THE BUSINESS MAGAZINE OF KENTUCKY PHYSICIANS AND HEALTHCARE PROFESSIONALS ISSUE #91
CARDIOLOGY AND PULMONOLOGY
LAND OF OPPORTUNITY Kendra J. Grubb, MD, MHA cardiovascular surgeon, joins U of L to build a transcatheter and minimally invasive heart surgery program at Jewish Hospital. ALSO IN THIS ISSUE REBUILDING OWENSBORO’S CARDIAC SURGERY PROGRAM
VOLUME 6•#2•MARCH 2015
NEW EP SERVICES IN NEW ALBANY, IN MANAGING HYPERTENSION A HEART TEAM EVOLVES PREVENTIVE CARDIOLOGY CT SCREENING FOR LUNG CANCER
With each new first, we give more people a second chance at
KentuckyOne Health was first in Kentucky to perform heart transplants and open heart surgery, first with transcatheter aortic valve replacement, first with ventricular assist devices, first with MitraClip procedure. We perform the most technologically advanced heart procedures in the region, because with each new first, we give more people a second chance at life.Â See all of our firsts atÂ KentuckyOneHealth.org/Heart. Jewish Heart Care and Saint Joseph Heart Institute are now known as KentuckyOne Health Heart and Vascular Care.
KentuckyOne Health. The one name in heart care.
TESTIMONIALS “M.D. Update provides me with the latest trends in medical services, practice management and cutting edge technology in the state. Reading it makes me feel like I am an active part of the regional healthcare community.” --- Darryl Kaelin, MD, Associate Professor, U of L, Medical Director Frazier Rehab Institute, Division of Physical Medicine & Rehab
“We have found that MD Update is the best way to inform our physician colleagues in the state of Kentucky about new and exciting things in our practice. It almost always garners a response from other physicians of: ‘I did not know you were doing that’. We will continue to use MD Update on a regular basis.” -- Richard Lingreen, MD Commonwealth Pain Specialists, Frankfort
“I look forward to receiving M.D. Update. No other publication gives me the same information and keeps me up to date on what other physicians in Kentucky are doing in their medical practice like M. D. Update. I read every issue.” -- William Wood, MD, founder Retina Associates of Kentucky
LETTER FROM THE EDITOR
Volume 6, Number 2 ISSUE #91
Read! Write! Participate!
Gil Dunn email@example.com EDITOR IN CHIEF
As we inch towards the first green buds that signal the new life of spring, I think the anticipation and onset of spring provides an opportunity to reevaluate, redirect, and renew. This issue, #91, continues MD-UPDATEâ€™s examination of Lifestyle Re-habituation through the skilled eyes, words and work of Kentucky and Southern Indian physicians and providers. This time the focus is cardiovascular and pulmonary health. On the heels of heart month, there is good news on the treatment front. From new minimally invasive valve procedures in Louisville and Lexington to robotic surgery services in Owensboro and electrophysiology studies in New Albany, In., there are increasingly advanced treatments available in this region to give patients the opportunity to change their habits and live longer, healthier lives. Preventive cardiology is a new frontier, and youâ€™ll hear from two physicians who are making it their mission to help patients develop healthier lifestyles and prevent these adverse cardiac events from happening in the first place. Healthy eating is always central to these conversations, and in this issue you also can read what a Kentucky organic farmer has to say about the benefits of organically grown produce. In the spirit of reevaluation and renewal, MD-UPDATE wants to hear from you. We want to know what you like about the magazine, what you want to see more of, and what you think we can improve. To that end, business reply cards are included in this magazine. Please take a minute to answer a couple of questions and share your thoughts with us. We do what we do for you, the physician reader, and your opinion is paramount to us. As patient feedback fuels your process improvement, so too, does your feedback fuel ours. Please take the time to weigh in on how we can serve you better. Sincerely, Jennifer S. Newton, Editor-in-Chief
Send your letters to the editor to: firstname.lastname@example.org, or (502) 541-2666 mobile Gil Dunn, Publisher: email@example.com or (859) 309-0720 phone and fax 2 MD-UPDATE
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CONTRIBUTORS: Jan Anderson, PsyD Atul R. Chugh, MD Jamie Wilhite Dittert Mike Marnhout Scott Neal Mac Stone
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COVER STORY 4 HEADLINES 5 LEGAL 7 FINANCE 8 Q&A 10 PHYSICIAN VIEWPOINT 11 COVER STORY 15 SPECIAL SECTION: CARDIOLOGY
Kendra J. Grubb, MD, MHA, cardiovascular surgeon, joins U of L to
23 SPECIAL SECTION: PULMONOLOGY
build a transcatheter and minimally invasive
25 COMPLEMENTARY CARE
heart surgery program
at Jewish Hospital.
LAND OF OPPORTUNITY PAGE 11
By Jennifer S. Newton
Cover photograph by Robert Burge Photography. Above by Tom Fougerousse, U of L.
SPECIAL SECTIONS CARDIOLOGY AND PULMONOLOGY
15 CHANGING PERCEPTIONS… AND LIVES: OWENSBORO HEALTH
17 GOT RHYTHM?: FLOYD MEMORIAL
18 UNDER PRESSURE: LEXINGTON CLINIC
20 THE BEAT GOES ON: SAINT JOSEPH
22 THE PREVENTION MODEL: UK
23 LUNG CANCER SCREENING: KENTUCKYONE HEALTH
Navigating Heart Recovery
Baptist Health Louisville selected for the American College of Cardiology Patient Navigator Program to help prevent hospital readmissions
Baptist Health Louisville is one of 35 hospitals in the country, and the only hospital in Kentucky, selected to participate in the American College of Cardiology (ACC) Patient Navigator Program, the first program of its kind in cardiology designed to support hospitals in providing personalized services to heart disease patients and to help them avoid a quick return to the hospital. “The only thing worse than coming into the hospital once, is coming into the hospital twice,” said Jesse Adams III, MD, FACC, with the Louisville Cardiology Group and Governor of the Kentucky Chapter of the ACC. “Teaming up with the American College of Cardiology through the ACC’s Patient Navigator Program allows us to apply a team-based approach to keep our heart patients healthy and at home after their hospital discharge. This is an exciting time and an excellent opportunity for our patients at Baptist Health Louisville.” Nearly one in five patients hospitalized with heart attack and one in four patients
hospitalized with heart failure are readmitted within 30 days of discharge, often for conditions seemingly unrelated to the original diagnosis. Readmissions can be related to issues like stresses within the hospital, fragility on discharge, lack of understanding of discharge instructions, and inability to carry out discharge instructions. The ACC created the Patient Navigator
Program to support a team of caregivers at selected hospitals to help patients overcome challenges during their hospital stay and in the weeks following discharge when they are most vulnerable. Hospitals chosen were given funding to establish a program that supports a culture of patient-centered care
that can be implemented in other hospitals in the future. AstraZeneca is the founding sponsor of the ACC Patient Navigator Program. “The ACC Patient Navigator Program provides evidence-based approaches to reducing hospital readmissions by meeting the unique Jesse Adams III, needs of each MD, FACC, is a patient,” said ACC cardiologist with President Patrick the Louisville O’Gara, MD, Cardiology Group FACC. “Baptist and governor of the Health Louisville’s Kentucky Chapter dedication to qualof the ACC. ity is a key component of this program, which emphasizes a team approach to help patients make a seamless and secure transition from the hospital to the home.” Hospitals in the program were selected based on their commitment to quality as demonstrated through participation in the National Cardiovascular Data Registry ACTION Registry-GWTG and Hospital to Home Initiative. Nearly 400 hospitals were eligible for the program, with only 35 ultimately selected based on readmission rates, having recognized leaders in cardiology on staff, an established culture of quality already part of the hospital infrastructure, and varied geographic location. ◆
2335 Sterlington Road, Suite 100 Lexington, Kentucky 40517 (859) 268-1040 Fax: (859) 268-6165 Email: lprober email@example.com www.barcpa.com
PHOTOGRAPHY COURTESY OF BAPTIST HEALTH
Recent Changes to the Role of Physician Assistants As the demand for healthcare rises, physician assistants provide a cost-effective way to address patient care needs. The Bureau of Labor Statistics estimates a 38 percent growth in physician assistant employment between 2012 and 2022, based on an aging population, population growth, rising instances of chronic diseases, federal health insurance reform, and the increasing specialization of physicians.1 Physician assistants help to bridge the gap between the demand for healthcare and the supply of qualified healthcare providers, and it is important to understand the roles and duties of each. Kentucky recently adopted statutory changes that give supervising physicians and physician assistants more latitude in adapting to the rising demands for care by reducing oversight over physician assistant treatment records and the time before a physician assistant can work in a separate location. This article discusses the relationship between and respective responsibilities of the physician assistant and the supervising physician. The scope of services that may be performed by the physician assistant depends on the licensure process. In order to render care, physician assistants are licensed through the Kentucky Board of Medical Licensure (KBML).2 Applicants must graduate from an approved program and pass an approved examination.3 The services and procedures that may be performed by a physician assistant are limited to those described in any application submitted to and approved by the KBML.4 For the purposes of workers’ compensation matters, however, physician assistants are not qualified to render a medical diagnosis.5 The physician must also obtain KBML approval to act as a supervising physi1 United States Department of Labor, Bureau of Labor Statistics, Occupational Outlook Handbook, Physician Assistants, http://www. bls.gov/ooh/healthcare/physician-assistants. htm#tab-6 (last accessed 10/27/14). 2 See KRS 311.840 to 311.862. 3 KRS 311.844(1). 4 KRS 311.858(1). 5 Mining v. Wilder, 2013-CA-000820-WC, 2014 WL 505912 (Ky. App. Feb. 7, 2014).
cian with respect to any service or procedure the physician assistant will perform.6 Moreover, the supervising physician must comply with technical requireBY Jamie Wilhite Dittert ments regarding the notification to patients of the physician assistant’s role in patient care and re-evaluations of the physician assistant’s work.7 Physician assistants can prescribe and administer certain medications. The supervising physician may vest the physician assistant with authority to prescribe and administer “all nonscheduled legend drugs and medical devices,” and to “request, receive, and distribute” sample drugs.8 The supervising physician is responsible for ensuring that the physician assistant does not prescribe or dispense controlled substances.9 While physician assistants can prescribe and administer certain medications, they are not authorized to dispense medications, or distribute non-sample drugs.10 Physician assistants can also be utilized in administering anesthesia, subject to special education and supervision requirements. A physician assistant can perform local anesthesia, provided that it is described in an approved KBML application, but he cannot administer or monitor general or regional anesthesia unless he has obtained special training in anesthesia.11 Additionally, the supervising physician must be present for induction and emergence, cannot perform concurrent anesthesia procedures, and must be able to provide an immediate physical presence in the room.12 Supervising physicians must exercise continuing oversight over the physician 6 KRS 311.854(1). 7 KRS 311.856 (3) – (5), (11), (12). 8 KRS 311.858(4). 9 KRS 311.856(2). 10 Ky. OAG 11-0004 (2011). 11 KRS 311.858(6); KRS 311.862. 12 KRS 311.862(3).
assistant’s actions because the supervising physician is legally liable for the negligent actions of his physician assistant. In performing medical services and procedures, the physician assistant is the supervising physician’s agent.13 Under Kentucky law, a principal – here, the supervising physician – is liable for the negligent actions of the agent because the principal has the authority to control the method and details of the agent’s work.14 Accordingly, the supervising physician should – and is legally required to - ensure that the physician assistant is given medical tasks that are commensurate with KBML approval and the physician assistant’s training, experience, and comfort level.15 The two changes that took effect on June 1, 2014 do not change this obligation. First, the supervising physician’s obligation to review and sign records of physician assistant services was reduced. Prior to June 1, 2014, supervising physicians had to sign all records of service rendered by a physician assistant to certify that the physician assistant performed the services as delegated. Now, supervising physicians must only review and countersign medical notes authored by physician assistants to the extent needed to “ensure quality of care.”16 The statute leaves the amount of notes to be reviewed to the discretion of the supervising physician, but the physician must review at least 10 percent of the medical notes authored by the physician assistant over every 30-day period. Additionally, Kentucky no longer requires that a physician assistant have experience in a non-separate location before moving to a separate location. Generally, a physician assistant can provide services in the offices and clinics of the supervising physician and any hospital or licensed healthcare facility, subject to receiving written permission and any scope of practice restrictions issued by the governing body.17 Physician 13 KRS 311.858(2). 14 See, e.g., Nazar v. Branham, 291 S.W.3d 599 (Ky. 2009). 15 KRS 311.840(6); 311.856(8). 16 KRS 311.856(10). 17 KRS 311.858(7). ISSUE#91 5
assistants can practice in separate locations, provided that the supervising physician is continuously available by telecommunication and KBML approval is obtained.18 For several years, Kentucky required 18 continuous months of experience in a non-separate location before a physician assistant could move to a separate location. Between June 25, 2013 and May 31, 2014, however, this requirement was reduced to three months.19 As of June 1, 2014, the requirement was eliminated completely.20 Physician assistants are expected to play an increasingly vital role in the provision of healthcare. Recent changes in Kentucky law reduce the supervising physician’s oversight over physician assistant service records and increase the mobility of physician assistants across multiple office locations. These changes, however, do not abrogate the supervising physician’s duty to ensure 18 KRS 311.860(4). 19 KRS 311.860(3). 20 Id.
SUPERVISING PHYSICIANS MUST EXERCISE CONTINUING OVERSIGHT OVER THE PHYSICIAN ASSISTANT’S ACTIONS BECAUSE THE SUPERVISING PHYSICIAN IS LEGALLY LIABLE FOR THE NEGLIGENT ACTIONS OF HIS PHYSICIAN ASSISTANT. that the physician assistant is performing appropriate tasks or the physician’s liability for any negligent actions by the physician assistant. Jamie Wilhite Dittert is an attorney at Sturgill, Turner, Barker & Moloney, PLLC, where she devotes a large portion of her practice to healthcare law and medical malpractice defense. She can be reached at (859) 2558581 and firstname.lastname@example.org. This article is intended as a summary of state law and does not constitute legal advice. ◆
Helping Kentuckians Live Healthier Lives Ask your colleagues about their experience with Passport and call us to learn more about joining our network.
www.passporthealthplan.com 6 MD-UPDATE pass3891v3_MD Update_7.375x4.8125.indd 1
2/23/15 8:45 AM
Opportunities in Real Estate Have you ever been approached to invest in real estate? If you not, you likely will be someday. We routinely assist our clients in assessing opportunities and risks associated with making investments in commercial and residential rental properties, as well as personal residences. Before turning to an assessment of personal residence to decide whether it can ever legitimately be considered an investment, let’s examine ways to look at commercial or residential rental property. Here we are going to focus on owning the physical asset vs. owning shares of a real estate investment trust (REIT). As investment managers, we have often advised that many clients should own the physical property rather than paying a REIT manager to do it for them. There are essentially four ways to earn a rate of return on rental property: 1) appreciation; 2) cash-on-cash; 3) income tax savings; and 4) use of debt financing. For years, the focus was on appreciation. The nearuniversal belief was that real estate “could never decline in value” because “they aren’t making any more.” I cannot tell you how many times I heard people voice that belief prior to the Greater Recession of ’08. Indeed, for the decades leading up to 2008, it was quite common to see property values systematically increase from two to five percent per year—thus, the belief appeared to be wellfounded. Reality struck and investors learned pretty quickly that real estate, like every other investment with growth potential, can also go down in value. The crisis of 2008 was systemic and overdetermined for sure. The mortgage industry bears a lot of the blame, but that’s a subject for another piece. The bottom line is that the bubble burst, and many are still paying the price for their prerecession beliefs. We often warn that the return from appreciation is often the result of a great purchase. The expected appreciation rate cannot simply be an average for the local area; it must be assessed property-by-property based on the original purchase price. This is the return technique most often employed by those who buy distressed properties. It’s a good strategy for the rest of us as well. We have seen other investors focus solely on cash-on-cash return by simply asking,
“Can I rent the property for more than my expenses?” We have seen this singular focus lead to a decrease in future returns because the investor has neglected to make needed repairs and upkeep BY Scott Neal for the sake of current cash flow. Cash flow is vital to any business, including real estate, but the decision of whether to invest cannot rest entirely on cash flow. One key component in assessing a potential real estate investment is an allowance for vacancies. A five to 10 percent vacancy allowance seems appropriate in many cases. Some often over-looked expenses are management fees (or the decline in income from your day-job if you manage it yourself) and setting aside a repairs allowance during those years when repairs are not necessary. In addition, unless you require a triple-net lease, there are always the more common expenses for annual property taxes and insurance. Real estate investments have long been sold based on their tax efficiency. The investor gets to take deductions for all the expenses of operation, including interest on the financing and deprecation. Being able to take a deprecation deduction on an asset that is actually appreciating appears to be too good to be true. Depreciation is a widely misunderstood tax concept and is one of the more hotly debated parts of the tax code. Many investors will overlook the fact that some depreciation may have to be recaptured as ordinary income upon the sale of property. Furthermore, years ago, Congress determined that real estate rentals are “passive activities” and that we cannot deduct passive losses against “active income” such as our wages. The losses essentially get suspended until the property is sold. The bottom line is that real estate investing is tax-advantaged but requires careful scrutiny to assess the true return from tax savings and must take into consideration the investor’s overall tax situation. Recently, there was a resurgence of TV
infomercials and local seminars touting an expert’s method of making money in real estate. No doubt, many of those centered on using OPM (other people’s money) as a key technique. Nearly all investment in real estate is leveraged and debt comes at cost (the up ront borrowing costs as well as the interest). Obviously, the more that is borrowed, the less equity involved—enhancing return on that equity. More leverage can result in greater tax savings, but it occurs at the expense of less cash-on-cash return as the payments on the loan will be higher. Furthermore, financing of investment property usually costs more than financing an owner-occupied residence. More leverage means more risk. Speaking of risk, each of these returns comes with its own form of risk. It is vital to assess the riskiness of each before jumping into a real estate investment. Finally, in evaluating a potential real estate investment, it is important to have a good exit strategy at the time of the investment. Over the life of the investment it is quite reasonable to expect that cash flow will increase via higher rents. However, it could also decrease due to higher repairs expenses caused by normal wear and tear, as well as inflation of other expenses such as insurance and management fees. Also, as the loan is paid down, the increase in equity suppresses the effect of leverage on return. Sooner or later, it probably makes sense to consider either selling or trading via a tax-free exchange made possible by Section 1031 of the tax code. Good money has been and can continue to be made in real estate investing, but realizing real estate’s true potential requires diligence in buying, operating, and selling. It is wise to set out a plan before jumping in and then revisiting the plan from time to time to insure that the investment is still pointed toward your goals. Next month, we will consider whether you can ever think of your personal residence as an investment. Scott Neal a CPA and CFP is president of D. Scott Neal, Inc. a FEE-ONLY financial planning and investment advisory firm with offices in Lexington and Louisville. He can be reached at scott@ dsneal.com or toll free at 1-800-344-9098. ◆ ISSUE#91 7
Dr. Preston Nunnelley has more to say This is Part 2 of a career retrospective on Preston P. Nunnelley, MD. With over 40 years in private OB/GYN practice, organized medicine, and hospital administration, Nunnelley is retiring as VP and chief medical officer for Baptist Health Lexington in February 2015. See MD-UPDATE #90 for Part 1 of this story.
MD-UPDATE: You’ve been active in organized medicine throughout your career. What were some of the offices you held?
NUNNELLEY: I’ve been president of the Lexington Medical Society, president of the Kentucky Medical Association (KMA), president of the Board of Licensure for the State of Kentucky, a delegate to the AMA, and on the Board of Trustees for the KMA.
Tell us about your work on the Kentucky Board of Medical Licensure.
I’ve been on the board for over 20 years and president for the last six to seven. These are gubernatorial appointments, and you are appointed in four-year terms. Governor Patton first appointed me. I’ve been through both Republican and Democratic administrations. I hope that means I’m doing a good job rather than being a political appointment. KBML has the three deans of the medical schools, the commissioner of public health, three consumers, and seven doctors. We meet every month with a general meeting and panel meetings. House Bill One required that we resolve cases in a shorter period of time, so we added four additional meetings to our annual schedule. Sometimes we review 30-40 cases each meeting. That is pretty time-consuming, so our members contribute a lot to the health of Kentucky. My term on the board ends in June 2016, and it’s time to turn it over to someone else. I’ve done that in most all of 8 MD-UPDATE
LEFT: (L-R) Stephen
K. Toadvine, MD, new chief medical officer, Baptist Health Lexington, with Preston P. Nunnelley, MD, who is retiring from the position.
my other positions. I think you need to rotate those positions – term limits. But you have to be careful, especially with the Board of Licensure. It takes a couple of years to get comfortable with it. It is the second term where people really get proficient in what they are doing.
What’s the biggest challenge for the Board of Licensure?
ABOVE: The University of Kentucky Medical School class That’s easy – prescripof 1970 graduated three physicians destined to become tion drug abuse; we have a Kentucky Medical Association presidentshuge number of complaints. (L-R) Dr. Ardis D. Hoven, Dr. William H. Mitchell, and Not all are actually abuse, Dr. Preston P. Nunnelley. Photo taken 1983. but some are. Unfortunately, when people die from overdoses, it’s possible a doctor wrote that pre- Bill One has been positive because docscription. It doesn’t mean he did anything tors can get a KASPER report. We have wrong, but we have to evaluate it. Not all to be extremely careful to treat legitimate prescription drugs come from physicians; pain. Patients have pain, and you have to we have pharmacy robberies and many deal with it. Some doctors think that the other ways people get the drugs. That takes restrictions and risks of prescribing pain a lot of time to sort through. House Bill medications are not worth it. If we have that One has mandated we look at every one of attitude, then we’ve failed. those cases. My involvement as the president of Board of Licensure is to reassure doctors What are your thoughts and say, “If you just follow the rules, you’ll on curbing addiction and be ok.” One very positive outcome from prescription drug abuse? House Bill One was mandated continual Pain management specialists have a real medical education. Dr. Patrick Murphy has challenge on their hands. Kentucky House been very involved, and through the Greater
ARCHIVED PHOTOS PROVIDED BY PRESTON P. NUNNELLEY, MD
Louisville Medical Society he has developed an educational program on prescribing. They’ve been very progressive, and he’s been one of the prime movers.
Kentucky has a welldocumented shortage of physicians. What can be done about that?
About three or four years ago, a study by the Kentucky Institute of Medicine said
Monning, MD, board chair of KMA, hears the oath of office from Preston P. Nunnelley, MD, as incoming KMA president in 1978.
we’re over 2,200 doctors short, particularly in primary care. The other issue is the Affordable Care Act, which has put more people seeking primary care. The deficiency is also geographically located in eastern and western Kentucky. There are big holes where we don’t have physicians, and we can’t seem to get them there. We’ve tried the rural Kentucky scholarship program, which pays medical school debt if the doctor practices in the underserved areas, but it hasn’t really worked. The only way to resolve this is to have more primary care doctors and changes in our educational system. We have two allopathic schools and one osteopathic school. When discussions about the osteopathic school began, it was to provide more primary care in the areas where the school was, and there’s been some success. The allopathic schools encourage students to go into primary
care, but in medical school you spend so little time in primary care and more in cardiology, dermatology, OB/GYN, surgery, and specialties. I don’t know that we need a new medical school, but increasing the class size may be appropriate. Also, there is no shortage of doctors in Louisville, Lexington, and Pikeville. People tend to stay where they train.
You’ve been chief medical officer of Baptist Health Lexington, which used to be Central Baptist Hospital. Talk about the evolution and growth of the hospital.
It’s evolved for 60-plus years from a small hospital to Baptist Health Lexington with just about every specialty. We were the first private hospital in the US to have a magnetic imaging system. Then we were the first to have two. We have robotics. We’ve gone from almost an exclusively primary care hospital to almost all subspecialties. We have a huge expansion to address quality of care. We’ll improve women’s care, cancer care, and treatment. We’ll have all new ICU’s to give our patients the best care available anywhere. I’ve been fortunate to practice at a hospital that’s willing to invest in quality. We’re not trying to be the biggest hospital in town, however we were recognized this year as being the best in the state. I think that is a wonderful reflection of the commitment that the leaders of this hospital have made to quality of care. I’ve heard Mr. Sisson, our president, say many times, “You take care of the patients, provide them with quality of care, and the hospital will be successful.”
What’s the future for Baptist Health Lexington?
I think you’ll see more physicians gravitate to this hospital because of the quality of care. If there are any questions, it’s where are we going and how big are we going to get? Not just this hospital but also the Baptist Health system. We’ve got quite a few hospitals; we cover from Corbin to Paducah. That has advantages in patient population
health. We have a beautiful network that can put a patient in a Baptist Health hospital without having to drive a long distance. Now, growth brings concerns; you can’t get around that. We’ll become more regional, with a combined effort between Lexington, Richmond, and Corbin. All doctors are concerned about how many doctors are going to be hired. How many are going to be working for whom? Do we treat a doctor differently if he is hired or independent? We treat them exactly the same through our medical staff office. We make no distinction.
What is your greatest accomplishment?
I am most proud of having helped patients to have a better life. The babies I have brought into this world and the management of women’s health makes me extremely proud. I’m also proud that I’ve received several distinguished service awards from KMA, the UK Alumni Association, and Eastern Kentucky University. I’ve received the Jack Trevey Community Award from the Lexington Medical Society for Outstanding Community Service. It’s not the award itself that is significant but the recognition of the things that caused you to get the award. That’s what makes me feel good about awards.
Any closing thoughts about your work as a doctor and physician leader?
I’ve had no second thoughts about the directions I’ve taken in my career, and I take a lot of pride in the relationships I’ve had with my patients. When I was president of KMA, I traveled across the state talking to the different medical societies. The theme of my message was “Pride in Medicine.” I took several Norman Rockwell prints with me - the ones with doctors and patients as the focus. I think those prints depict the best of the physician-patient relationship. You can see the emotion in those patients’ faces and the trust that they have in their doctors. I still feel that’s what being a physician is all about - establishing a relationship with your patients so that they have that trust in you. ◆ ISSUE#91 9
The Quiet Power of Preventive Medicine It is hard to deny that we live in an era of almost miraculous cardiovascular interventions. Cardiovascular specialists can fix cardiac valves, either stenotic or regurgitant, without opening the chest. We can visualize the heart in realtime and in three dimensions, sending patients home with a 3D “printout” of their own hearts to lodge on the mantel alongside other mementos. We can inject stem cells into damaged parts of the heart to spur regeneration. From the viewpoint of scientific discovery and innovation, it is an exciting time to be a cardiologist! Having first-hand experience with some of these developments, I can attest to the powerful pull of these medical breakthroughs. Where our performance as cardiologists often falters though is in our ability to help patients avoid some of these heroic measures in the first place. Despite jaw-dropping technological solutions, cardiovascular disease remains the number one killer in the United States. In Kentucky, our rates of disease are some of the highest in the world. One of the reasons why we fail to adequately emphasize prevention may be because the work of preventive medicine is seldom captivating enough to make our collective imaginations spring to life. Most preventive tests would not make it onto an episode of Star Trek. The majority of acts in preventive cardiology are solitary, inconspicuous missions in austerity and self-discipline performed by patients such as an obese, diabetic mother of three who wants to live to see her grandchildren go to school, or a hypertensive man who doesn’t want to follow in his father’s footsteps of dying from a heart attack at the age of 54. These intrepid patients – taking the quiet, brave steps of making difficult life changes – are my heroes and the reason why preventive cardiology has a powerful magnetism for me. For a very long time, physicians within the preventive realm did not have much to offer. We would try to predict a cohort at higher risk using the Framingham Risk Score (FRS), developed studying the fairly homogeneous and prosperous population of Framingham, Massachusetts. It is hard to 10 MD-UPDATE
compare a “highrisk” patient from such a place to a place like eastern Kentucky, where it is common to find a 60-year-old man who started smoking when he was in second grade. BY Atul R. Chugh, MD The newly developed atherosclerotic cardiovascular disease (ASCVD) risk estimator has some benefits not associated with the FRS. For one, the ASCVD risk score allows us to include stroke as one of the outcomes. Most importantly, the ASCVD score may also perform better in women and minorities – groups that have had devastating rates of cardiovascular disease but aren’t well represented in the FRS. This newer score comes with a fair share of controversy in that some authorities estimate that the score may exaggerate
cise physiology allows workouts to be more efficient and effective so that an exercise regimen can be more than a January resolution that fizzles by February. For blood pressure control, we now perform 24-hour blood pressure monitoring and encourage the use of Wi-Fi-enabled measurement devices, giving us a detailed picture of whether blood pressure is controlled consistently as a patient goes about her routine day rather than the mere snapshot we get during an office visit. The advent of newer medication classes such as the PCSK9 inhibitors and anti-fibrotic agents in development may further attenuate the end-organ damage created by hyperlipidemia and hypertension, respectively. Thus, the process of discovery and innovation is alive and well in preventive medicine as well. The field has its own “miracles” – foremost among them the brave and difficult lifestyle changes embraced by patients. Using these and other tools, I hope to help this part of the country break the cycle between risk factors and disease by keeping
EMERGING DISEASE MARKERS, SUCH AS CORONARY CALCIUM SCORES, CAROTID INTIMAL THICKNESS, AORTIC STIFFNESS INDICES, HS-CRP, AND LP-PLA2, AMONG OTHERS, ALLOW US TO FURTHER PINPOINT RISK AND AUGMENT THERAPIES AS NEEDED. cardiovascular risk in some subsets of the population. Hence, other additive predictors may be required to guide the degree to which risk factor modification is performed in an individual patient. Emerging disease markers, such as coronary calcium scores, carotid intimal thickness, aortic stiffness indices, hs-CRP, and Lp-PLA2, among others, allow us to further pinpoint risk and augment therapies as needed. Our increasing knowledge of exer-
PHOTO COURTESY BAPTIST HEALTH LEXINGTON
the risk factors at bay. Given the state of preventable disease in Kentucky, for me, aiding the daily, personal battles of prevention is the most challenging and rewarding pursuit in cardiovascular medicine today – even if we won’t be seeing it on Star Trek anytime soon. Dr. Atul R. Chugh, a cardiologist with Baptist Health Medical Group Lexington Cardiology, practices at Baptist Health Lexington. ◆
LAND OF OPPORTUNITY Kendra J. Grubb, MD, MHA, cardiovascular surgeon, joins U of L to build a transcatheter and minimally invasive heart surgery program at Jewish Hospital. BY JENNIFER S. NEWTON
Photography by Robert Burge Photography and Tom Fougerousse, U of L
While in residency, Grubb was attracted to cardiac surgery in part because of “the impact factor, the ability to influence patients’ lives.”
Ask most three-year-olds what they want to be when they grow up, and you will likely get the typical ideology of preschool minds – ballerina, fireman, superhero, teacher. Not so for Kendra J. Grubb, MD, MHA, cardiovascular surgeon with University of Louisville Physicians, Inc., who at the age of three answered – surgeon. Growing up in the rural Pacific Northwest, Grubb’s father ran a veterinary practice out of their home. “That was my first exposure to medicine and surgery. Seeing my father operate on animals was nothing short of magical,” says Grubb. At three years old, her path was set. Grubb spent her undergraduate years at the University of Southern California (USC) in the late 1990s where, much like Kentucky, healthcare was in flux with the onset of managed care. Several physician friends advised her not to go into medicine but to go into business. Rather than relinquish her dream, Grubb spent two years pursuing a Master of Health Administration before going to medical school. “It was incredibly interesting and allows for a very different perspective on the way the healthcare system works,” she says. Remaining at USC for medical school, in the sun-soaked, celebrity-laced city of Los Angeles, Grubb initially dreamed of becoming an orthopedic surgeon and working with professional athletes like the Los Angeles Lakers. “However, I very quickly realized there was something missing from that dream. Orthopedic surgeons are amazing, but I wanted something more,” she says. Following her instincts, she attended the University of Illinois in Chicago for general surgery residency. Grubb went on to explain, “During residency I was exposed to cardiac surgery and immediately knew this was what I wanted to do. It had all the elements I was searching for – the physiology, the fine detail – and the impact factor, the ability to influence patients’ lives.” A penchant for groundbreaking opportunities began to emerge LOUISVILLE
PHOTOGRAPH BY ROBERT BURGE
when Grubb matched at the University of Virginia (UVA) in Charlottesville for her cardiothoracic surgery fellowship, where she had the opportunity to become the first woman trained by the program. “It is a very traditional program, and like many CT surgery programs, it was known as an ‘old boys’ club,’” says Grubb, also the first female adult cardiac surgeon at U of L. Following her training at UVA, Grubb pursued an additional fellowship in interventional cardiology and transcatheter therapies at Columbia University in New York City, one of the busiest transcatheter programs in the nation. Once again breaking new ground, Grubb became the first woman trained in both cardiac surgery and interventional cardiology in the US.
Cardiothoracic Surgeon Dr. Kendra Grubb prepares to complete the mediansternotomy for a coronary artery bypass graft.
If You Build It, They Will Come
Grubb’s experience at Columbia with transcatheter aortic valve replacement (TAVR), a treatment for high-risk and inoperable patients with severe symptomatic aortic stenosis, was one of the driving forces that brought her to Louisville to Jewish Hospital, a part of KentuckyOne Health. Initially she planned to stay in a larger market, but, “It became very apparent there were lots of people already doing what I wanted to do, and probably better than I could at that point, as I was still finishing my training,” she says. When Dr. Mark Slaughter, chief of U of L’s Thoracic and Cardiovascular Surgery Division and executive director of cardiovascular services for the KentuckyOne Health Louisville market, approached her about coming to Kentucky, she says, “It was immediately clear there was an incredible amount of opportunity here.” With a budding TAVR program, in addition to other minimally invasive procedures, Grubb felt she could make an impact. The other side of opportunity lay in the state of Kentucky’s health. “This part of the country has an amazing amount of heart disease, and the opportunities to educate the public are vast,” she says. Having established her practice in Louisville in July 2013, Grubb says, “It’s been surprisingly easier than I expected,” due in part to positioning herself where there was a need. She describes it as a case of, “If you build it, they will come.” 12 MD-UPDATE
PHOTOGRAPHY BY TOM FOUGEROUSSE, U OF L
Grubb harvests the left internal mammary artery (LIMA) to be used as a conduit for bypass to the left anterior descending (LAD) coronary artery.
Teresa Ray completes the endoscopic saphenous vein graft harvest from the right leg. Grubb and scrub nurse, Bart, create the pericardial well, the step prior to cannulating the aorta and right atrium for cardiopulmonary bypass.
Grubb (right) completes the coronary artery bypass graft, LIMA sewn to the LAD coronary artery, with the assistance of Teresa Ray (left).
Hired to help expand the TAVR program, Grubb has become the surgical director of the Valve Team and has taken the program to new levels. Most notably, the Valve Team is now performing TAVR totally percutaneously, with patients awake and not under general anesthesia. One fantastic outcome of performing the procedure this way is that it often results in only an overnight hospital stay rather than four to six days of in-hospital recovery. “To come from a place that was ahead of the TAVR learning curve and have the opportunity to apply those innovations here has been a very rewarding experience,” she adds. Grubb believes TAVR is possibly the most impactful recent development in heart care. “Aortic stenosis is the most common valvular pathology, and often diagnosed at an advanced age. With TAVR, you can take a disease that kills 50 percent of symptomatic patients within 18 months, and all of the sudden you can treat them,” she says. TAVR is not the only procedure Grubb has been advancing, though. Recently she and Valve Team Interventional Cardiologist Dr. Michael Flaherty began performing a percutaneous procedure for mitral regurgitation called MitraClip. “For patients suffering from heart failure because the mitral valve is leaking, instead of open heart surgery, we can go in through the groin and put a clip on the mitral valve leaflets,” says Grubb. While she cautions MitraClip is not as good as repairing or replacing a valve through open surgery, it is a viable option to help high-risk and inoperable patients feel better and add years to their life expectancy. Hybrid revascularization is another innovative procedure Grubb has brought to Jewish Hospital. While she contends open coronary artery bypass graft (CABG) is still the gold standard, “There are less invasive strategies where you can combine all of the benefits from cardiac surgery with the benefits of interventional cardiology.” The hybrid procedure is done off-pump, so the patient does not have the risks of going on cardiopulmonary bypass. For a patient to be a candidate for hybrid revascularization, they need to have a blockage in the left anterior descending (LAD) or left main coronary artery. “The LAD is one vessel that makes surgery better than stents,” says Grubb. “Stents and saphenous vein graft bypass have never been shown to have a survival ISSUE#91 13
advantage, but the left internal mammary artery (LIMA) to LAD bypass actually does.” During the procedure, Grubb does a direct LIMA to LAD off-pump through a small incision between the ribs, while an interventional cardiologist puts a stent in the other coronary arteries. The result is “complete revascularization without sternotomy and without cardiopulmonary bypass,” she says. While she is pushing the envelope of minimally invasive procedures, Grubb says her practice is, and always will be, based in traditional open heart surgery. Currently she and the Valve Team perform transcatheter procedures one day a week with hopes to expand.
Grubb may be uniquely female in a male-dominated field, but one area where women are incredibly prominent is the incidence of heart disease. “First and foremost, I think many people don’t realize heart disease is the number one killer of women. All forms of cancer combined do not kill as many women as heart disease annually,” she contends. She is not alone in her efforts; the Department of Cardiovascular and Thoracic Surgery is unique as there are currently four female physicians – two critical care specialists, a congenital heart surgeon, and Grubb – dedicated to caring for patients with cardiovascular disease. Among the challenges, women often present differently than men, with symptoms other than crushing chest pain, resulting in a delayed diagnosis and treatment. Mortality outcomes are higher, and women also have worse procedure-related mortality rates, although doctors do not know why. “Other than TAVR, every procedure we do for women, their mortality is worse than men,” says Grubb. To further education on this issue, Grubb initiated the Louisville Symposium on Heart Disease in Women last year – a status report on treatment and prevention of heart disease in women for physicians, nurses, allied health professionals, and the community. She will be offering the program again this year on Saturday, May 16, 2015.
Reminiscent of her days dreaming of working with the Lakers, Grubb believes heart care is best performed as a team sport. “I very much believe in the heart team approach to patient care, where collaboration between 14 MD-UPDATE
PHOTOGRAPH BY ROBERT BURGE
disciplines results in a better outcome for the individual patient. When we collaborate at that level, we are able to get the best of all skill sets,” she says. Disciplines Grubb frequently collaborates with include interventional cardiology and vascular surgery. Although there are many upsides to the opportunity she has found here, there are plenty of downsides to the pervasiveness of heart disease suffered in Kentucky. “Until I came to Kentucky, I had never seen such coronary disease in 30- and 40-year-olds. It didn’t exist at the institutions where I trained at the rate that I see it here,” says Grubb. She attributes this to the state’s rates of obesity, smoking, diabetes, and genetics. In addition, Grubb says the prevalence of endocarditis in 20-year-olds is another unique occurrence in her experience here, due to the epidemic of heroin and drug abuse in the area, often cited as a side effect of KASPER laws to curb prescription drug abuse. Tellingly, Grubb paints a picture of the ICU with octogenarian TAVR and bypass patients on one side and 20-something endocarditis patients on the other. Even with all the challenges she faces, opportunity continues to knock for Grubb in Louisville and Kentucky. Looking for a place to make a big impact, she has found an overwhelming need and a practice home with a reputation for innovation that matches her own level of inquisitiveness and determination. It’s becoming increasingly clear that she’s in the right place at the right time. ◆
SPECIAL SECTION CARDIOLOGY
Changing Perceptions… And Lives
Dr. R. Douglas Adams helps reinvent the Owensboro Health Cardiothoracic Surgery program BY JIM KELSEY - They say perception is reality. For a while, the perception in Owensboro was, in order to get top-notch cardiac, thoracic, or vascular care, you needed to go to a bigger city with a bigger facility. It’s taken some time, but the medical staff at Owensboro Health Cardiothoracic Surgery has changed that perception, and the reality is that most patients are now staying in Owensboro. “We refer very few folks out,” says R. Douglas Adams, MD, FACS, ABTS. “From a cardiac standpoint, we now capture about 90 percent of the folks from this area.” In 2004, Adams and fellow cardiac surgeon Sohit Khanna, MD, were recruited to Owensboro to resurrect a cardiovascular and thoracic surgery program that had been closed for nearly a year. In the 10-plus years since, they have established a comprehensive program that performs cardiac, thoracic, and vascular procedures. Cardiac procedures include minimally-invasive techniques for aortic and mitral valve repair and replacement and off-pump coronary bypass surgery. Adams, who did his general surgery residency at Wake Forest University, came to Kentucky after his residency and fellowship in cardiovascular and thoracic surgery at Rush-Presbyterian in Chicago, where he practiced for six years. He is particularly proud of the recently developed lung cancer early detection and prevention program. The program launched three years ago, and Adams says it has been “ahead of the curve” since day one. “It has just become the standard within the last 8 to 12 months,” he says. “We have one of the highest, if not the highest, incidences of lung cancer in the country.” Adams and his staff have offered earlydetection lung CAT scanning in a training program since 2012. It is multidisciplinary involving radiology, pulmonary, and thoracic surgery and adheres to the nationally defined criteria. “The program is comprehensive from start to finish,” Adams says. OWENSBORO, KY
Dr. R. Douglas Adams, cardiovascular and thoracic surgeon, has spent more than a decade resurrecting and reinventing the cardiothoracic surgical program at Owensboro Health to provide cutting-edge, comprehensive care to area residents. LEFT
Sohit Khanna, MD, is fellowship trained in Cardiopulmonary Transplantation and Cardiothoracic surgery. He joined Owensboro Health’s cardiothoracic surgical program in 2004. BELOW
“And once you have diagnosed lung cancer, we have a full spectrum of minimally invasive robotic surgery. We also have two very skilled radiation oncologists that do not only conventional radiation, but also stereotactic radiation. We have four oncologists who offer not only the full line of chemotherapy treatments but also appropriate protocol-driven follow up. And then of course we have the support services in place for all these therapeutic options.” Adams reports that Owensboro Health Cardiothoracic Surgery has scanned more than 250 people since PHOTOGRAPHY PROVIDED BY OWENSBORO HEALTH
SPECIAL SECTION CARDIOLOGY
the inception of the lung cancer screening program; eight were diagnosed with cancer, seven of which had cancer surgeries. Not only is the screening process ahead of the curve, but so are the surgical procedures. Adams and Khanna, who came to Kentucky after a fellowship in Cardiothoracic Surgery at The Medical College of Georgia in Augusta, Ga., perform robotic surgeries utilizing the da Vinci® surgical system. They have completed approximately 600 robotics cases in the last five years. “The robot is the cornerstone of our thoracic surgical program,” Adams says. “Over 99 percent of the patients who undergo a thoracic malignancy-related procedure leave here with a minimally invasive procedure. “It accomplishes the same anatomic reception and a more thorough lymph node evaluation, all with considerably less nega-
THE DA VINCI® ROBOT IS THE CORNERSTONE OF OUR THORACIC SURGICAL PROGRAM. OVER 99 PERCENT OF THE PATIENTS WHO UNDERGO A THORACIC MALIGNANCY-RELATED PROCEDURE LEAVE HERE WITH A MINIMALLY INVASIVE PROCEDURE. tive physiological impact on the patient,” he says. “Instead of a thoracotomy with a big incision, patients have four- and five- millimeter incisions. That translates into shorter hospital stays, considerably fewer complications – fewer than two percent of our patients go to the ICU – and overall much accelerated recovery.” In the past, patients undergoing open-incision procedures had a length of stay of about six days. Adams reports that has now been reduced to an average stay of just three days. The program is also designed to evaluate and begin treating patients much more quickly than they might expect traveling to other locations. “From a lung cancer
standpoint, we can work them through the process of being evaluated and put into appropriate treatment within seven to 10 days from presentation,” Adams says. “You couple that with the outcomes we’ve had from a minimally invasive surgical standpoint and the word is starting to get out that this is a program that is worth coming to if you have that particular pathology.” Word is already out about the cardiac and vascular programs. The practice performs more than 200 heart surgeries annually. They now also have added transmyocardial laser revascularization (TMR) capability. “We have a very robust aortic endovascular program that has had excellent results with a mortality that is considerably lower than the natural average,” Adams says. Not only is the staff at Owensboro Health Cardiothoracic Surgery focused on treatment, but also in education and prevention. Changes in lifestyle can help reduce the risk of cardiac, thoracic, and vascular pathology. “As we’re in the process of treating it and working with it on the back end,” Adams says, “there are efforts on the front end toward lifestyle modification, behavior modification, and improvement, so that 15-20 years from now this is less of an issue in this area.” And don’t be surprised if most of the practitioners are still there in Owensboro then. Their efforts have helped change perceptions in the area and are impacting the overall health and treatment of the local population. That’s a source of pride for a staff which is looking to continue to build upon their momentum and make a difference in the lives of the community they serve. “I think in many ways Owensboro Health Cardiothoracic Surgery is a little bit like our town in that it���������������������� ’��������������������� s a little underestimated,” Adams says. “Other practitioners and I have had opportunities to go to larger facilities or facilities with bigger names, but the commitment of the folks at this institution providing front line, top quality, cutting-edge care is why we’ve stayed.” ◆
SPECIAL SECTION CARDIOLOGY
Floyd Memorial Heart and Vascular Center adds a cardiac electrophysiology lab to treat cardiac arrhythmias BY JENNIFER S. NEWTON
Since it opened its doors in 2006, the Floyd Memorial Heart and Vascular Center has been breaking new ground in Southern Indiana. The area’s first, and only, open heart surgery program, Floyd Memorial’s comprehensive services allow Southern Indiana residents to get the latest treatments without crossing the Ohio River into Louisville. The newest addition to Floyd Memorial’s cardiac services is a cardiac electrophysiology (EP) lab, which opened in September 2014. “We have had two cardiac cath labs for several years, but one of the areas we were missing was EP studies,” says Daniel Eichenberger, MD, chief medical officer for Floyd Memorial Hospital and Health Services. In addition to providing a needed service to the community, Eichenberger says, “It will increase our specialty referrals from surrounding counties for procedures not offered on this side of the river.” A specially outfitted cardiac catheterization lab, the EP lab is used to diagnose and treat problems related to the electrical activity of the heart, or cardiac rhythms. “The electrophysiologists map the electrical system of the heart, find where the problem arises, and using different techniques, can actually stop an accessory track from firing at an inappropriate time,” says Eichenberger. “Using mapping and medications, they can figure out what’s best for the patient.” Cardiac electrophysiology is its own specialty and therefore required Floyd Memorial to create a new training program to launch the EP program with appropriately qualified staff. Floyd Memorial has recently employed Satya Garimella, MD, to provide EP services. Three University of Louisville physicians also provide EP services – Gregory Deam, MD, Rakesh Gopinathannair, MD, and Brad S. Sutton, MD, as well as Baptist Medical Associates’ NEW ALBANY, IN
EP lab at Floyd Memorial Dr. Daniel Eichenberger is chief medical officer for Floyd Memorial Hospital and Health Services, and as an internal medicine and pediatric specialist, he sees the direct benefits of having EP services on site at the hospital. RIGHT:
John M. Mandrola, MD. While physicians at Floyd Memorial already had the ability to place pacemakers, the new EP lab and staff have expanded treatment options to include other implantable devices such as implantable cardioverter defibrillators (ICDs). Eichenberger, an internal medicine and pediatric specialist who has been a physician at Floyd Memorial since 1992, can particularly appreciate the benefits the EP lab provides in the continuum of care for patients. “Especially from a primary care standpoint, in the past, if we had a patient with rhythm problems, our option was to have a general cardiologist see them, and they were typically limited to medication only to fix the rhythm,” says Eichenberger. Upon discharge from the hospital, the patient would have to follow up with an EP physician in Louisville as an outpatient and potentially schedule a procedure in Louisville. Now, says Eichenberger, “If it������������������� ’������������������ s an urgent procedure, we can have a physician see the patient while they’re here in the hospital, get the study scheduled, and get them back home without all the other delays.” To educate area primary care physicians about the new services, Gopinathannair will be doing outreach courses. Because EP is relatively new, Eichenberger says physicians may not realize, “They don’t have to
go through general cardiology; they can go straight to EP. It’s a mindset family practice and internal medicine physicians haven’t been trained in.”
Turn Up the Volume
In addition to expanding its services, Floyd Memorial��������������������������������� ’�������������������������������� s Heart and Vascular Center continues to grow its volume. Eichenberger says the center’s growth is not only on track, but “probably above some estimates. The program is very highly rated compared to national benchmarks.” The new EP lab has been used for about 10 EP studies, and it is also doing double duty as an overflow cath lab, something that was much needed. “Our volume in two cath labs has been in excess of 80 percent, and usually when you hit 70 percent and above, that’s the typical indicator your volumes are at capacity,” says Eichenberger. All in all, it seems Floyd Memorial is keeping beat with Southern Indiana’s heart needs. ◆
PHOTOGRAPHY PROVIDED BY FLOYD MEMORIAL
SPECIAL SECTION CARDIOLOGY
Detecting and managing hypertension early BY SARAH WILDER One of the most Jason Zimmerman, MD, common cardiovascular FACC, MSPH, RPVI. “It conditions, if left undeis important for us, as phytected and untreated, can sicians, to detect and treat lead to the number one this issue early to help prekiller in America: cardiovent further complications vascular disease. That confor the patient, including dition is hypertension, or cardiovascular disease.” high blood pressure, and Board-certified in carit affects almost one-third diovascular disease and of the U.S. adult populaboard-eligible in intertion. Studies suggest that ventional cardiology, more than 350,000 deaths Zimmerman is recognized occur each year in the as a clinical specialist in United States as a result of hypertension certified Lexington Clinic cardiologist, M. high blood pressure. through the American In 2007 the American Jason Zimmerman, MD, FACC, Society for Hypertension. Heart Association (AHA) MSPH, RPVI He is also a clinical lipidolreleased guidelines recomogist, or lipid management mending aggressive control of blood pressure specialist, certified through the American (<130/80 mm Hg) among those at high risk Board of Clinical Lipidology. He holds for coronary artery disease, individuals with additional certifications in nuclear cardidiabetes mellitus, chronic kidney disease, ology and echocardiography through the coronary artery disease or other risks, and a Certification Board of Nuclear Cardiology Framingham risk score greater than or equal and National Board of Echocardiography, to 10. In 2011 the AHA and the American respectively. As a highly-trained cardioloCollege of Cardiology recommended a less gist, he emphasizes the importance of early aggressive approach of < 145/90 mm Hg for detection and treatment for hypertension as individuals over the age of 80 years. one of the best measures available to prevent “In the past few years, we have seen an further issues. increase in the number of cardiology patients To treat this condition, it must first be we treat for hypertension. This number is detected and diagnosed, which is often difexpected to continue to rise as more and more ficult to do as hypertension can go unrecAmericans see an increase in blood pressure ognized until it reaches a dangerous level. as they age or due to lifestyle and dietary hab- Nearly one-third of those who have hyperits,” said Lexington Clinic cardiologist, M. tension are unaware of their condition until LEXINGTON
tested and discovered by a physician. For this reason, it is recommended that patients are screened for any signs of hypertension at least every two years, beginning at age 18, unless they are considered at risk for cardiovascular disease (have a family history, high tobacco exposure, high cholesterol, obesity, lethargy, diabetes, or consume unhealthy diets or abuse alcohol) or have previously been diagnosed with hypertension. If that is the case, screening should be performed at more frequent intervals. “Screening is usually performed by a primary care physician. This is where the majority of hypertension cases are diagnosed and treated,” said Zimmerman. Once detected, the next step is finding a treatment plan that fits the patient’s needs and effectively lowers their blood pressure levels. Treatment options for hypertension vary, depending upon not only the needs of the patient, but also on the severity of the condition. For some, it can be remedied with lifestyle changes, including a healthier diet, lower salt intake, regular exercise, cessation of smoking, and weight loss. If adaptations and changes to a patient’s lifestyle are not effective, several different types of medications should be considered. In extreme cases, none of these treatments work, and a patient may be diagnosed with resistant hypertension, meaning their blood pressure is difficult to control. If initial treatment does not work or the condition worsens, it is at this point that a cardiologist should be considered. “If a patient’s blood pressure is still high after
APRIL 24-26 LEXINGTONOPERAHOUSE.COM 18 MD-UPDATE
PHOTOGRAPHY PROVIDED BY LEXINGTON CLINIC
trying various treatments, it is time to refer them to a specialist,” said Zimmerman. “A specialist can determine if a patient is taking the appropriate medications for their condition, and can also determine what may be inhibiting their treatment. If left untreated or improperly treated, the excessive pressure on the walls of a patient’s arteries as a result of hypertension could eventually lead to issues much worse than high blood pressure. The longer this condition goes untreated, the worse that damage becomes. Possible damage can include heart attack or stroke, aneurysms, heart failure, weakened or narrowed blood vessels in a patient’s kidneys, thickened, narrowed or torn blood vessels in the eyes, metabolic syndrome, and trouble with memory or understanding.” “If managed correctly, hypertension can be controlled and further complications, including cardiovascular disease, can be avoided,” said Zimmerman. “However, as every patient is different and their medical needs vary, the treatment plan for their hypertension will vary. All aspects of a patient’s health should be considered when determining how to treat hypertension. It is extremely important for primary care physicians and specialists to work together.” ◆
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SPECIAL SECTION CARDIOLOGY
The Beat Goes On
Saint Joseph Hospital Heart Team handles technology changes, FDA approvals, and growing collaborations … and doesn’t miss a beat BY JIM KELSEY In February 2014, MD-UPDATE Issue #84 shared the story of the “Heart Team” at KentuckyOne Health Cardiology Associates at Saint Joseph Hospital in Lexington. The team included cardiothoracic surgeons – Dermot Halpin, MD, FACS, Hamid Mohammadzadeh, MD, FACS, and Robert Salley, MD, FACS; and two cardiologists – Nezar Falluji, MD, MPH, FACC, FSCAI, and Michael Schaeffer, MD, FSCAI. “�������������������������������������� At Saint Joseph Hospital, we���������� ’��������� ve developed what I call a ‘Heart Team’ approach to caring for the cardiac patient,” Halpin said. “This unique team approach is a game changer, and it puts the patient at the heart of the matter.” On the aortic stenosis front, the percutaneous valve team is now using the newly introduced self-expanding CoreValve® by Medtronic. This valve has a smaller sheath size, enabling it to be delivered in patients whose femoral arteries are not large enough to accommodate the Edwards SAPIEN Transcatheter Heart Valve™. “With the CoreValve, the size of the delivery system makes it very easy to deliver in most if not all patients,” says Falluji, executive codirector of KentuckyOne Health Heart and Vascular Care. “The selection between the two valves is based on the patient’s profile, the size of their vessels, and the other anatomical considerations. These are the only two valves available currently, but others are coming.” On the mitral valve front, the team performed its first procedure together on July 7, 2013 at Saint Joseph Hospital (first LEXINGTON
EXPERIENCE BRINGS SUCCESS BECAUSE THE MORE YOU DO THE BETTER YOU GET AT THIS.
– NEZAR FALLUJI, MD EXECUTIVE CO-DIRECTOR, KENTUCKYONE HEALTH HEART AND VASCULAR CARE
PHOTOGRAPHY BY LIZ HAEBERLIN
surgeon Dermot Halpin, MD, calls the Heart Team a “game changer.” RIGHT: Cardiologist Nezar Falluji, MD, MPH, FACC, FSCAI, is the executive co-director of KentuckyOne Health Heart and Vascular Care.
in the state of Kentucky), but much has changed since then, and even more since early 2014. A significant change was the FDA approval for commercial repair of mitral valves in people with mitral valve disease. These patients are deemed high-risk by a surgical evaluation secondary to comorbidities or prior open-heart surgeries. “Patients who have severe mitral regurgitation struggle with symptoms of heart failure and are frequently hospitalized due to heart failure symptoms,” Falluji says. “Now with this minimally invasive approach, these patients get a repair percutaneously using the Mitraclip system, a metal clip placed between the leaflets of the mitral valve, eliminating or at least reducing, mitral regurgitation. This reduces their hospitalization and gives them a better quality of life, making them breathe better and reducing symptoms of heart failure.”
Falluji reports that KentuckyOne Health Cardiology Associates has successfully performed 16 of these procedures. “That makes us the most experienced center in the state,” Falluji says. “I think experience brings success because the more you do, the better you get at this.” The reduced hospital stay for patients is notable across the board. The longest stay for any of these patients has been two to three days, with many returning home in less than 48 hours. The Heart Team is about to launch a clinical trial called “The Parachute Trial.” This is another minimally invasive procedure in which a device is deployed percutaneously for patients with severe heart failure secondary to prior myocardial infarction-related damage to the front and apex of the heart. Yet another relatively new procedure for KentuckyOne Health Heart and Vascular Care is the LARIAT Procedure, which became FDA approved about a year and a half ago. This procedure is used on patients with atrial fibrillation who have difficulty with blood thinners, putting them at risk for strokes. “With the LARIAT procedure, we isolate the left atrial appendage of the heart, which is the source of clot formation in patients with atrial fibrillation,” Falluji says. “This potentially eliminates that risk in patients who are unable to take blood thinners.” “The device is deployed coming through the groin and also by a small incision under the sternum,” Falluji continues. “We create a rail, and we connect that rail with magnets through the atrial appendage wall. A little
noose is then advanced over that rail, and we use that noose to ligate the appendage at its neck, isolating it from the rest of the atrium and from the rest of the circulation. It is a minimally invasive procedure with a recover y time of about two days after the procedure.” While all of the new procedures, technologies, and capabilities are significant, perhaps the biggest ongoing change for Falluji and his peers is the formation of KentuckyOne Health. “The evolution of this organization is a very important development in the state,” Falluji says. “This is a big organization now. It has opened up relationships with academia, brought up the experience of private practices, and put those together in order to establish centers of excellence between Louisville and Lexington.” He concludes, “Our collaborative relationship has been very helpful because it brings the University of Louisville Medical School’s academic excellence to that of the well- known, well-established hospitals, which have a long tradition of excellent cardiovascular care.” ◆
FOR PATIENT REFERRAL CONTACT:
Nezar Falluji, MD KentuckyOne Health Cardiology Associates 1401 Harrodsburg Road, Suite A-300 Lexington, KY 40504 859.276.4429 ISSUE#91 21
SPECIAL SECTION CARDIOLOGY
The Prevention Model
Preventive Cardiologist Dr. Alison Bailey advocates eating locally and teaching healthy lifestyle habits to improve the state of disease in Kentucky BY JILL DEBOLT “You are what you eat!” Alison Bailey, MD, preventive cardiologist and associate professor of medicine at UK College of Medicine would agree with that age-old adage. According to Bailey, there is overwhelming evidence that healthy eating habits play a crucial role in the prevention and treatment of cardiovascular disease, as well as other lifestyle diseases that contribute to significant morbidity and mortality in Kentucky and in the US. As director of ambulatory cardiology and cardiac rehab at the UK Gill Heart Institute, Bailey focuses on the emerging specialty of preventive cardiology. “The specialty of preventive cardiology evolved from treating patients that were left debilitated from heart disease,” says Bailey. “With improvements in the diagnosis and treatment of cardiovascular disease, the principles of cardiac rehabilitation and lifestyle/dietary changes can be applied to patients with multiple risk factors and can keep patients from suffering multiple heart attacks over a lifetime.” As evidence, Bailey cites a National Geographic article (June/July 2009: Longevity Expedition), which described populations with the highest longevity. While widely disparate in many other factors, the populations had the following characteristics: plant-based diet with little processed food, small intake of animal products, and an active lifestyle. The food in these cultures does not come in bags, boxes, and wrappers. The population remains active even into their 70s and 80s with physical activity, not structured exercise, as part of their daily routine. LEXINGTON
The Role of the Preventive Cardiologist
Bailey sees patients from 20 years old to 80+. About two-thirds of her patients have already experienced a myocardial infarction or other adverse cardiac event; one-third of her patients have not, but generally have cardiac risk factors. “The current health insurance model in the US is based more on treatment than 22 MD-UPDATE
PHOTOS COURTESY UK HEALTHCARE
Dr. Alison Bailey, with a cardiac rehab patient, stresses the importance of lifestyle and diet over prescriptions and pills.
prevention, and consequently, preventive cardiology services are often only paid for after a heart attack and/or cardiac bypass,” says Bailey. Through cardiac rehab, these patients learn the skill set to lead a healthier life. Bailey contends the link between risk factors and cardiovascular disease makes prevention a more desirable model both for improved patient health as well as lower health care costs. For all of her patients, Bailey stresses the importance of lifestyle and diet over prescriptions and pills. Her advice in a nutshell: • Don’t smoke. • Consume a healthy, plant-based diet. • Get regular physical activity - walking 30 minutes a day or equivalent. • Control body weight. • Limit sugar intake. • Control blood pressure. In her teaching role, Bailey works with medical students to provide nutritional and lifestyle counseling sessions for mothers and children at the Salvation Army Center in Lexington. Her goal is to empower the community with the primary message that it is possible to eat a healthy, plant-based diet on a budget.
Obesity and Eating Disorders
The latest statistics on the state of obesity
in the US and Kentucky are well-known and distressing. Over a third of the adult population is obese with a BMI greater than 30. Kentucky is fifth highest in the nation for obesity rates, and the rates are increasing each year. Even more concerning, 20 percent of US children are obese, and this number has skyrocketed in the last 20 years.1 Overeating and obesity show a definite link to cardiovascular disease, says Bailey. While this appears to be the most prevalent eating issue in the US and many developed countries, it is not recognized by the American Psychiatric Association (APA) as an eating disorder. This may be due to the difference between eating habits and eating disorders that are driven by obsession with dietary intake. Currently, anorexia and bulimia are the most common clinically diagnosed eating disorders recognized by the APA. As Bailey states, these disorders affect a small subset of the population, usually young females, and rarely lead to typical cardiovascular disease. However, cardiac effects such as cardiac scar tissue and arrhythmias secondary to electrolyte disturbances can occur in patients with eating disorders.
Bailey’s message for Kentucky physicians is to encourage their patients to “eat local,” incorporating as many fresh fruits and vegetables as possible while minimizing processed food. “If we incorporate more local food into our diets and more fresh vegetables into schools, it will lead to better health for Kentuckians and a boost for local agricultural economy,” says Bailey. She also advocates for Kentucky physicians to spend more time teaching healthy lifestyles than prescribing medicines. “I know that teaching and coaching take more time, but the end results are happier, healthier patients and decreased medical costs,” she concludes. 1 Trust for America’s Health and Robert Wood Johnson Foundation. (2015, February 18). The State of Obesity. Retrieved from The State of Obesity: stateofobesity.org ◆
SPECIAL SECTION PULMONOLOGY
Lung Cancer Screening Comes to Central Kentucky KentuckyOne Health’s new early detection program uses low-dose CT scans to find potentially malignant lung nodules BY TIM CORKRAN
Lung cancer kills more Americans than the next four most common cancers combined, but for some Kentuckians, a new early detection program at Saint Joseph Hospital and Saint Joseph East could make the difference. Pulmonologist Eliseo A. Colon, MD, KentuckyOne Health Pulmonology Associates is helping KentuckyOne Health harness the power of the National Lung Screening Trial (NLST) to build a program that can help smokers detect potentially malignant growths in their lungs in the preclinical phase. Colon states that while other common cancers have long had early detection methods – such as colonoscopies, mammograms, pap smears – “We did not have anything to screen for the leading cause of cancer deaths in America; now we have a tool that could reduce lung cancer mortality by 20 percent in some groups.” That tool is low-dose CT scan, which uses as little as 20 percent of the radiation of standard CT scans. Its ability to detect nodules using limited radiation is extremely valuable. In KentuckyOne Health’s program, when screening detects nodules, protocols are enacted. Colon notes, “We will be able to track and follow those patients, following up every three months to have the nodules checked for growth.” Nodules that show signs of growth may be further examined. The program is available for long-time smokers between the ages of 55 and 74, or those who have quit within the last 15 years. Colon is excited to offer this to residents of central and eastern Kentucky and proud of the process KentuckyOne Health has devised. LEXINGTON
Historically, attempts at early detection of lung masses through screening have had
Eli Colon, MD, KentuckyOne Health Pulmonology Associates is helping KentuckyOne Health harness the power of the National Lung Screening Trial to build a program that can help smokers detect potentially malignant growths in their lungs in the preclinical phase.
no effect on mortality rates. Chest x-rays and sputum cytology were the only tools deemed possibly effective, but they never panned out as such. Some uncontrolled studies using CT arose internationally and showed that low-dose was effective at revealing lung nodules that are three centimeters or less in size. The KentuckyOne Health program screens patients for such nodules. Colon explains that if nodules are discovered, two protocols are enacted. First, a full profile of the patient’s risk factors is created; then the nodules are checked every three months for signs of growth. He continues, “Follow-ups allow us to see if that nodule is growing over the course of the year. Depending on the size of the increase, we adjust the frequency of follow-up screenings. An increased nodule in someone who is a smoker runs the risk of being a malignancy.” While the cause of a nodule might be cancer, Colon notes that “not every nodule is malignant.” Infection, vasculitis (rheumatoid arthritis), and fungal infections like histoplasmosis could each cause nodules.
Once a nodule is tracked and determined to be potentially malignant, the treatment course is highly individualized. Closer investigation might be done with a bronchoscope or ultrasound, or a biopsy might be taken. PET scans to determine nodule activity might be called for. If removal is deemed necessary, a thoracic surgeon is contacted. Colon stresses that screening is important because most nodules are asymptomatic. He says, “My recommendation is that anyone who is a smoker and is between the age of 55 and 70 years, and has smoked for at least 30 years, should get the low-dose CT scan – and continue to get one every three years thereafter.”
Building the Case for Screening
KentuckyOne Health’s program has the force of the first highly controlled and peerreviewed study on the process for screening. The National Lung Screening Trial (NLST) included more than 50,000 persons enrolled at 33 US centers. Smokers between 55 and 74 with at least 30 pack years, or those who had quit within the last 15 years, were eligible for the study. It compared groups who had the low-dose CT scans with those who had chest radiography. The latter was used as the control, as it had been definitively shown not to reduce patient mortality rates in a previous study. All participants received three years of annual screenings. The mortality rate in the group that had PHOTO BY GIL DUNN
SPECIAL SECTION PULMONOLOGY
the low-dose CT scan was 20 percent lower than that of the control group. Colon lauds this finding as highly actionable, saying, “That is a significant advance because we had nothing that worked before.” This amounts to three fewer deaths per 1000 high-risk persons. Colon notes, “Historically, getting private insurance and Medicaid/Medicare to approve coverage for the screening has been a challenge. This data from the NLST has been the key to obtaining authorization for coverage.”
Hitting the Ground Running
According to Colon, Medicare just approved the lung screenings and KentuckyOne Health’s new program is already serving patients. The process is simple, Colon says: “After we conduct the screening, we inform the patient’s primary care physician (PCP)
so that they can pursue any needed next step.” KentuckyOne Health’s current challenge is to reach out to the smokers who could benefit. Most are referred to Colon by primary care physicians who have heard about the program, but marketing campaigns are in development. Colon says there is also an outreach program to go directly to PCPs and introduce them to the program. Colon knows he can have a positive impact on lives here in Kentucky, as this is a screening test that definitively reduces mortality. Progress to that end will depend on patient compliance and coordination of healthcare professionals to utilize the data. Colon notes, “The program is a multi-disciplinary approach, which not only involves lung physicians, but radiologists, oncologists, and thoracic surgeons.” He concludes,
“The goal of our program is to work together as a team and help the patient navigate through the process. ◆
Call 855.34.KYONE (59663) to schedule a low-dose CT screening at one of our convenient locations. KentuckyOneHealth.org/lung-care
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SLEEP MEDICINE/COMPLEMENTARY CARE
New Software Increases Compliance among CPAP Patients Sleep apnea is serious keep up the good work. This disease that is now getting the helps patients know that they attention it deserves. Insurance are not alone in this process companies, aware of the signifiand that their DME provider cance of this disease, are encouris monitoring their usage and aging their members to be tested. encouraging them along the Diagnosing, testing, and treating way. The benefits of using the patients for sleep apnea is conU-Sleep software include: sidered preventative medicine • Early detection/intervenbecause co-morbidities exist with tion of compliance and therasleep apnea patients: py issues promotes improved BY Mike Marnhout 48% have type 2 diabetes adherence. 30% have hypertension • Rules can identify patients requiring 77% have obesity alternative therapy. 36% have congestive heart failure • Management by exception ensures With the growing use of continuous patients needing attention are promptly positive airway pressure (CPAP) therapy in treating sleep apnea, patient compliance is now the new challenge presented to durable medical equipment (DME) companies. Treating the patients initially is one thing, but keeping them compliant has become a difficult task. Advances in technology have placed a wireless modem on the patient’s CPAP machine enabling DME companies to monitor 24/7, but this requires daily monitoring of every individual patient, an impossible task to perform. New software, named U-Sleep, is now available to perform the monitoring function. U-Sleep is a secure, innovative, cloud-based compliance management solution that monitors CPAP usage and “coaches” patients into therapy compliance. U-Sleep will notify the DME supLasts 8.25 hours on 2 LPM. FAA Approved plier when their patient has been out Up to 4 LPM Pulse and only 4.8 lbs. of compliance for three days in a row, Oxygen Therapy which enables the DME to fix any issues • Portable Concentrators in real time, instead of months down • Lightweight in home concentrators the road when they would have done a • Free in-home oximetry testing download on their machine. This application has helped DME providers obtain Durable Medical Equipment an increased compliance rate on their • Walkers/Rollators patients. U-Sleep coaches through phone • Wheelchairs calls, emails, and text messages letting the • Hospital Beds patient know that they are either not being compliant or are doing a great job and to Patient Referrals: 800-404-8838 LEXINGTON
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• www.bluegrassoxygen.com ISSUE#91 25
How to Give Your Patients A Better 10 Minutes “He only has a certain amount of time with you … But he says, ‘How are you doing?’ and he’s typing. He only hears me sortakinda.” Patient, Chicago Is there a way to better connect with patients, even with the compressed time constraints that plague clinicians today? A national survey of healthcare providers and patients living with type 2 diabetes suggests that the answer is a definite “yes,” citing specific language used by clinicians that leaves patients not just feeling better about visits with their doctors, but actually doing better in actively managing their disease.
First The Bad News
When it comes to how well patients think they’re doing in the self-management of their disease and what their doctors think, it appears the two groups are on different planets. [SEE CHART 1]
Now the good news
chart 2 chart 2
chart 1 chart 1
An analysis of the data revealed what doesn’t work with patients, as well as what does, including specific messages and optimal language that can help clinicians improve their influence on how people with type 2 diabetes manage their disease. I predict that the “dialogue starter” tools found effective with patients in managing their type 2 diabetes — a com-
plex disease that requires active self-management by a patient that may not even feel sick or any different from the way he or she felt before being diagnosed BY Jan Anderson, PsyD, LPCC with diabetes — will also be found effective in helping healthcare providers encourage better self-care for many illnesses, injuries, and conditions. The findings in the study resonate with what I’ve learned as a psychologist, as a marketing executive, and as a corporate trainer specializing in interpersonal communication skills. [SEE CHART 2]
The Shift From Providing Information To Forming A Partnership
The study identified specific language that signals to patients an attitude of partnership in their care and was found to resonate both with practitioners and patients: ENCOURAGING GOAL SETTING: “Our long-term goal is to get and keep your diabetes under control so that you can feel better more often and avoid complications. But that’s not going to hapWhat patients believe What healthcare providers believe pen overnight. Let’s talk 79% ofpatients patients believe they are 75% ofhealthcare clinicians believe their patients are What believe What providers believe effectively managing diet NOT effectively managing diet about some first steps 79% of patients believe they are 75% of clinicians believe their patients are 62% of patients believe 65%effectively of clinicians believe diet their patients are effectively managing diet they are NOT managing you can take that will get effectively handling exercise NOT effectively handling exercise 62% of patients believe they are 65% of clinicians believe their patients are you moving in the right effectively handling exercise NOT effectively handling exercise direction.” LISTENING AND USING core research FindinGs SIMPLE LANGUAGE: Communication emphasizing the benefits of influencing positiveFindinGs behavior core research “My job is to help you better self-management (better energy level, Communication the benefits of influencing positive behavior feeling healthy)emphasizing is more motivating to patients understand what’s hapbetter self-management (better energy level, than the threat of potential complications feeling healthy)blindness). is more motivating to patients pening to your body (amputation, than the threat of potential complications and what gradual When patients feel like they are being heard, listening to build trust (amputation, blindness). they are more open to what healthcare changes you can make When patients feel like they are being heard, listening to build trust professionals are offering and report feeling they arecommitted more opentototheir what healthcare to feel better more more treatment regimen. professionals are offering and report feeling often. Tell me what Straightforward, factual explanations of more committed to their treatment regimen. optimizing education what is happening in their bodies resonated you’re having the hardStraightforward, factual explanations of optimizing education more strongly with patients, as opposed to what is happening in their bodies resonated est time with.” metaphors or analogies. more strongly with patients, as opposed to FOCUSING ON THE Patients are optimistic about their metaphors or more analogies. building confidence ability to make lifestyle changes when POSITIVE: Patients are more optimistic about their building confidence healthcare professionals break down type 2 ability to make lifestyle changes “One of the keys to livdiabetes self- management skillswhen into a series healthcare professionals of manageable steps. break down type 2 ing with diabetes is to diabetes self- management skills into a series of manageable steps.
understand that you CAN live well with it; you CAN manage it. Let’s talk about what’s been giving you the hardest time and see what changes you can make so things are a little easier for you.” INCORPORATING TREATMENT INTO ROUTINES: “I know diabetes can make life very difficult. It is a complicated disease that affects almost everything you do. Eventually, though, managing your diabetes will become something that’s part of your daily routine. It won’t feel like something you have to work as hard at. Tell me how it’s affecting your day-to-day life right now.” MANAGING UPS AND DOWNS: “Sticking to a treatment plan isn’t easy, but it’s important if you want to smooth out the ups and downs. Which parts of your treatment plan are the most challenging for you? Let’s talk about how we can make it work for you.” For a complete overview of the study, go to www.ConnecT2Day Diabetes.com.◆
Organic Produce and Meats Equal Better Nutrition and Better Health Joining an Organic CSA saves a lot more than money! The benefits of consuming organic produce are so obvious that some healthcare providers offer rebates to customers who have a contractual agreement with a local organic farmer as part of their wellness programming. With what we know about the benefits of eating fruits and vegetables consistently and with what we are learning from the Human Microbiome project (http://commonfund. nih.gov/hmp/overview), it makes sense that these customers are considered healthier. If there’s a surcharge for smokers, why shouldn’t there be an incentive to be in a lower risk category. Let’s do a little math to explain why this makes sense. First the biology, and it’s all about the biology. As organic farmers, we use leguminous plants that draw nitrogen from the air, blend it with the compounds produced through photosynthesis that are released into the soil in a symbiotic relationship with a bacterium that is attached to the roots. When these types of plants are well managed, they provide hundreds of pounds of nutrients to feed the Soil Food Web (SFW) around them. (http://www.nrcs.usda.gov/ wps/portal/nrcs/detailfull/soils/health/biolo gy/?cid=nrcs142p2_053868) The SFW is a wildly complex jungle of creatures from single-celled bacteria and fungi, to more structurally complex nematodes, worms, and insects, up to mammals. Two basic laws of nature are at play here: 1) the more diverse an ecosystem is, the more stable it is; and 2) the more complex an organism is, the higher its carbon-nitrogen (C:N) ratio is. Basically, a more complex organism consumes several less complex organisms to fulfill its carbon demand, but releases all the unneeded nitrogen back into the soil, which other organisms, like plants, need to thrive. Typical commercial salt-forming fertilizers kill these natural systems. It’s estimated that there are tens of thousands of species of bacteria and at least that many species of fungi. Some like it hot, others cold. Some wet, others dry, some low pH, others high pH, dark, light, etc. Organic farming
systems encourage a diverse array of microbes underground and a similar web of activity thrives above the soil as well. Since organic farmers do not use toxic fungicides, insecticides, nematicides, BY Mac Stone miticides or acaracides, we have not limited the diversity of species or the population among a given species. The complex array of organisms acts as our prophylactic shield against pestilence. If or when, a pathogenic bacterium like E. coli or salmonella finds its way into the system, the multitude of good bacteria degrades and consumes this lone ranger, much like school kids running the bully off the playground. By consuming organically grown fruits and vegetables raised in this microbially rich environment, we are feeding the flora and fauna in our digestive tract what they need to thrive. The Human Microbiome Project has drawn a direct correlation between gut health and the human immune system. It is not just the individual vitamins, minerals, carbohydrates, proteins, and fats in the food that are important, but this diverse array of beneficial microbes along for the ride on our fresh foods. How well can you wash broccoli or lettuce? This valuable microbial resource is not washed away with a simple cold water rinse in the sink, since they are integral to the fruit or vegetable itself.
The Economics of Buying Local Organic Produce
Becoming a member of a Community Supported Agriculture (CSA) gives individuals the opportunity to consume the most beneficial produce available on a regular basis. Most CSA contracts require their members to pay for an entire season of produce, before the season starts. This provides
valuable capital to the farmer for inputs like seed, labor, and green house heat early in the season. It also gives the customer the feeling of “We better eat everything we get, since it is already paid for.” Many CSAs offer recipes, and customers often share their excitement of learning how good beets or dinosaur kale can be, therefore expanding their interest and desire to eat even more vegetables. By delivering the produce directly to the shareholder immediately after harvest, the freshness and quality is maintained. Another immediate benefit to the community is that, with a contract with a local farm, money stays in the local economy. We believe that someone who contracts with a local farmer to consume fresh wholesome produce that stimulates the microbiome is someone with a healthconscious lifestyle. Would it not behoove the Kentucky medical community to incentivize their customers to adopt this lifestyle, like they have at FairShare CSA Coalition in Wisconsin? (http://www.csacoalition.org/ about-csa/csa-insurance-rebate/) You do want healthy patients, don’t you? Maybe the facility where you work would be willing to host a local CSA farm to deliver their weekly bounty for people in the office or neighborhood to pick up? Find an organic farmer in your area and improve your health. It’s not only good for you and your community, it tastes really, really good! Mac farms with his wife, Ann Bell Stone, and extended family at Elmwood Stock Farm, their Scott County, Kentucky farm. The family produces certified organic beef, vegetables and small fruit, eggs, chicken, heritage turkeys, and tobacco. Mac was the executive director of Marketing for the Kentucky Department of Agriculture, administering the Kentucky Proud Program among many others. He was appointed by USDA Secretary Vilsack to serve on the National Organic Standards Board, which he chaired last year. He focuses on farming and marketing wholesome organic foods for the family farm and working with non-profit agriculture and food organizations. ◆ ISSUE#91 27
NEWS EVENTS ARTS
Evans joins KentuckyOne Health Primary Care Associates
Tamea Evans, MD, has joined KentuckyOne Health Medical Group. She is practicing at KentuckyOne Health Primary Care Associates, formerly Jefferson Medical Associates. The office is located at 1900 Bluegrass Avenue, Suite 300, in Louisville. Evans is a board-certified internal medicine physician and a practicing diabetologist. She received her undergraduate degree from Kalamazoo College in health sciences in 1993. She attended the University of Kentucky College of Medicine, earning her doctorate of medicine degree in 2003. She further trained at the University of Kentucky and the Christ Hospital in Cincinnati for her internal medicine residency and internship, respectively. Her goal is to provide quality, comprehensive care to adult patients. Her interests include comprehensive primary care, women’s care, and diabetic health. LOUISVILLE
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U of L Announces Two Endowed Chairs in Neurological Surgery
The University of Louisville Department of Neurological Surgery has established two endowed chairs focused on physical medicine and rehabilitation, underscoring the department’s commitment to patient healing and quality of life. Darryl L. Kaelin, MD, has been named the University of Louisville Endowed Chair for Stroke and Brain Injury Rehabilitation. Kaelin specializes in neuro-rehabilitation with a focus on traumatic brain injury and stroke. He serves as chief of the division of physical medicine and rehabilitation. Kaelin obtained his undergraduate degree from the University of Notre Dame and his medical degree from the University of Louisville School of Medicine. He completed his specialty training at the Medical College of Virginia where he was chief resident. Prior to assuming his current positions at U of L, Kaelin served as mediLOUISVILLE
Lexington Clinic Announces 2015 Board of Directors At Lexington Clinic’s annual meeting of the board of directors, new officers were chosen to serve for 2015. Other members of the board include Michael W. Eden, MD, Kimberly A. Hudson, MD, Wayne A. Marlowe, MD, Andrew C. McGregor, MD, Gregory V. Osetinsky, MD, and J. Sloan Warner, Jr., MD. Lexington Clinic’s 2015 board of directors is comprised solely of physicians from Lexington Clinic and its associate practices. It is appointed to govern and oversee all programs of Lexington Clinic in alignment with the core values and mission statement.
U of L Welcomes Johnson to School of Public Health & Information Sciences
Christopher E. Johnson, PhD, is the new chair of the Department of Health Management and Systems Sciences in the University of Louisville School of Public Health and Information Sciences. Johnson came to U of L from University of Washington effective January 1, 2015. Johnson is a graduate of the United States Naval Academy and a former infantry officer in the United States Marine Corps. He received his PhD in health services research, policy and administraLOUISVILLE
cal director of the Acquired Brain Injury Program at Atlanta’s Shepherd Center, a catastrophic care hospital for people with spinal cord and brain injuries. While at the Shepherd Center, he also served as the medical director of Brain Injury Research in Emory University’s School of Medicine. Steven R. Williams, MD, has been appointed the Owsley Brown Frazier Endowed Chair in Physical Medicine and Rehabilitation. Williams specializes in spinal cord medicine including activity-based therapies and functional recovery, prevention of secondary effects of paralysis, consumer education, advocacy, and emerging technologies. He is director of the spinal cord medicine program. Williams was previously chairman of the Department of Rehabilitation Medicine at the Boston University School of Medicine. He received his medical degree from Eastern Virginia Medical School in Norfolk and completed his residency at the Rusk Institute for Rehabilitation at New York University School of Medicine. Both endowed positions became effective Dec. 1, 2014.
President Stephen C. Umansky, MD
Secretary J. Elizabeth Lehmann, MD
Vice President Michael T. Cecil, MD
Treasurer Cheryl A. McClain, MD
tion from the University of Minnesota. At the University of Washington, Johnson served as an associate professor of health services, director of the graduate program in health services administration, and the Austin Ross Chair in Health Administration in the Department of Health Services in the School of Public Health. Johnson is best known for work that seeks to understand how healthcare organizations and communities impact healthcare outcomes for veterans, underserved populations, and the elderly. Johnson and colleagues at the Department of Veterans Affairs (VA), Rehabilitation Outcomes Research Center of Excellence, studied the impact of nursing home services on the provision of care to residents diagnosed with stroke and the general quality of care for veterans within the long-term care system. Johnson was in the first cohort awarded a VA Health Services Research & Development Merit Review Entry-level Program Career Development Award, a non-clinical PhD highly competitive multi-year grant designed to assist new researchers transition to mid-career success.
Goldstein Named Chair of the UK Department of Neurology
Dr. Larry B. Goldstein, a highly acclaimed expert in stroke and related disorders, has been named the next chairman of the Department of Neurology at the University of Kentucky College of Medicine and co-director of the Kentucky Neuroscience Institute. Goldstein will be joining UK from Duke University where he is professor of neurology and Chief of the Division of Stroke and Vascular Neurology and director of the Duke Stroke Center and an attending neurologist at the Durham VA Medical Center. Goldstein will begin his post in June. Goldstein received his bachelor’s degree in 1977 from Brandeis University and his medical degree from Mount Sinai School LEXINGTON
of Medicine in 1981. His subsequent professional training included an internship and neurology residency at Mount Sinai Medical Center, New York, and a research fellowship in cerebrovascular disease at Duke University. Goldstein’s focus in his clinical, research, educational, and service activities is on stroke and ischemic neurologic disorders. He has published more than 650 peerreviewed journal articles, editorials, book chapters, abstracts, and other professional papers. His research has spanned strokerelated laboratory-based studies, clinical trials, quality of care, and care delivery studies, as well as clinical effectiveness and epidemiological investigations.
UK Neonatologist’s Study Trial Supports Alternative Therapy for Drug-Addicted Babies
In the past decade, the number of Kentucky babies starting life with a drug dependency, or neonatal abstinence syndrome (NAS), has skyrocketed from 1.3 per 1,000 births to 19 per 1,000 births. Just like adults coming off drugs, babies whose mothers used opiate drugs during pregnancy will suffer from a number of withdrawal symptoms, including tremors and irritability. The most common form of treatment for babies suffering from withdrawal is the opiate morphine, which can hinder brain development during a critical growth period in a baby’s life. The treatment period for infants requires hospitalization and can last weeks or even months, resulting in high hospitalization costs. Dr. Henrietta Bada, a neonatologist at Kentucky Children’s Hospital, has conducted preliminary research supporting an alternative drug to morphine that will help babies recover from NAS faster and with fewer neurological effects. Bada recently published findings from a pilot study determining whether clonidine, a nonopiate, non-addictive drug commonly used to treat hypertension, LEXINGTON
would result in improved neurobehavioral performance in babies when compared with morphine, an opiate. The research, which was published in the February 2015 issue of the journal Pediatrics, presents encouraging evidence that clonidine was as effective as morphine. Bada’s research was the first known trial to examine clonidine as a single-drug therapy for babies with NAS. The study also suggests clonidine treatment could be completed after discharge, allowing babies to go home earlier and also reducing hospital stay costs. Bada stressed that more research will be required to validate these findings. A copy of the published report is available upon request to firstname.lastname@example.org.
Gill Heart Institute Cardiologist Launches Journal Dedicated to VADs
Dr. Maya Guglin, director of mechanical assisted circulation at the University of Kentucky’s Gill Heart Institute, has launched The VAD Journal, a publication focused exclusively on mechanical assisted circulation. “Mechanical assisted circulation is the most rapidly developing area of cardiology, but there is no journal dedicated to papers in this area,” Guglin said. “The growing number of patients with heart failure, the limited pool of donors for cardiac transplantation, and several technological breakthroughs have all made the option of implanting a ventricular assist device as destination therapy more important, and therefore it’s essential to give cardiologists a dedicated forum to share their research and opinions on the topic.” The VAD Journal will be an open access publication, meaning that its content is available online without significant financial, legal or technical barriers. The VAD Journal can be accessed at http://uknowledge.uky.edu/vad/ ◆ LEXINGTON
Bensema, MD, medical director of clinical and pathology services at Baptist Health Lexington, and David Bensema, MD, chief information officer for Baptist Health and KMA president, with Michelle Ripley, president at Commonwealth Fund for KET, and husband Barry Stumbo, regional foundation executive, Baptist Health East Region.
Kentucky Heart Ball 2015 honoree, Luther Deaton, president of Central Bank with Gil Dunn, publisher of MD-UPDATE.
Dunn, MD-UPDATE, with Dr. Sylvia Cerel-Suhl, past president, Central KY American Heart Association board.
Central Kentucky Heart Ball Honors Luther Deaton Nearly 600 corporate and medical professionals attended the 27th Annual Central Kentucky Heart Ball on Friday, February 20, 2015. The event highlighted the breakthroughs in cardiovascular research, while raising funds to reduce the impact of heart disease and stroke - No. 1 and No. 5 killers of men and women. “The Heart Ball is one of our largest and most important events,” said Mike Turner, Special Events Director for the American Heart Association. The Heart Ball honored heart disease survivor and community leader, Luther Deaton, president of Central Bank, while celebrating the results of research, advocacy, and educational programs at work. The evening also featured Metropolitan Opera singer Gregory Turay and raised a record $460,000 to support the American Heart Association. All proceeds from the Heart Ball support the American Heart Association, which funds public and professional education, advocacy, and scientific research. Research funded by the association has yielded important discoveries such as CPR, life-extending drugs, pacemakers, bypass surgery, surgical techniques to repair heart defects, and more. ◆ LEXINGTON
PHOTOGRAPHY BY JOE OMIELAN
Dr. Robert Salley, executive director of Cardiovascular Services for Saint Joseph Hospital, and wife Kristy Salley with Alice and Jon Bowen, MD, chair of the department of Anesthesiology for Saint Joseph. (L-R)
Scott Hickman and wife Alison Bailey, MD, UK associate professor of medicine and preventative cardiologist at the 2015 Heart Ball.
Rukavina, MD, and wife Amy with Lisa and Gery Tomassoni, MD. Rukavina and Tomassoni are both with Baptist Health Medical Group Lexington Cardiology. (L-R) Lexington
Mayor Jim Gray with Mike Turner, special events director for the American Heart Association, and Gil Dunn, publisher of MD-UPDATE.
John Stewart and wife Dr. Magdalene Karon at the 2015 Heart Ball in Lexington.
American Heart Association presents the Louisville Heart Ball
On Saturday, February 21, more than 700 community leaders and medical professionals gathered at the Louisville Heart Ball in the Downtown Marriott to raise funds for the American Heart Association. This black tie event highlighted the breakthroughs in cardiovascular research, while raising funds to reduce the impact of heart disease and stroke – the No. 1 and No. 5 killers of men and women. The event raised $500,000 for the mission, which will be used to fund cardiovascular research, preventative education efforts, and advocacy initiatives in Kentucky. ◆ LOUISVLLE
Vinod Solankhi, left, her husband Dr. Naresh Solankhi with KentuckyOne Health Cardiology Associates, Dr. Jesse Adams with Baptist Medical Associates, and his wife Kim Adams
Councilman David Yates, left, Councilwoman Marianne Butler, and Gregory P. Karem, DMD
Dr. Kelli Dunn and Dr. David Dunn, executive vice president of Health Affairs for the University of Louisville, attend the 2015 Louisville Heart Ball, sponsored by the American Heart Association, Saturday, Feb. 21, 2015 at the Louisville Marriott Downtown in Louisville, Ky
Jan Kensicki and Dr. Paul Kensicki
Sally and Dr. Greg Postel, CEO of University of Louisville Physicians, and Terri and Steve A. Bass, a part-owner in Louisville Cyberknife
Partnering with physicians to keep hearts healthy. To make a referral, please call 812.949.7088 or visit:
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FloydMemorial.com/Heart PHOTOGRAPHY BY BRIAN BOHANNON
“Coping with change is like the grieving process, says Francee Preston, senior consultant in Organizational Dynamics.
Lexington Medical Society Offers CME
On Saturday, April 18, 2015, Joe Mull, author of Cure for the Common Leader: What Physicians & Managers Must Do to Engage & Inspire Healthcare Teams will present a leadership masterclass of the same name for Lexington Medical Society member physicians and their administrative managers at the Lexington Center from 8:30am to 4pm. Mr. Mull is the former head of Learning and Development for one of the largest physician groups in the country and is a leading authority on employee engagement in healthcare. Cure for the Common Leader is an immersive leadership course that translates the latest research on employee engagement and motivation into seven actions physicians and managers must take to trigger effort and investment among healthcare employees. This program is an exclusive member benefit for LMS member physicians, who are invited to attend at no cost. LMS members may bring their practice or office manager at no additional cost. The cost for non-member physicians is $300 and $150 for their office or practice manager. Breakfast and lunch are included. This event has been approved for 6.5 AMA PRA Category 1 Credits. Additional information, including program objectives, and more, can be found on the Lexington Medical Society LEXINGTON
First Meeting of 2015 for Blue Grass MGMA LEXINGTON The
first meeting of 2015 of Blue Grass MGMA was at Sal’s Restaurant in Lexington. The guest speaker was Francee Preston, senior consultant in Organizational Dynamics with State Volunteer Mutual Insurance Company (SVMIC). Preston’s topic was “Coping with Change during 2015.” Preston discussed the different approaches to change such as “intellectualizing change,” which is an attempt to control it and creates pressure. An emotional approach to change, said Preston, usually induces stress. Preston cited the story of William Tell, who famously shot an apple off his son’s head with an arrow, to demonstrate the difference between “pressure and stress.” The father felt pressure to perform, while the son felt stress because he had no control over the situation. Preston attributes the William Tell story to Liz Wiseman from her book Multipliers and realized it has a huge impact on change. Coping with change in the workplace takes intellectual and emotional energy, said Preston, and is similar to the grieving process with five stages: shock/fear, denial, frustration, depression, and finally acceptance. More on the grief process analogy is available in Changing Minds by Elizabeth Kübler-Ross. New Blue Grass MGMA President Martina Denny, MHA, CMPE, practice administrator at Pediatric & Adolescent Associates, PSC, presided. More information on Blue Grass MGMA is available at www.bgmgma.com. ◆
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Issue #92 May – WOMEN’S HEALTH, Women’s Health, Pediatrics, Endocrinology / Genetics/ Sexual Health Issue #93 June/July –MEN’S HEALTH, Dermatology, Plastic Surgery / Sports Medicine, Fitness
At the January 13, 2015 meeting of the Lexington Medical Society were (l-r) Thomas H. Waid, MD, past-president, David J. Bensema, MD, president KMA and Stephan K. Toadvine, MD, chief medical officer, Baptist Health Lexington.
Danesh Mazloomdoost, MD, vice president-elect and B.T. Westerfield, MD, Administrative Council chair enjoyed a moment together at the January 13, 2015 meeting of the Lexington Medical Society. (L-R)
Daniel E. Kenady, Sr., MD, and Ira P. Mersack, MD got together at the January 13, 2015 meeting of the Lexington Medical Society.
website, www.LexingtonDoctors.org. Seating is limited and registration is on a first come, first served basis. ◆
Issue #94 August/September MUSCULOSKELETAL HEALTH Orthopedics, Physical Medicine, Rheumatology / Occupational Health Issue #95 October – SURVIVING CANCER, Oncology, Radiology, Imaging / Hospice, Home Health
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