHAEL D. MALONE, MD, FACS
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ith advances in the medical field and prolonged survival rates, hemodialysis patients are a rapidly growing population that provides a unique set of challenges to outpatient vascular laboratories. Currently, hemodialysis allows more than 550,000 patients in the United States to live with the disease. FISTULA-FIRST CATHETER-LAST WORKSHOP COALITION The Fistula-First Catheter-Last Workshop Coalition, formed in 1995, is important in the management of hemodialysis access patients today. Its mission is focused on supporting the renal community and End Stage Renal Disease (ESRD) networks to improve vascular access outcomes. This group realizes that appropriate vascular access is the lifeline for these patients. The development and implementation of system changes that support arteriovenous (AV) fistula placement in suitable hemodialysis patients is key to sustainable access. At the same time, this approach reduces central venous catheter use. The use of an AV fistula leads to lower infection, hospitalization and mortality rates while preserving vital Medicare measures. INITIAL CONSULTATION At the initial consultation, the vascular team assesses the patient and formulates an appropriate operative plan to ensure proper care given the patient’s clinical scenario. As outlined in the Fistula First initiative, all attempts are made to use an autogenous vein as a source of conduit if at all possible. To that end, all patients undergo noninvasive venous duplex ultrasound to evaluate the size of the basilic and cephalic veins as possible conduits for hemodialysis. In addition, the patient undergoes duplex ultrasound of the subclavian and jugular veins to assess for patency. Many of these chronic patients may have had central lines for hemodialysis in the past, and to that end these veins may be scarred or damaged. This allows the clinician to glean additional information about the condition of the central venous vasculature, which may be helpful in preoperative planning, as well as in determining a possible source of the problem if the access does fail. OPERATIVE PROCEDURE Based on the finding of the initial assessment and noninvasive evaluation, the patient is scheduled for one of three vascular procedures to provide access for hemodialysis. Ideally, the patient is scheduled for an autogenous arteriovenous fistula where a surgical connection is made between an artery and vein either at the wrist, forearm or upper arm. Autogenous arteriovenous fistulas have the highest patency and lowest infection rates. If an appropriate vein for creating an autogenous fistula is found, the next step is to place a synthetic AV graft. In this instance, a synthetic graft joins the artery to the vein to provide a location where the graft can be accessed for dialysis. Finally, if no suitable conduit is available for creating an arteriovenous fistula and no vein is available for graft placement, then a tunneled catheter can be used for dialysis.
THE FAILING DIALYSIS ACCESS This subset of patients have had an access procedure that has either occluded or is malfunctioning and needs to be corrected. In the past, these patients would have required an operative procedure to correct their occluded or failing dialysis access. However, with the current technology available at CVM, these patients can be treated on an outpatient basis in our freestanding catheterization laboratory. CLINICAL ASSESSMENT The clinician can determine whether this is an acute problem or a chronic problem with a history of prolonged dialysis run times or elevated flow pressures. A history of any hypercoagulable may contribute to premature access failure. On physical examination, clinicians look for a bruit or a thrill to determine if the access is patent on initial assessment. A duplex ultrasound can be performed to look for flow, assess for narrowing or stricture formation and determine non-invasively if there is thrombus formation. In addition, the duplex ultrasound can determine if there are any intrinsic factors such as hematoma or seroma that may be compromising flow in the fistula or graft due to compression. In a slowly maturing AV fistula, side branches can be assessed that may have to be treated at a later date to allow the fistula to mature adequately. This study can be performed in the office in a relatively short period and can help to formulate an appropriate game plan. CONTRAST STUDIES/PERCUTANEOUS TREATMENT In these patients, a percutaneous study can be performed either with a fistulogram or graft study to evaluate the patency of the access site. A declotting procedure can be performed during which a small balloon is inserted under fluoroscopic guidance, and any newly formed thrombus can be removed. Further, clot dissolving agents such as TPA can be used to assist in removing thrombus. Mechanical thrombolytic devices can be used to mechanically dissolve and suction out the thrombus at the time of the contrast study. Once the thrombus is removed, a contrast study can be performed to look for any areas of narrowing in the access site that are amenable to angioplasty. As in the coronary population or in the peripheral arterial disease (PAD) population, a small balloon can be inserted to open up any blocked areas of the graft or native vessels of the fistula or graft. After successful angioplasty, a repeat contrast study can be performed to check for improvement or correction of any abnormalities. If there still appears to be evidence of residual narrowing, a percutaneous stent can be placed as a ‘scaffold’ to correct abnormalities and allow dialysis to continue. To meet the needs of the steadily growing hemodialysis population, an action plan has to be developed when their dialysis access graft is not functioning. With newer technology and advances in outpatient catheterization suites (like Center for Vascular Medicine), a great number of these procedures can be performed in a safe outpatient setting that allows these delicate patients to get the individualized attention they deserve. www.cvmus.com
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he Center for Vascular Medicine (CVM) has been recognized as a national leader in the utilization of intravascular ultrasound (IVUS) in the outpatient setting due to the expertise of its physicians. CVM has become a national training site for physicians that wish to expand their knowledge of this diagnostic technology. In an effort to provide the highest quality of care to patients, CVM has been utilizing IVUS for over two years as a standard diagnostic tool for those suffering from Deep Venous Disease. What is IVUS? Intravascular ultrasound, which uses a catheter equipped with a camera to visualize a vessel from the inside, was first introduced to vascular medicine providers in the late 1980s. It is inserted via a sheath, and is valuable in assessing the patency of a vessel. It is also useful in determining the possibility and degree of obstruction and narrowing.It can also allow the interventionalist to obtain dimensions of the vessel wall for the purpose of stent sizing. CVM has applied this technology as a diagnostic modality for deep vein disease. How does IVUS affect patient care? Many patients may suffer from venous
outflow obstruction (i.e., iliac vein compression) for years without a diagnosis. 4HEY TYPICALLY WILL PRESENT WITH THE FOL lowing symptoms: s 5NILATERAL ,EG 3WELLING s 5NILATERAL ,EG 0AIN s .ON (EALING ,EG 5LCERS s 0ELVIC 0RESSURE s 6ARICOSE 6EINS IN THE INNER THIGH BUTTOCK PELVIC REGION IVUS provides a three-dimensional view of the interior of vessels, allowing physicians to determine the presence and degree of venous disease. In addition, and perhaps more importantly, this technology will determine whether the compression is intrinsic or extrinsic. Intrinsic obstruction occurs due to a
problem from within the vessel and extrinsic obstruction results from an external structure causing compression. Both will cause an increase in resistance to blood flow as it attempts to return from the leg. Who is at risk for venous outflow obstruction? s 0ATIENTS WITH A HISTORY OF $64 DUE to post-thrombotic scarring of the vessel wall s 0ATIENTS WITH PRIOR HISTORY OF PELVIC or lower abdominal surgeries s /BESE PATIENTS s 0ATIENTS WITH MULTIPLE PREGNANCIES (>2)
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POLICY
Today’s Skilled Nursing Facility: Not Your Parents’ Nursing Home
OE DEMATTOS, JR., MA, president of the Health Facilities Association of Maryland (HFAM), an organization that represents more than 150 long-term care providers in the state, including assisted living, post-acute, rehabilitation and skilled nursing facilities (SNFs), discusses the role of long-term-care facilities in keeping patients healthier while reducing healthcare system costs.
Q:
What impact has CMS’ twomidnight rule, which is on hiatus, had on the industry and what do you see as the future of this rule?
It’s a national challenge. One of the things we did at HFAM several years ago is that we worked with Sen. Dolores Kelley to pass legislation that requires Maryland hospitals to inform patients that they’re on observation status and may not qualify for a stay in a longterm-care facility. Senator Kelley was a real and gifted leader in this work. We’ve run into this issue many times, and she was an incredibly passionate advocate. I’ve encountered this problem both personally and professionally. Some patients with a hospital discharge document in place that need rehabilitation services in a SNF don’t realize until they show up at the SNF that they might not have a qualifying stay.
Q:
Is there movement on the national front? Nationally, the
Improving Access to Medicare Coverage Act of 2015 (HR 1571) was introduced by Congressman Joe Courtney (D-CT) in March of 2015; the Republican lead on the bill is Representative Joe Heck (R-NV). It currently has 55 co-sponsors. The Senate version is S. 843, introduced by Senator Sherrod Brown 28 | CHESPHYSICIAN.COM
(D-OH). It currently has 10 co-sponsors, including Senator Ben Cardin. But the rub is that the Congressional Budget Office doesn’t score the savings on the hospital side from this move, it just scores the increase in spending on the skilled nursing side. That’s why this issue has never gained traction. Sen. Cardin has been a leader on this issue because he realizes that, net-net, there will be savings for the system, and that SNFs cost onethird to one-half of the hospital stay.
Joe DeMattos, Jr., MA, president of the Health Facilities Association of Maryland (HFAM)
Q:
Does Maryland’s new waiver have the potential to impact this issue? Yes. Where
Maryland has a unique advantage on this front is in our new hospital waiver, which the state renegotiated over the last two years. Even with the requirement that hospitals have to inform patients if they don’t have a qualifying stay, patients sometimes show up with their family not knowing if they’re covered or not. The old waiver set prices for procedures but it didn’t limit volumes, and it didn’t link the procedures to healthier outcomes. The new waiver caps total hospital spending and the rate of growth in spending, and it tracks hospital readmissions as a quality measure. We’re just now in the first year of that new waiver and the state is starting to think about how to modify the waiver for the years ahead.
What we could do in Maryland is to create a pilot program where you eliminate the three-day-stay requirement under certain circumstances. We think that can improve outcomes, reduce costs and make it better for families.
Q:
What advice do you have for practicing physicians and how will their practices be affected by the trend towards value-based care?
The first thing I’d say to physicians is that they’re more important than ever and the immediate future will be challenging because we’ve entered into an era where talk is turning into action.
PHOTO COURTESTY OF HFAM
J
BY LI N DA H A RD ER
Payers will expect better clinical outcomes with more targeted utilization and less of a spend. Also, physicians more likely than not will maintain more contact with their patients across care settings. For example, I think we’ll see, at least in efficient long-term-care centers, that the cardiologist will continue working with his or her patient when they’re in a rehab facility. This is likely to especially impact cardiology, orthopaedics, endocrinology and psychiatric care, because the readmission rate for these diagnoses is high. Today, the primary care physician may have an electronic health record (EHR), the hospital will have an EHR, but the SNF may not have an EHR that can be used for Meaningful Use. So you’ll see an integration of the EHRs. The Chesapeake Regional Information System for Our Patients (CRISP) is a good beginning, but it provides only
Meaningful Use EHR is to assign an interdisciplinary team, and to challenge that team to work with external partners like physicians and hospitals.
Q
: What should physicians look for when selecting an SNF? If I were a physician in practice and had a choice of working with one SNF over another, I’d look at whether they have an EHR and whether they either directly employ physicians or have a long-established relationship with a quality physician practice. Many of my members, such as FutureCare and Genesis Healthcare, employ physicians. Others use services that act like employed physicians but that are co-employed. That makes up about half of the marketplace. A third thing I’d consider is selecting centers that have a vigorous chronic disease management program. What
…SNFs have most of the capabilities of hospitals at tremendously reduced costs. We have an opportunity to make these centers part of the solution. reports, not the images themselves. Only a handful of rehab centers are plugged into CRISP, although about half have an EHR.
Q
: How prevalent are EHRs in skilled nursing facilities? Six years ago, about 35% of SNFs had EHRs for Meaningful Use, and today it’s about 55%. Almost every SNF has some type of EHR in place for billing and for pharmacy, but for Meaningful Use, it’s almost half that. I don’t believe providers can be competitive in the coming years without having a Meaningful Use EHR. I think it’s a minimum bar for success in the near term. SNFs were not federally subsidized for EHRs like other settings were, so our members have to pay for these systems. Having an EHR for Meaningful Use is a minimum requirement for any provider to deliver quality care. Pharmacy is a major factor in preventable events so it’s a driver for electronic communication and provides a competitive advantage. Key in any center’s development of a
you’re likely to see in the future for diabetes, COPD, congestive heart failure and psych issues, is that the primary care physician remains connected with the patient across all settings. In the best cases, physicians may actually visit the patient in the SNF, or at least be involved in the protocols. They share documents with the hospital and their clinical teams, and with the primary care physician. They literally have one document that’s their ‘playbook.’
Q
: How have SNFs changed over the years? Where Maryland is at the cutting edge is that, 30 years ago, it created a rate-setting system that incentivized SNFs to take care of hospital-level patients – really medically sick patients. Patients used to walk into SNFs, but today they’re too sick to walk in. In our state, we have 233 centers with some 30,000 beds that are in every political jurisdiction. Northern Virginia is somewhat comparable today, but hasn’t had the same system for as long as Maryland. In DC, the income disparity is more dramatic district-wide than it is
in Virginia or Maryland state-wide, and you have fewer centers in a smaller geographic area. Genesis has a building, PowerBack Rehabilitation, in Lutherville, Maryland, that, by special agreement with the state, is 100% rehab. The facility is a concierge model, with food on demand. They immediately tell you what your discharge date is and provide intensive rehab to get patients home as soon as possible. Another provider, Lorien, offers Wi-Fi and iPads on loan to patients. Their Encore building has a pub onsite. FutureCare, which also offers à-la-carte dining, was voted several years in a row as a top employer by the Baltimore Sun, and has buildings certified to treat wounded warriors faced with amputations. At FutureCare Centers, a family member can come in for any meal and pay only $2. At some Lorien Centers during the summer, grandchildren can come to visit, eat at the pub and use the pool. Another Lorien facility in Bel Air, Maryland, has a restaurant that’s open to the public. The truth is that many, if not all, of HFAM’s member centers are innovating quality care in some way. It’s not what people think of when they think of nursing homes – today’s SNFs are not their fathers’ nursing centers.
Q
: Long-term care used to be perceived as a less attractive place to be a provider or a patient. How would you characterize it today? Certainly, there remain extremes in SNFs in Maryland and across the country. It’s a challenge because lower-quality facilities do exist. But as a whole, these really are mini post-acute hospitals set in the community. Physicians should realize that in today’s healthcare world, where we focus on doing more with less and providers are more accountable to keep people as healthy as they can, SNFs have most of the capabilities of hospitals at tremendously reduced costs. We have an opportunity to make these centers part of the solution. And we’re proving that now, in terms of improving transitional care, infection control and reducing the off-label use of psychiatric medicines. Joe DeMattos, Jr., MA, president of the Health Facilities Association of Maryland
JULY/AUGUST 2015
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