July/August 2016 Public Health Update

July/August 2016

Doctors Metro MetroDoctors THE JOURNAL OF THE TWIN CITIES MEDICAL SOCIETY

Public Health Update Health

HIV

s Genetic Menthol Opiates

In This Issue: • • • •

Vacc i

nes

What’s New in Public Health?

Zika Forum - July 26, 2016 Medical Students Receive ACP Training Luminary of Twin Cities Medicine

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CONTENTS V O L U M E 1 8 , N O . 4 J U LY / A U G U S T 2 0 1 6

3

IN THIS ISSUE

Beyond Your Own Walls

By Peter J. Dehnel, M.D.

4

PRESIDENT’S MESSAGE

Dearly Beloved, We are Gathered Here Today

By Carolyn A. McClain, M.D.

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TCMS IN ACTION

By Sue Schettle, CEO

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PUBLIC HEALTH

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Colleague Interview: A Conversation with Kevin Garrett, M.D., Senior Vice President, Chief Medical Officer – HealthEast; Brian Rank M.D., Executive Medical Director – HealthPartners; Tim Sielaff, M.D., Chief Medical Officer, Senior Vice President – Allina Health; and Beth Thomas, D.O., Interim Chief Medical Officer – Fairview Health Services

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SPONSORED CONTENT:

Page 32

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Integrative Care for Low Back Pain: Implementing Evidence-Based, Non-Opioid Treatments

By Florin Orza, M.D., and Roni Evans, D.C., Ph.D.

Page 27

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Prescribing Naloxone in Minnesota

By Paul Satterlee, M.D.

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Menthol’s Grip on Health Inequities

By Ellie Parker, MPH

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Genetic Tests: Is Primary Care Ready?

Impact on Public Health

By Shari Baldinger, MS, CGC

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Buzz Topics: Vectorborne Diseases of Minnesota

By Franny Dorr, MPH

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U.S. Adult Immunization Rates are Not Good...Please Help

By Deborah Wexler, M.D.

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Future Physicians Hone End-of-Life Skills

By Karen Peterson

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Twin Cities Medical Society Foundation

29

Senior Physicians Association Career Opportunities

Page 5 MetroDoctors

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In Memoriam

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LUMINARY OF TWIN CITIES MEDICINE

William Keith Henry, M.D. The Journal of the Twin Cities Medical Society

Much of medicine is about public health. Articles, beginning on page 6, provide new and updated information.

July/August 2016

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Doctors MetroDoctors THE JOURNAL OF THE TWIN CITIES MEDICAL SOCIETY

Physician Co-editor Peter J. Dehnel, M.D. Physician Co-editor Robert R. Neal, Jr., M.D. Physician Co-editor Marvin S. Segal, M.D. Physician Co-editor Stephanie Misono, M.D. Physician Co-editor Richard R. Sturgeon, M.D. Physician Co-editor Charles G. Terzian, M.D. Medical Student Co-editor Katherine Weir Managing Editor Nancy K. Bauer TCMS CEO Sue A. Schettle Production Manager Sheila A. Hatcher Advertising Representative Betsy Pierre Cover Design by Emily Larsen MetroDoctors (ISSN 1526-4262) is published bi-monthly by the Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. Periodical postage paid at St. Paul, Minnesota. Postmaster: Send address changes to MetroDoctors, Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413.

To promote its objectives and services, the Twin Cities Medical Society prints information in MetroDoctors regarding activities and interests of the society. Responsibility is not assumed for opinions expressed or implied in signed articles, and because of the freedom given to contributors, opinions may not necessarily reflect the official position of TCMS.

July/August Index to Advertisers

TCMS Officers

President: Carolyn A. McClain, M.D. President-elect: Matthew A. Hunt, M.D. Secretary: Thomas E. Kottke, M.D. Treasurer: Nicholas J. Meyer, M.D. Past President: Kenneth N. Kephart, M.D. TCMS Executive Staff

Sue A. Schettle, Chief Executive Officer (612) 362-3799; sschettle@metrodoctors.com Nancy K. Bauer, Associate Director, and Managing Editor, MetroDoctors (612) 623-2893; nbauer@metrodoctors.com

Allina Health System........................................29 ClearWay Minnesota ........................................16 Coldwell Banker Burnet..................................10 Crutchfield Dermatology.....................................

Inside Front Cover Entira Family Clinics .......................................31 Fairview Health Services .................................31

Karen Peterson, BSN Executive Director, Honoring Choices Minnesota (612) 362-3704; kpeterson@metrodoctors.com

Healthcare Billing Resources, Inc. ...............26

Lynn Betzold, Program Coordinator, Honoring Choices Minnesota (612) 362-3703; lbetzold@metrodoctors.com

Lakeview Clinic .................................................30

Annie Krapek, Assistant Project Coordinator Physician Advocacy Network (612) 362-3715; akrapek@metrodoctors.com Emily Larsen, Marketing & Communications Coord.

(612) 623-2885; elarsen@metrodoctors.com Helen Nelson, Administrative Assistant, Honoring Choices Minnesota (612) 362-3705; hnelson@metrodoctors.com Ellie Parker, Project Coordinator Physician Advocacy Network (612) 362-3706; eparker@metrodoctors.com

HealthPartners Medical Group .....................30 M Health ................................................. 12 & 13 Melrose Center ................. Outside Back Cover PrairieCare ...........................................................19 Saint Therese.......................................................26 Senior LinkAge Line.........................................15 St. Cloud VA Medical Center ............................

Inside Back Cover Uptown Dermatology & SkinSpa.................. 2

Send letters and other materials for consideration to MetroDoctors, Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. E-mail: nbauer@metrodoctors.com.

For advertising rates and space reservations, contact: Betsy Pierre 2318 Eastwood Circle Monticello, MN 55362 phone: (763) 295-5420 fax: (763) 295-2550 e-mail: betsy@pierreproductions.com MetroDoctors reserves the right to reject any article or advertising copy not in accordance with editorial policy. Advertisements published in MetroDoctors do not imply endorsement or sponsorship by TCMS. Non-members may subscribe to MetroDoctors at a cost of $15 per year or $3 per issue, if extra copies are available. For subscription information, contact Andrea Farina at (612) 623-2885.

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July/August 2016

MetroDoctors

The Journal of the Twin Cities Medical Society

IN THIS ISSUE...

Beyond Your Own Walls WELCOME TO THIS ISSUE of MetroDoctors as we focus on the broader world of public health!

Seeking to improve the lives and health status of patients “beyond your own walls” is something that many of you do on a regular, if not daily, basis. My sincere hope is that all of us will look for more ways to enhance the health of the people in the Twin Cities on a broader basis. There are many opportunities for physicians to do this, and the challenge may actually be to decide in which area you should direct your efforts.

If you are looking for new ideas or areas to pursue, please use this edition of MetroDoctors as a springboard for your thinking and exploration. The first article is our standard “Colleague Interview” in a not-so-standard format. We have invited the Chief Medical Officers from HealthEast, HealthPartners, Allina Health and Fairview Health Services to give their perspectives on critical public health issues and how each of their respective organizations is approaching these challenges in a meaningful and intentional way. This includes the vexing problem of disparities in health outcomes for significant population groups in Minnesota.

Low back pain is a problem at an individual level, but based on the number of individuals affected and the resources needed to enhance pain reduction, this issue wells up to a population health concern. Florin Orza, M.D. and Roni Evans, DC, Ph.D. give their perspectives and insights on integrative care approaches to address this often disabling condition.

It is difficult to talk about back pain without hitting the issue of opiate overuse and addiction head on. Paul Satterlee, M.D., informs us about the legislature’s passage of “Steve’s Law” in 2014. This law establishes a triad of enhancements to community-based opiate overdose treatment: it provides for broader availability of naloxone by ambulance providers to treat opiate overdoses acutely; it provides immunity for those who call for help in the event of an opiate overdose; and it provides significant protections for prescribers who prescribe naloxone to help people who may be at risk for an overdose.

This is seen as a critical development to immediately address the burgeoning number of deaths related to this preventable condition.

By Peter J. Dehnel, M.D. Member, MetroDoctors Editorial Board

MetroDoctors

The Journal of the Twin Cities Medical Society

Ellie Parker, MPH, Project Coordinator for the Physician Advocacy Network, provides a timely reminder of the power that the tobacco industry still holds in this country, and how menthol is frequently an additive to enhance acceptance and use of a broad range of tobacco products.

Just when we all thought that the battle against tobacco had been essentially won, this issue is coming back with a new and different twist.

Genetic testing is a blossoming area of scientific and medical activity, with over 60,000 different genetic tests available in 2016 — either testing individual mutations or combinations of genetic mutations. Shari Baldinger, MS, CGC, provides some needed insights into how clinicians should approach these expanding number of options. This testing has implications for medicine at both the individual health level as well as the population level.

No edition on public health would be complete without a discussion of vector-borne diseases and immunizations. Franny Dorr, MPH, from the Minnesota Department of Health, gives an update on both tick-borne as well as mosquito-borne disease in Minnesota. Deborah Wheeler, M.D. encourages us all to do better in ensuring that all ADULTS are properly vaccinated to prevent, or at least mitigate, a whole host of diseases.

Immunize.org offers up-to-date CDC recommended vaccines and schedules.

Finally, Marv Segal, M.D., provides another excellent “Luminary” focusing on the tireless efforts of William Keith Henry, M.D., to combat the morbidity and mortality associated with HIV/AIDS. There are few modern day public health success stories that are equal to what has been accomplished with this condition.

I hope you enjoy this edition of MetroDoctors. I also hope it inspires you to look at what else you might do to enhance the health of others on a broader basis.

July/August 2016

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President’s Message

Dearly Beloved, We are Gathered Here Today CAROLYN A. McCLAIN, M.D.

On April 21, 2016, Prince, one of Minnesota’s most famous citizens, was found dead in an elevator in his Paisley Park home. The autopsy report has confirmed that opiates were involved. This tragic event lends both a famous and local face to the growing public health crisis of opiate overdoses. Unfortunately for us as physicians, the responsibility for this crisis is landing right in our laps. A recent headline in the satirical newspaper The Onion stated, “Doctor Quickly Scribbles Prescription That Will Lead To 30-Year Battle With Painkiller Addiction.” Amy Kloubuchar, our U.S. Senator has introduced a bill to improve the prescription database and empower pharmacists. Although I applaud her much needed efforts, it is those same lawmakers who are enabling this crisis to continue.

As we all lament, in the early 2000s pain became the “5th vital sign.” Regardless of the patient’s chief complaint, it became the physician’s role to decrease the patient’s pain even if that was not the appropriate treatment for the patient. At office and ER visits the nurse would ask the patient, “How would you rate your pain.” It was clear, that this number should be lower after the visit. If this was not the case, a complaint could be written and the physician would be shamed into doing a better job next time, i.e. prescribing Percocet.

If that wasn’t bad enough, our overall compensation is now tied to “patient experience.” Patients are sent surveys from HCAHPS, Press Gainey, Studer, and more that ask: “Did the doctor treat your pain?” This question assumes your pain not only could be alleviated but should have been. A patient’s experience of pain is not a reflection of the quality of their medical care. During my second daughter’s birth, I waited 2 ½ hours for my epidural. I had pain, but my doctors did nothing wrong. Bringing life into the world hurts, it just does. Tying pain control to physician and hospital compensation is the last thing the government should mandate when in 2014, 18,893 Americans died of opiate overdoses alone.

As physicians our job is to decrease suffering, which although related, is different than treating physical pain. As an Emergency Medicine physician, I spend a lot of time discussing with my patients why I am not prescribing them opiates. These are long conversations that usually start with a pleasant tone and end with a disgruntled patient and a call to my medical director warning of a future complaint. It is exhausting. And yes, sometimes I cave and write the prescription. I’m sorry.

I don’t do it that often. But each time I do, I like myself and my job less. In an environment where physician burnout is growing and a doctor shortage looms, this has to stop. As physicians, we need to feel empowered by the systems we work in to do the right thing for our patients. This is often, not giving opiates. When we do this, we should not have to fear that our patient satisfaction scores will decrease or that we will face another patient complaint. As a medical society, we need to contact JCAHO, CMS, and our lawmakers to take the “treatment of pain” out of our patient experience surveys so we are not reprimanded for giving our patients the best possible care.

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July/August 2016

MetroDoctors

The Journal of the Twin Cities Medical Society

TCMS IN ACTION SUE A. SCHETTLE, CEO

TCMS Hosts Emergency Medicine Educational Event Twin Cities Medical Society hosted a very unique Emergency Medicine physicianfocused educational event on Wednesday, May 18, 2016 at Hennepin County Medical Center. The purpose of the event was to improve patient safety by enhancing physician communication skills in the ER. TCMS received a Patient Safety Research Grant from MMIC to support this activity.

Nearly 50 Emergency Medicine providers, mostly physicians, were grouped into 11 different cohorts and rotated in 3-hour increments throughout the day at HCMC’s Interdisciplinary Simulation and Education Center. The Center is led

by Danielle Hart, M.D. who served a crucial role in the event. Actors, known as “standardized patients” portrayed scenarios that were unique to EMD settings and interacted with each physician upon entering the “exam room.” TCMS President Carolyn McClain, M.D. is the lead investigator on the project and will be writing a research paper highlighting the findings.

Comments received from participants included: “This was a useful exercise since it has been a long time since I have seen others interact with patients with different styles.” “Good activity! It was painful, but very good to have to watch ourselves on video.” “This event should be provided on a regular basis…it would go a long way toward team building and helping decrease Carolyn McClain, M.D. burnout.” We offering suggestions to participants at the agree and have event.

MetroDoctors

already heard from some metro-based health systems about their desire to do something similar.

To learn more, contact TCMS at TCMS@metrodoctors.com.

Physicians in cohort group gathered to watch films of each other interacting with the standardized patients.

“Summer of Zika” Forum Date Set TCMS is inviting physicians, residents, medical students, and other healthcare professionals to attend an educational forum on Tuesday, July 26, 2016 from 6 p.m.-8 p.m. at Moos Tower at the University of Minnesota. The purpose of this free event is to help equip physicians and others with the tools and resources they will need to talk with their patients about the Zika virus. We know that Zika is primarily an issue in the southern hemisphere however many Minnesota physicians are being asked to provide input on travelers going to or coming from affected areas. Attendees will hear the most up-to-date information. The event will be moderated by Peter Bornstein, M.D., an infectious disease specialist with St. Paul Infectious Disease Specialists, Ltd. Other speakers include Frank Rhame, M.D. an infectious disease specialist from Allina, Dave Neitzel, MS, from MDH’s vectorborne disease unit and Elizabeth Schiffman, MA, MPH also from MDH. The event is co-sponsored by most all of the metro-based hospitals and health systems. To register visit www.metrodoctors.com. This is a FREE event. A light dinner will be provided.

The Journal of the Twin Cities Medical Society

Grant Awarded to TCMS to Engage, Educate and Empower Physician Leaders TCMS is pleased to have received a $150,000 two-year Physician Leader grant from the Physicians Foundation to support the replication of our Physician Advocacy Network (PAN) to other county and state medical associations throughout the United States. Our model builds on three main tenants — engage physicians, educate them on the topic, and empower them with the tools and resources to affect change at the city, county and state level. TCMS has built this successful model over the past decade — using it to advocate for city and county ordinances for smoke-free environments. It was used again for our work in obesity prevention, and we continue to use it today to educate physicians about e-cigarettes, hookahs and other tobacco products. The PAN model is effective and we are pleased to be able to share it with others.

Physician Volunteers Needed We are looking for physicians to join our “Honoring Choices Physician Ambassador” group. If you are interested in helping to spread the message of the importance of advance care planning please consider volunteering to speak at community groups, faith-based organizations, nursing homes, etc. The time commitment can be as little or as much as you’d like. If you’re interested contact Lynn Betzold at lbetzold@metrodoctors. com or call the Honoring Choices staff at (612) 362-3704.

July/August 2016

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Public Health

Colleague Interview

E

ditor’s note: Executive leadership from four local health systems were invited to participate in a “group” colleague interview addressing the question, what is the role of health systems in addressing public health issues? Their responses comprise this issue’s Colleague Interview.

Kevin Garrett, M.D., Senior Vice President, Chief Medical Officer – HealthEast

Brian Rank M.D., Executive Medical Director – HealthPartners.

What do you see as the primary public health concern in the Twin Cities metro area?

Kevin Garrett, M.D. – The overarching community health issue for the metro region currently is mental health/wellbeing. We see evidence of this issue every day in our hospitals and clinics.

At HealthEast, we recognize that to be effective, mental health care must be provided in a way that is culturally appropriate for the patient and their family. Our key focus is to develop/support a continuum of care provided close to the patient’s family and friends.

We are addressing those needs in part by integrating mental health care into primary care. At our primary care clinics in St. Paul and throughout our service area, we have placed a psychotherapist in the clinic. These therapists are available to work with patients who may be living with both a chronic medical condition such as diabetes and also have a mental health concern.

Brian Rank, M.D. – Nearly every public health issue has the high cost of care somewhere in its roots — either as a direct cause or as a contributing factor. As an integrated system of care and coverage, we see affordability challenges affecting not only our patients but also the premiums our members pay and the costs their employers face.

There are cost examples that get headlines, like egregious price hikes for specialty drugs. As a nation, we pay the most for clinical 6

July/August 2016

Tim Sielaff, M.D., Chief Medical Officer, Senior Vice President – Allina Health

Beth Thomas, D.O., Interim Chief Medical Officer – Fairview Health Services

health care and our outcomes don’t reflect it. But affordability challenges thwart health in myriad smaller ways affecting all of us.

Most of what determines individual and public health has little to do with a doctor’s office. It has much more to with education, healthy habits and nutrition, good jobs and safe environments.

The high costs of health care divert significant resources from these needs.

To truly support public health, we need to change what we’re paying for and why. We need to continue to move away from the outmoded fee-for-service model of care and toward payment systems that reward value instead of volume. And we need to continue to strive for Triple Aim-oriented care and coverage transformations that achieve affordability, health and experience simultaneously.

Tim Sielaff, M.D. – In the Twin Cities and across Minnesota, mental health and obesity continue to be two of the most pressing public health concerns — we see this in the public health data and we hear this from our communities through the Community Health Needs Assessments Allina Health completes every three years. Layered on top of these two public health issues is the growing statewide concern about health inequities in Minnesota.

Minnesota (and Allina Health) has some of the best health outcomes in the country — but not for everyone, particularly if you are a person of color or low income. For example, Allina Health MetroDoctors

The Journal of the Twin Cities Medical Society

stratifies our health outcomes data by demographic characteristics such as race, ethnicity and language to identify disparities and drive action. To address these health concerns, it is vital that we build cross-sector partnerships and collaborations to address the social determinants of health or health-related social needs, such as housing, transportation, food security, and others.

Beth Thomas, D.O. – The most pressing and prevalent concern we see in the metro area and throughout our entire system is mental health. It was the primary concern identified in our most recent Community Health Needs Assessment, a set of detailed reports that shed light on the evolving health needs of the people we serve and help us assess how best to meet those needs going forward.

In our 2015 assessment, every community we serve identified mental health as a top need.

We know that there’s a need for greater access to mental health care. We are focused on improving access through efforts like co-locating therapists within Fairview’s primary care clinics, which enables therapists to collaborate closely with primary care providers in providing a more holistic, integrated care experience.

We also strive to increase education and awareness of mental health issues. We offer free “Mental Health First Aid” trainings that teach police officers, educators and other community members how to respond when someone is having a mental health crisis.

The Minnesota Department of Health has set a priority to eliminate disparities in health and health equity in our state. What can your system do to better address the disparities issue?

Brian Rank, M.D. – HealthPartners has long considered elimination of disparities a top priority. About 15 years ago, we built a strategic foundation for improving equity in care in our clinics, hospitals and within our health plan. As we’ve worked since then, both alone and in partnership, we’ve found these four factors important to addressing disparities: 1. Drive from the top. The development and execution of a strategic plan to reduce disparities requires full support and commitment from organizational leaders.

2. Become data driven. The strategic collection of data — race/ ethnicity, language preference, and country of origin data — is a necessary foundation for monitoring health care quality and patient satisfaction while identifying gaps and opportunities.

3. Begin with standardization. Standardized patient workflows that bridge cultural, language, linguistic, socioeconomic and other barriers are necessary to enable quality care for all patients.

4. Engage people at the gaps. Patients, community partners, front-line staff and others have meaningful, first-hand knowledge that can make disparities reduction efforts more effective.

Space prohibits detail in this forum, but we’ve followed these guidelines to support disparities reduction work in many areas, including breast cancer and colorectal cancer screenings, as well as diabetes care, in disadvantaged communities.

Tim Sielaff, M.D. – To better address disparities, Allina can continue to: • Stratify our clinical quality outcomes by demographic data (e.g. race, ethnicity and language) to identify opportunity.

• Unpack and understand these disparities by sitting down and talking with the communities that are actually experiencing them. For example, focus groups and personal interviews with health consumers, particularly those who we aren’t reaching, can reveal where we are not connecting with patients, and enhance how we provide care and where we provide care.

• Build capacity within our clinical service lines to implement clinical and community-based interventions to tackle disparities. For example, Allina is eliminating many common barriers to colorectal cancer screening by mailing out colorectal cancer screening test kits to patient’s homes. Instructions and frequently asked questions are translated into the four most common languages and are responsive to cultural concerns.

Allina’s Somali population has very low screening rates; to address common cultural and language barriers, Allina is reaching this population through a newly released Somali colorectal cancer screening video.

• Assess and address our patients’ non-medical health needs and the socio-economic determinants of health. For example, Allina employs “Care Guides” (non-clinical lay healthcare workers) to meet patients in their clinics, homes and communities to serve as an ally to patients in navigating the healthcare system, achieving their care goals, and uncovering/addressing barriers to health such as housing instability, financial resource strain, food insecurity, transportation, and social support.

• Develop a strategic plan to advance diversity, inclusion and (inter)cultural competency. This plan will strengthen our ability to: 1) train, seek, attract and hire diverse talent that represents the communities we serve; 2) cultivate an inclusive work environment where diversity is supported, developed and leveraged; and 3) empower our workforce with the experiences, skills, policies and practices to provide care that is culturally-responsive to needs of the patients and communities we serve.

• Address language barriers by providing interpreter services, translated written materials, translated websites and other multimedia.

Beth Thomas, D.O. – One way we try to eliminate disparities in health care is through a strong commitment to providing culturally competent care. One example is our work to build a strong relationship with the Somali community near Fairview Ridges Hospital in Burnsville, MN. There is a large Somali population in the Burnsville area, and we want to make sure Fairview, being a large health care provider, does a good job of reaching out.

We set out to meet with members of the Somali community so we could help them better understand how to effectively navigate the health care system and — just as importantly — listen to the community so we can better understand their health needs. Out (Continued on page 8)

MetroDoctors

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Public Health Colleague Interview (Continued from page 7)

of this work, we developed an ongoing education event series that has covered topics such as mental health, autism, care for fevers and when to access different levels of care. By building stronger connections to the communities we serve, we’re able to provide better care.

At Fairview, we’ve found that this is one simple way a health system can begin to address health disparities. More work is certainly needed, and we’re committed to continuing and expanding our efforts.

Kevin Garrett, M.D. – At HealthEast we are using the FY 2016 – 2018 community health improvement plan (CHIP) as the platform for our work around this challenging issue. The CHIP committee chose to address the priority health issues of access to health services, obesity and mental health, through the lens of health equity. The implementation plan focuses on meeting the needs of the following priority populations: aging residents; residents in poverty; populations of color.

Our goal is to create a dashboard of key EHR metrics to include social risk factors to understand where health disparities might exist among our clinic patients and then hot spot geographically to look for potential neighborhood/community interventions with social determinants.

Please describe one public health initiative your organization is currently engaged in to improve community health.

Tim Sielaff, M.D. – While there are a number of specific initiatives Allina Health is engaged in to improve community health (e.g., Heart of New Ulm, The Backyard Initiative, Healthy Communities Partnership, Neighborhood Health Connection), we are most excited by our organization’s focus on population health as a key strategic initiative and a core component of our organizational scorecard. What does that mean? We track and report on important population health measures across our patient population, including BMI, tobacco status, and quality of life and are implementing programs to move the needle. Collecting and reporting data on such a large scale allows us to identify key macro initiatives we need to engage across our system, as well as identify hotspots and areas that have larger gaps where we need more specific micro initiatives. Eventually we will add more measures to this “community health index” and broaden this agenda to include our employees and community members.

This total population health strategy allows an organization of our size to think systematically about what we can do across our large geographic area and our substantial human footprint to improve the environments and supports for everyone as they live, learn, work, pray, and play.

Beth Thomas, D.O. – Here’s one example that’s been very successful. Based on the results of our community health needs assessment, staff at Fairview Southdale Hospital in Edina, MN, 8

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knew that access to preventive medicine was a major concern for members of the Latino community, who are less likely to have health insurance. Through a partnership of our community health and oncology departments, we began a health education and outreach initiative focused on colon cancer.

The effort was led by a community health worker on our staff, who shares the language and culture of the community served. This approach allowed us to provide education, outreach and support to build trust between the community and those involved in the initiative.

The program proved so successful when first conducted in 2014 that we expanded it to a second hospital last year. As a result, health education efforts reached more than 160 people and 32 free colonoscopies were provided to uninsured adults at high risk of developing colon cancer.

Kevin Garrett, M.D. – We are committed to working in Ramsey County, where many people are struggling with the cost of health care and mental health, as well as access to healthy food and physical activity. Much of this work is defined through HealthEast’s Neighborhood Integration (NI) strategy. NI is grounded in our belief that health depends largely on what happens where we live, work, learn and play — long before people enter our clinics and hospitals. NI is focusing on forming and nurturing partnerships with community-based organizations. Monthly meetings with East Side partner organizations have transitioned into coordinated strategic action workgroups, which are working to launch one or two pilot health and well-being initiatives for the East Side by the end of 2017.

• The workgroup focused on mental health and stress-resilience and has developed a goal to “foster holistic well-being of and with East Side communities through culturally responsive training for providers and emotionally focused tools, services, and spaces for families and youth across East Side neighborhoods.” Their efforts will be designed to better equip providers and go to where people live to get daily stress relief, break out of isolation and build meaningful connection.

• The second workgroup, focused on expanding access to healthy foods, will be working to increase East Siders’ consumption of fresh fruits, vegetables and other healthy foods.

Their current discussions focus on the creation of a “Let’s cook” campaign to influence residents’ food selection. Tactics may include food tasting, cooking demonstrations and community meals, all reflecting the area’s ethnic and cultural diversity.

HealthEast has provided facilitation, partner grants and communications support to the workgroups and is anticipating completion of the work plans in June, with initial implementation beginning in July.

In addition to our CHIP, HealthEast is engaged in a number of community collaboratives to improve the health of the community including, Woodbury Thrives, Ramsey County Public Health SHIP Community Leaders Committee, Promise Neighborhood and Center for Community Health.

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The Journal of the Twin Cities Medical Society

Brian Rank, M.D. – Given the strong link between health and well-being early in life and the same later in life, HealthPartners sees a major opportunity to focus investments in the health of children from prenatal stages through childhood.

The aim of this work, collectively known as our Children’s Health Initiative, is to improve the health and well-being of the children we serve, from pregnancy to 5 years old. A team of physicians and leaders from across our organization identified 10 initiatives, focusing on three key areas, to support mothers and children: promotion of early brain development; provision of family centered care; and strengthening of communities.

For example in 2015, we implemented Reach Out and Read — a national program to help young children develop the skills to learn to read by age five — in every primary care clinic across our organization. In 2015, we gave out 95,000 books through the Reach Out and Read program. Other initiatives involve promotion of breastfeeding, screening for postpartum depression, support of high-risk families in our community, and more.

What steps is your organization taking to enhance the overall level of health within your own employees?

Beth Thomas, D.O. – Our vision is to drive a healthier future, and in many ways that begins with healthy employees. Advancing employee well-being is a key priority for Fairview and we have a broad portfolio of services and benefits in place to promote employee health and wellness — from weight management programs to health club discounts and farmers markets.

This year, we are adding to this portfolio with the launch of a new online health and well-being platform. Employees can access the platform from anywhere — work, home or mobile device — and keep track of their healthy activities. Participants can read health tips, join fitness and nutrition challenges, and get customized support for achieving their own health and well-being goals.

Another key effort is our work to support physician wellness and prevent burnout through a number of programs, including “Heart of the Healer” retreats to help caregivers stay passionately and purposefully engaged in their work.

Kevin Garrett, M.D. – Well-being is an important component of our work at HealthEast — so important that we included it in our vision statement: “Optimal health and well-being for our patients, our communities and ourselves.” Well-being will enable our employees to enjoy each day and get more out of life, while also boosting the well-being of your friends, family members, colleagues, employees and others in your community.

Brian Rank, M.D. – As an integrated system of care and coverage, HealthPartners has a unique perspective on employee health, in part because we offer health and well-being services to employer clients of our own. As such, we don’t need to be persuaded about the health benefits, productivity advantages and significant

MetroDoctors

The Journal of the Twin Cities Medical Society

financial ROI associated with encouraging and supporting an employee population to be physically and emotionally fit.

Our health and well-being approach at HealthPartners is known by our colleagues as “Be Well.” Recognizing that physical fitness is an important part of health but by no means the only one, our model focuses on six areas of health and well-being: physical, community, emotional and mental, social and interpersonal, financial, and career. We offer our team members support in all these areas with the aim of helping them find meaning and purpose through healthy living each day, and in a way that is consistent with their values and beliefs.

These resources include a wide range of programs and activities from gym discount incentives to health coaching and virtual coaching; online training about managing anxiety and depression; sleep, tobacco and weight tracking, personal finance training and more.

In 2015, we also were proud to have been one of the health first care organizations in the region to commit to removing most sugary beverage options from our hospitals and clinics.

Tim Sielaff, M.D. – Within Allina Health, we have partnered internally with the Penny George Institute for Health and Healing to improve the well-being of our employees. We know that building health, resilience and wellbeing within our employees will also help us build these in our patients. For example, Allina Health has a variety of programs that are subsidized or free for our employees such as Resilience Training for depression and anxiety, mindfulness training, weight management classes, health coaching, and holistic tobacco cessation. Allina Health is working to change our internal environment and culture to be one that makes the healthy choice the easy choice. For example, we removed our deep-fat fryers, we are removing our sugar sweetened beverages, and we are removing our McDonalds. We look forward to continuing to foster a culture of health where we “walk our talk” and we look forward to being one of the first organizations to lead improvements on staff burnout.

What public health project is your organization willing to collaborate on with the other health systems across the state and who should lead that effort?

Kevin Garrett, M.D. – We are currently and will in the future look to collaborate with like-minded organizations and community partners around health priorities for the communities we serve — priorities such as those we are focusing on right now — mental health, access to health services and obesity.

Brian Rank, M.D. – We believe that leadership on our most pressing and complex issues must be shared broadly. While HealthPartners plays a role in many important partnerships across a range of initiatives, we’re especially interested in strengthening statewide partnerships supporting mental health.

(Continued on page 10)

July/August 2016

9

Public Health Colleague Interview (Continued from page 9)

Our mental health challenges present a good example of how we need creative approaches and a willingness to work across traditional boundaries.

In 2003, for example, we were proud to help form the East Metro Mental Health Roundtable — a collaborative group of social service agencies, hospitals, governments, health systems, law enforcement and many others who have a vested interest in mental health care in the eastern Twin Cities. This group has remained engaged since, forging new connections to help coordinate and maximize the too-scarce resources we have across our region — especially for those needing chronic and emergency mental health care.

We’ve also enjoyed the partnership and support of many behind MakeItOk.org, the online and community effort designed to help ease conversations about mental illness and to stop associated stigma.

We believe these partnerships suggest the promise of more and deeper collaboration around the state in support of mental health, which we would very much like to see — especially in support of rural areas where resources are thinnest.

Tim Sielaff, M.D. – Allina Health is eager to collaborate on health equity. We recognize that eliminating health inequities cannot be

Beth Thomas, D.O. – Fairview is always open to collaborating with other health systems across the state on public health issues — in fact we already do collaborate on a number of issues, including mental health. Our community health team actively looks for opportunities to collaborate with other health systems and community groups throughout the state.

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accomplished within our individual silos. Closing the gap will take aggressive collective impact efforts amongst care delivery systems, community-based clinics, payers, cross-sector partners (e.g. faith communities, schools and employers) and — most importantly — the communities experiencing the health inequities. Allina Health is part of the Minnesota Disparities Leadership Program Alumni Consortium (MNDLP) — a consortium of Minnesota healthcare institutions who are sharing best practice, thought leadership and our challenges and successes in advancing health equity. The MNDLP is in the very early stages of exploring cross-institutional collaboration to look at how we might leverage our economies of scale to measurably advance health equity within our shared communities and across our state. Organizations such as the Institute for Clinical Systems Improvement (ICSI) and Stratis Health have successfully led statewide collective impact campaigns such as the Reducing Avoidable Readmissions Effectively (RARE) Campaign and may be uniquely positioned to convene collaborators such as the MNDLP and others around a targeted health inequity.

July/August 2016

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Sponsored Content

Integrative Care for Low Back Pain: Implementing Evidence-Based, Non-Opioid Treatments Contributed by Florin Orza, M.D., and Roni Evans, D.C., Ph.D.

There has been increasing recognition that pain, especially when chronic, is a complex disease that jeopardizes public health and productivity.1 The prevalence of pain in the United States is significant, with persistent pain affecting more Americans than diabetes, heart disease, and cancer combined. Results from the 2012 National Health Interview Survey found over half of the U.S. population experienced pain in the previous three months, and nearly 1 in 10 individuals had pain daily.2 Almost 20% had pain that is classified as more severe, which is associated with greater healthcare utilization and disability. Low back pain (LBP) is the most reported form of pain, with over 80% of adults experiencing it at some point in their lives. While most patients with acute LBP recover, a small percentage of cases become chronic. It is these persistent cases, however, that account for the lion’s share of the associated burdens and costs.3 LBP and pain management overall are gaining increased attention as concerns mount regarding the rise of opioid use in the United States. With an estimated 1 in 5 noncancer pain sufferers receiving an opioid prescription despite extensive evidence of the medication’s potential harms, there has been a pivotal shift in the management of the most commonly presenting pain conditions.4 Most notable is the Centers for Disease Control and Prevention’s recent recommendation of nonopioid pharmacologic and nonpharmacologic approaches to pain management.4 Complementary healthcare, used by one-third of U.S. adults, is a common means of treating pain.2 Developed outside of mainstream medicine, these approaches are also sometimes called “alternative”; however, most individuals use such treatments in

MetroDoctors

conjunction with conventional medicine. The most common are natural products, which include dietary supplements other than vitamins and minerals, and are used by nearly 20% of U.S. adults. Other common complementary approaches are deep breathing (11% of population); movement exercises like yoga, Tai Chi, or Qigong (10%); chiropractic or osteoFlorin Orza, M.D. Roni Evans, D.C., Ph.D. pathic manipulation (8%); and meditation (8%). Pain is the most common have been shown to be associated with an health condition for which individuals use increased risk of adverse events versus that complementary therapies. Once thought to found with placebo, serious harms were rare be inconsistent with conventional medical in clinical trials. care, these approaches are gaining acceptance The AHRQ review also found several in medical settings, and there is a growing nonpharmacological therapies to be effective interest in how to best blend conventional for improving LBP pain or function, with and complementary approaches. This is esno evidence of serious harms.5 These include pecially true for the burdensome and costly more conventional approaches like exercise, LBP conditions, for which the body of repsychological therapies, multidisciplinary search investigating the mechanisms, benrehabilitation, and low-level laser therapy, efits, and risks of complementary therapies as well as complementary self-management continues to grow. approaches, such as yoga and Tai Chi. Provider-based complementary treatments Pharmacologic and such as acupuncture, spinal manipulation, Nonpharmacologic Care and and massage also demonstrated benefit.

Injections for Low Back Pain Little difference in effectiveness was found According to the recently released Agenamong different exercise, massage, spinal cy for Healthcare Research and Quality manipulation, or acupuncture techniques (AHRQ) review, research supports several or among different types of psychological conventional and complementary treatments therapies. Of interest is new and emerging for relieving symptoms of LBP.5 These inresearch on mindfulness meditation that clude NSAIDs, skeletal-muscle relaxants, demonstrates its effectiveness in addressing and opioids (buprenorphine patch), which LBP.6 While there is still little high-quality were associated with small effects for acute research evidence on nonpharmacologic apLBP, and NSAIDs, tramadol duloxetine, proaches for radiculopathy, one randomized and benzodiazepines for chronic LBP. The clinical trial conducted by University of Minevidence for the effectiveness of pharmaconesota faculty found spinal manipulation logic approaches for radiculopathy is still (Continued on page 12) very limited. While pharmacologic therapies

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July/August 2016

11

Integrative Care for Low Back Pain (Continued from page 11)

was insufficient to evaluate effectiveness of sacroiliac joint corticosteroid injections.

beneficial when added to home exercise and advice.7 Overall, research on the range of nonpharmacologic treatments, including complementary approaches, is promising.

This bodes well for LBP patients, who can now benefit from a greater range of options through integrative care.

The 2015 AHRQ Technology Assessment provides the best available research (through 2014) regarding the effectiveness and harms of epidural, facet joint, and sacroiliac corticosteroid injections for LBP conditions.8 Epidural corticosteroid injections for radiculopathy have been shown to provide immediate, albeit small, improvements in pain and possibly function; however, these benefits are typically not sustained over the long term nor do they appear to prevent need for surgery. No differences in effectiveness were found based on injection technique, corticosteroid, dose, or comparator. Limited evidence suggests that epidural corticosteroid injections are not effective for spinal stenosis or nonradicular back pain and that facet joint corticosteroid injections are not effective for facet joint pain. The evidence

An Integrative Approach to Low Back Pain Management The Institute of Medicine has called for a cultural transformation in pain prevention, diagnosis, and management, recommending greater collaboration between different clinical disciplines.1 The University of Minnesota’s new Clinic for Comprehensive Pain Management (CCPM) takes such an approach, offering state-of-the art, comprehensive, and integrative care to managing pain. From its onset, the CCPM has aimed to diminish the reliance on opioids and focuses on providing patient-centered, evidence-informed care that includes a range of conventional and complementary nonpharmacologic, nonopioid pharmacologic, and injection approaches.

Psychological comorbidities (e.g., depression, anxiety) and maladaptive approaches for living and managing pain (e.g., fear avoidance, catastrophizing) are associated with pain chronicity. CCPM clinicians work to address not only the biological aspects of patients’ pain but also their psychological and social needs.

CCPM clinicians educate patients on the benefits and risks of therapeutic options so patients can make informed choices aligned with their preferences. Emphasis is placed on empowering individuals to better care for themselves. This is accomplished by using conventional and complementary provider-based therapies to provide symptom relief and facilitate patient engagement in longer-term self-management approaches.

Preference is given to procedures for which there is reasonable research evidence. However, commonly practiced approaches for which evidence is lacking or just emerging may be recommended, particularly when no other evidence-based alternatives are available and a patient’s quality of life is severely impacted.

Thus, a person with uncomplicated LBP may receive a short course of nonopioid pharmacologic treatment like NSAIDS or muscle relaxants, coupled with recommendations for acupuncture, massage therapy, spinal manipulation, or physical therapy and advice to stay active. For patients with more persistent and disabling LBP accompanied by radiculopathy secondary to a confirmed disc herniation, epidural steroid injections may be recommended for symptom relief.

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Supervised rehabilitation and possibly psychological support or training in mindfulness meditation might also be suggested to facilitate long-term self-care. In all cases, the potential benefits, risks, and costs need to be considered and monitored alongside patients’ values and preferences.

The National Center for Complementary and Integrative Health (https://nccih. nih.gov) serves as a useful resource for those wishing to learn more about these increasingly popular forms of pain management.

National Institutes of Health examine the optimal dose of spinal manipulation, as well as its cost-effectiveness. Several other studies are under development to further examine how best to combine conventional and complementary approaches and to examine the mechanisms by which these treatments work. This includes identifying which therapies might be best for which patients based on promising biomarkers like genetic profiles, brain functional connectivity, among others.

Pain Research at the University of Minnesota The new Integrative Care for Pain Research Group at University of Minnesota rigorously examines the potential of the full range of pharmacologic, nonpharmacologic, and injection therapies for LBP and other painful conditions. This research group includes scientists and clinicians from conventional and complementary healthcare backgrounds who share a common vision for delivering safe-and-effective patient-centered care.

Members of the group are investigating manipulation, exercise, and self-management treatments for LBP in adolescents and adults.

Other research-group studies funded by the

Bibliography 1.

Institute of Medicine. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research.

Washington, DC: National Academies Press; 2011.

2.

Nahin RL. Estimates of pain prevalence and severity in adults: United States, 2012. J of Pain. 2015;16(8):769-780.

3.

Chou R, Shekelle P. Will this patient develop persistent disabling low back pain? JAMA 2010;303(13):1295-1302.

4.

Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain – United States, 2016. MMWR Recomm Rep 2016;65(1):1-49.

5.

Chou R, Deyo R, Friedly J, et al. Noninvasive Treatments for Low Back Pain [Internet].

Rockville, MD: Agency for Healthcare Research and Quality; 2016.

6.

Morone NE, Greco CM, Moore CG, et al.

A mind-body program for older adults with chronic low back pain: A random-

7.

8.

ized clinical trial. JAMA Internal Medicine.

2016;176(3):329-337.

Bronfort G, Hondras MA, Schulz CA, et al.

Spinal manipulation and home exercise with advice for subacute and chronic back-related leg pain: A trial with adaptive allocation.

Ann Intern Med 2014;161(6):381-391.

Chou R, Hashimoto R, Friedly J, et al. Pain Management Injection Therapies for Low Back Pain. Technology Assessment Report ESIB0813. Rockville, MD: Agency for Healthcare Research and Quality; 2015.

Florin Orza, M.D., Division Chief and Medical Director of Pain Management, University of Minnesota. Dr. Orza’s research and training focus has been in the management of chronic pain, particularly in the integrative therapies that can allow patients to manage their pain.

He has educated residents and fellows and has provided leadership in the development of pain management services at a series of locations, including University of Minnesota Medical Center.

Roni Evans, D.C., Ph.D., Research Director, Integrative Health and Wellbeing Research Program at the Center for Spirituality and Healing, University of Minnesota. Dr. Evans conducts comparative effectiveness research on conservative treatments for individuals struggling with musculoskeletal pain, investigating manual therapies, exercise, self-management, and complementary and integrative approaches to pain management.

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13

Public Health

Prescribing Naloxone in Minnesota

I

n 2014, the Minnesota legislature passed a law, Statute 604A.04, 604A.05 also known as Steve’s Law. The law amended one, and added to three existing laws to broaden the availability of naloxone in our state. At the time, there were eight states in the U.S. with similar laws. That number has grown to more than 35 states as the U.S. tries to change the trajectory of a rapidly worsening opiate epidemic.

The family and friends of Mr. Steve Rummler, who lost his life from an opiate overdose after a long struggle with chronic pain, championed the law. They were joined by a number of individuals and families who have been impacted by this opiate problem. The Steve Rummler Hope Foundation convinced the Minnesota State Legislature to take a leading role in providing support for those that are willing to provide naloxone in the event of an opiate overdose.

The law specifically allows for basic life support ambulance providers to carry and administer naloxone for opiate overdose. Up to this point, basic ambulance providers in Minnesota were limited to administering glucagon, inhaled beta agonists, sublingual nitroglycerine and intramuscular epinephrine in the appropriate clinical setting.

Another aspect of Steve’s Law is the protection it provides to those who call for help in the event of an opiate overdose.

Within defined criteria, a person calling for help can avoid being prosecuted for drug possession or use if it is deemed that

By Paul Satterlee, M.D.

14

July/August 2016

they acted in the interest of a person who was suffering from a drug overdose.

For the practicing medical professional, the law established clear language about prescribing, possession and liability for those who prescribe or administer naloxone. First, the 2014 law states that a prescribing provider may directly or by standing order prescribe, dispense, distribute, or administer an opiate antagonist to a person without being subject to civil liability or criminal prosecution for the act.

It goes on to state that this liability protection applies even if someone other than the name on the prescription administered the naloxone and if the medication was given to someone other than to whom it was prescribed.

This is a significant change in how many providers think of the prescribing process. The State had ample input from the Minnesota Board of Pharmacy during this process and the language is supported.

In 2015, the Emergency Department and Department of Pharmacy at Abbott Northwestern Hospital committed to a program to dispense naloxone kits to emergency department patients who were at risk of overdose or were in a social situation where they might encounter an opiate overdose. This program was supported by the generous donation of naloxone kits from the Steve Rummler Hope Foundation. This has allowed us to provide free naloxone and the necessary tools for administration to numerous people who may use it to save a life. The kits are often

given to overdose victims though they are commonly more willing to take the kit if we remind them it can be used to help a friend and is not just for them.

Fortunately, I have also been able to provide the kit to a grieving family as they discussed their worries about a grandchild in the midst of a deep addiction problem.

By giving them a kit, they had a tool to use in an emergency and no longer felt helpless.

When we introduced the program to other providers, it was very helpful to quote the language of the law and the liability protections it affords. I can also quote the medical malpractice company our private physician group uses and their support based on the law’s explicit language.

Some providers were concerned about the liability despite the law. It would seem that there is more liability in continuing the current opiate prescribing habits in

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the setting of an opiate epidemic. It would not be unlike a bar being held liable for the events caused by a patron who was drinking at their establishment.

Others were concerned that the presence of naloxone may allow for more risktaking behavior by those using opiates recreationally. Through numerous discussions with addiction specialists, patients and treatment facilities, no one has confirmed this as a risk that should prevent the wide distribution of naloxone.

One myth that needs to be dispelled on a continuing basis is the idea that people will wake up violent if they are given naloxone. I hear this in every education session I do, but am yet to experience it in 15 years of emergency medicine practice and EMS leadership. Further, none of the people I have queried can give me an example other than anecdotes they were told about. I liken it to providing defibrillation in cardiac arrest or glucose in a hypoglycemic emergency. We would never advocate

someone wait for more people to administer a life-threatening treatment out of fear the person may be confused, belligerent or upset when they recover. Continuing the discussion of violent patients who have received naloxone will cause someone to delay and they are going to miss the chance to save a life.

In 2014, Minnesota took a leading step forward in the fight against the opiate epidemic. It has provided clear support for providers to prescribe, distribute, dispense and administer naloxone so that it is available to families, friends and caregivers in a time of need. It is now up to the medical community to further the progress. We must identify and support those at risk by making naloxone available to anyone who may be able to help someone in need.

Under the direction of Dr. Charlie Reznikoff, the SRHF has underwritten a lecture series of 10 CMEs in partnership with the University of Minnesota and the Minnesota Medical Association. The hope

of the lecture series is to create a medical curriculum on pain, opioids and addiction as it should be evidence-based information free of commercial bias. These CMEs are offered free of charge to all prescribers across the nation.

To access the webinars visit www. mnmed.org/painseries.

Paul Satterlee, M.D. is a board-certified Emergency Medicine physician and works for Emergency Care Consultants, in Minneapolis MN. While practicing Emergency Medicine, Dr. Satterlee is an associate Medical Director of a large EMS system and a member of the Minnesota EMS regulatory board.

He has extensive experience working with patients, first responders and pre-hospital medical providers to ensure optimal care is provided prior to arrival at the emergency department. Dr. Satterlee can be reached at paul.satterlee@eccemergency.com.

MinnesotaHelp.infoÂŽ is brought to you by the State of Minnesota to connect people with services in their communities.

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The Journal of the Twin Cities Medical Society

July/August 2016

15

Menthol’s Grip on Health Inequities

T

he good news is: Tobacco use in Minnesota has decreased. The bad news is: Tobacco is still a problem and smoking rates remain high in certain communities. Smoking is the leading preventable cause of death in the U.S., and at a point in time when many healthcare organizations are emphasizing health equity it’s worth examining the disparity caused by menthol-flavored tobacco. Mentholflavored tobacco products are the source of addiction for many smokers and disproportionately affect minority populations.

Menthol is added to 90% of tobacco products, even those not marketed specifically as menthol cigarettes.1 Menthol is a compound used in many consumer and medicinal products that has cooling and analgesic properties.

When used in cigarettes, menthol makes it easier to begin smoking and more difficult to quit. Menthol’s anesthetic effect makes it easier to inhale and take in more nicotine while smoking.2 Nicotine and menthol stimulate the trigeminal nerve in the mouth and throat to activate taste buds and produce strong sensory effects.3 Evidence suggests that menthol’s sensory effects enhance the addictiveness of cigarettes and increase the difficulty of quitting. Menthol’s taste and odor are pleasurable for menthol cigarette smokers and may reinforce smoking behavior.

Menthol smokers attempting to quit are susceptible to relapse as menthol from food or toothpaste could serve as a sensory cue and prompt a craving.3

By Ellie Parker, MPH MetroDoctors

health impact of these products. Internal tobacco company documents have exposed their efforts to target ‘inner city’ African Americans and low-income households.

When an R.J. Reynolds executive was asked why he didn’t smoke his response was, “We don’t smoke that s---t. We just sell it. We reserve the right to smoke for the young, the poor, the black and stupid.”8 Next time you fill up your vehicle with gas take a trip inside the gas station and observe the egregious marketing of menthol products.

Menthol’s Targeted Approach

Menthol usage rates are highest among racial and ethnic minority smokers, including African Americans (82.6% of African American smokers), Pacific Islanders (32.3%), Hispanics or Latinos (32.3%), and Asian Americans (31.2%), compared to White smokers (23.8%).4 Nearly half of all teen smokers use menthol tobacco products and 71% of LGBT smokers use menthol. The prevalence of menthol usage is highest among unemployed people, and those making less than $10,000 per year.4 It’s not a coincidence that racial minorities are using menthol products at increased rates. Tobacco companies have targeted African American communities for decades through tactics including donating to black community organizations, sending cigarette sampling vans to black neighborhoods, and discounting menthol cigarettes in areas with higher proportions of African American students.5,6,7 Tobacco companies use menthol to target communities most vulnerable to the adverse

The Journal of the Twin Cities Medical Society

Addressing Menthol and Flavorings Through Policy

The 2009 Family Smoking Prevention and Tobacco Control Act (Tobacco Control Act) prohibited cigarettes from containing any characterizing flavor, including candy, fruit and alcohol flavors, except for menthol and tobacco flavors.9 This prohibition extends to flavored cigarettes and cigarette “component parts,” such as their tobacco, filter or paper. Non-cigarette tobacco products such as snuff, cigars, cigarillos and e-cigarettes are exempt from this ban. In 2011 the Tobacco Products Scientific Advisory Committee released a report which concluded that removing menthol cigarettes would benefit public health after examining the impact of menthol on public health, including use among children, African-Americans, Hispanics, and other racial and ethnic minorities.3 In the absence of federal government regulation state and local governments have taken action. In 2013 Chicago was (Continued on page 18)

July/August 2016

17

Public Health

Minnesota Physician Opinions of Menthol Cigarettes The Physician Advocacy Network surveyed Minnesota physicians about their knowledge, perception, and beliefs related to the harms caused by menthol cigarettes. The survey also examined physician awareness of the health equity discrepancies caused by menthol cigarettes. The survey results revealed an opportunity to better educate physicians on the harms of menthol cigarettes and their role in health inequities. Below are summarized highlights of the results.

To view the full survey results, visit www.metrodoctors.com.

■ How often do you ask patients about tobacco use?

■ How often do you discuss menthol use with your patients that report using tobacco?

Always Always

49%

1%

Most of the st of the me time

35%

4% 7% 7%

Some mes Sometimes

3%

Rarely Rarely

26% 6%

Never Never

62%

How addictive are menthol cigarettes compared to non-menthol cigarettes?

How harmful to one’s health are menthol cigarettes compared to non-menthol cigarettes?

48%

46%

38%

32% 19%

15% 1%

1% Less Less addic ve

addictive

Equally Equally addictive addic ve

More More addictive addic ve

Not Not sure sure

LessLess harmful

harmful

Equally Equally harmful harmful

More More harmful harmful

Not Not sure sure

To what extent do you agree or disagree with the following statements?

Q1. Menthol makes it harder for smokers to quit.

Q2. The sales and marketing of menthol cigarettes should be regulated more tightly than they are now.

Strongly agree 11% Q1

Strongly disagree Disagree 2% 5%

Neutral 52%

Agree 30%

Q2 23%

44%

24%

5%

5%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

This survey was funded by BlueCross BlueShield Center for Prevention and conducted by the Physician Advocacy Network, a project of the Twin Cities Medical Society

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July/August 2016

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Menthol’s Grip on Health Inequities (Continued from page 17)

the first city in the U.S. to restrict the sale of all flavored tobacco products, including menthol at any location that has a property line within 500 feet of the property line of any public, private, or parochial elementary, middle or secondary school located in the City of Chicago, and the Hawaii Legislature considered a bill that would remove menthol flavored products in 2014.4 Locally, Minneapolis and Saint Paul both recently enacted policies restricting the sales of flavored tobacco products other than menthol, such as e-cigarette juice, hookah, cigars, cigarillos, etc. to adult only tobacco shops where consumers must be over the age of 18 to enter. Conversations about including menthol products in these bans are beginning.

TCMS Response

The Physician Advocacy Network (PAN), a project of TCMS, was recently awarded a grant by the Association for Nonsmokers – Minnesota to educate and engage Health Science students at the University of Minnesota to understand the impact of flavored and menthol tobacco. With this grant the PAN will begin work with students in all of the College of Health Science programs including the Medical School, School of Dentistry, School of Nursing, College of Pharmacy and the School of Public Health. The education will discuss harms associated with menthol and how tobacco companies target communities and adolescents. These students and future health care professionals will have the opportunity to become trained advocates and engage in local level policy discussion about regulating menthol.

In April the PAN project conducted a survey of physician’s knowledge, perception and beliefs related to harms caused by menthol cigarettes. Survey results (described on page 18) illustrate that many physicians appear to have limited knowledge of menthol cigarettes. The majority of respondents (68.5%) were unsure that menthol is regulated differently than other flavorings; however, 66.4% strongly agreed or agreed that the sales and marketing of

MetroDoctors

menthol should be regulated more. A minority of respondents (19%) knew that menthol cigarettes are more addictive than non-menthol cigarettes. To address this gap of knowledge new educational resources for physicians and patients are being developed by the PAN and will soon be available online under the PAN section of www.metrodoctors.com. To view a full report of survey results along with additional information pertaining to menthol visit www.metrodoctors.com.

If you or your practice would like to learn about hosting a menthol presentation please contact Ellie Parker (eparker@ metrodoctors.com) or Annie Krapek (akrapek@metrodoctors.com).

Ellie Parker, MPH, Project Coordinator, Physician Advocacy Network.

References 1.

Perfetti, T.A. (1985). Menthol and the design of mentholated cigarettes course. Module 1.

Menthol and mint flavor additives-General history and applications.

2.

Ahijevych, K. and Garrett, B.E. (2004) Menthol pharmacology and its potential impact on cigarette smoking behavior. Nicotine and Tobacco Research, 6(Suppl 1), S17-28.

3.

Tobacco Products Scientific Advisory Committee. (2011). Menthol cigarettes and public health: Review of the scientific evidence and recommendations. Available at http://www. fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/TobaccoProductsScientificAdvisoryCommittee/UCM269697.pdf 4.

Tobacco Control Legal Consortium. (2015).

Regulating menthol tobacco products.

5.

Gardiner, P.S., (2004). The African Americanization of menthol cigarette use in the United States. Nicotine & Tobacco Research, 6(1), 55–65. http://www.fairwarning.org/wpcontent/uploads/2015/10/AfricanAmericanizationGARDINER.pdf 6.

Yerger, V.B., Przewoznik, J., & Malone, R.E. (2007). Racialized geography, corporate activity, and health disparities: Tobacco industry targeting of lower income inner city residents.

Journal of Health Care for the Poor and Underserved, 18(S4), 10-38.

7.

Henriksen, L. et al., (2011). Targeted Advertising, Promotion, and Price For Menthol Cigarettes in California High School Neighborhoods. Nicotine & Tobacco Research, 2012;14(1):116-121. doi:10.1093/ntr/ntr122.

8.

Giovanni, J. (1992). Come to Cancer Country; USA; Focus. The Times of London, August 2, 1992 [quoting Dave Goerlitz, RJ Reynolds’ lead Winston model for seven years, re what an R.J. Reynolds executive replied to him when Goerlitz asked why the executive did not smoke].

9.

U.S. Food and Drug Administration. (2009).

Tobacco Control Act. Available from http:// www.fda.gov/TobaccoProducts/GuidanceComplianceRegulatoryInformation/ucm246129. htm.

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Genetic Tests: Is Primary Care Ready?

Impact on Public Health Primary care physicians play a key role in identifying patients who would benefit from the growing number of genetic tests.

In addition, due to the complexities and limitations of such testing, results have often been misinterpreted and led to error in risk stratification and, therefore, management.

The correct utilization of such tests can save lives and health care dollars but a correct understanding of their limits is also essential.

As I was sitting before my 61-year-old patient with stage 3 serous carcinoma of the ovary, I asked why? Not why she was referred, as 20-25% of such women will have a mutation in BRCA1, BRCA2 or other gene in that DNA repair pathway AND if so, this patient may have improved survival with a PARP (poly ADP ribose polymerase) inhibitor, but why did she have cancer? She was diagnosed with breast cancer at age 35.

While gene testing was not available at that time, it was when she was 40 and 50 and 55 — not one of her care providers she saw annually said a thing.

I also wondered why I was explaining to a 47-year-old that a tumor screen, now universally done on all colon tumors, suggested she may have Lynch syndrome as a cause of her stage 2 colon cancer. She was being screened every five years with colonoscopy because her grandmother died of colon cancer in her 30s, but my patient had a uterine cancer at 40. An appropriate recognition that 16% of individuals with colon cancer before 50 may have a heritable form of colon cancer, mostly Lynch, would have likely identified this woman’s disease before her uterine cancer at age 40; her screening for colon cancer would have been annual, starting at 20-25 and she would have been

By Shari Baldinger, MS, CGC

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able to lower the risk for all cancers with appropriate screening and chemoprevention (aspirin). Fortunately, the tumor screening recognized what a failed history evaluation did not. In fact the universal tumor screening for Lynch likely saves more lives than all of newborn screening.

These two cases represent a failure of the ‘ordering’ and/or interpreting one of the simplest genetic tests — family history.

A big step toward personalized medicine involves something as low tech as proper taking and interpretation of family history, i.e. recognizing the ‘red flags.’

The proper identification of those who would benefit from such appropriate genetic testing can help identify the three of four patients at risk for hereditary breast and ovarian cancer or Lynch syndrome (USPSTF release-2013) who are unaware. As a consequence, patients who would benefit from earlier-onset screening, additional screening modalities and/or chemoprevention do not have access to this care. If patients are not first identified as high-risk for breast, colon or other cancers, they are never given the opportunity to make informed decisions about their options for early detection or

prevention. We can’t help the high risk patients unless we find them first.

We have proposed the use of two simple screens, one based on the National Comprehensive Cancer Network (NCCN) for hereditary breast and ovarian cancer identification, the other for hereditary colon cancer (based on publication by F Kastrinos – 2009; Am J Gastroenterol) to facilitate patient identification for referral to genetics services (see screening questions on page 21).

Once flagged, referral to genetic counseling is recommended.

Advances in genetics have prompted the need for primary care providers to become more familiar with the incorporation of genetics into practice, the choice of tests and the interpretation of results.

While many physicians have felt confident ordering tests that look at common single genes such as BRCA1 or BRCA2 for breast cancer, accurate use and accurate interpretation has been lacking. In fact, the literature (Karina L. Brierley, MS, CGC et al, Connecticut Medicine, August 2010;74(7):413-423.) suggests there are three areas of significant concern arising from genetic counseling services being provided by non-qualified providers: 1. Wrong genetic test ordered; 2. Genetic test results misinterpreted; and 3. Inadequate genetic counseling.

Negative outcomes included unnecessary prophylactic surgeries, unnecessary testing, psychosocial distress, and false reassurance resulting in inappropriate medical management.

Almost one-third of medical laboratory test orders for complex gene tests contained mistakes in handling by ordering clinicians.

This finding comes from a study by ARUP Laboratories, Inc.

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Next-generation sequencing technology has allowed for an array of genes to be examined with a single test which is more expedient and more cost-effective, but also more difficult to interpret. It is even more critical to have adequate pretest counseling.

Primary care providers should be aware of expert genetic resources to help in this regard.

In fact, this has led ASCO (American Society of Clinical Oncology) to suggest providers with expertise in risk assessment should be involved in ordering and interpreting multigene panels that include genes of uncertain clinical utility and genes NOT suggested by the patient’s personal and/or family history.

Before ordering a test, the goals and expectation must be addressed and patients must be prepared for numerous possible results: • Positive: a mutation in one or more genes with well-known phenotypes and management=helpful results. One can target for therapy or have an explanation for history and improved management options to prevent cancer or diagnose it earlier for more successful treatment.

• Positive surprise results inconsistent with phenotype — does this mean the same in a family not suggestive of a known syndrome e.g. does a CDH1 mutation suggestive of a high risk for diffuse gastric cancer and the need for gastrectomy mean the same thing in a breast cancer only family?

• Ambiguous results (VUS-variant in the genome of uncertain significance): This is NOT ACTIONABLE — whether in well described or newly identified genes.

Random variation in the reference sequence of genes occurs frequently across the population, not associated with any clinical effect. This is true whether the person has cancer or not. Non-pathogenic variation in a gene sequence is as frequent in the general population as in the cancer population. While it is tempting to think the VUS is the ‘culprit’, most such variation is of little or no significance. As a result, no one should be tested for the presence or absence of this variant outside of a research setting.

• Negative=UNINFORMATIVE; most MetroDoctors

of the genetic tests available today account for only a fraction of familial/ heritable cancer and an even smaller proportion of the attributable risk to cancer. A normal or negative result is of limited value without informative genomic information on a relative. Many can still be high risk after a normal genetic test and may still benefit from increased screening and prevention.

• Disappointing results: A mutation in a gene without much literature on risk and management.

• Possible discovery they may be at risk for having children with a recessive disease such as ataxia telangiectasia or Fanconi anemia.

“Increasingly we will be the recipients of data that we did not anticipate, or perhaps, even seek to know. Accordingly we will be in the uncomfortable position of reacting to that data on the basis of an immature and incomplete understanding of what that data mean.” D.Hayes, M.D. FASCO president elect.

Health care systems need to ‘hard wire’ the EMR for patient identification and create best practice alerts for genetic evaluation.

Once an inherited risk is found then the EMR could be hardwired to alert the PCP to the correct personalized management plan for the patient. Genetics and genetic testing is no longer solely about rare disease but about common disease, health maintenance and treatment choices. The perils to public health of missing high risk patients and/ or misinterpreting complex tests is great.

Primary care needs to partner with genetics professionals until there is a great shift in medical school education to address the gap in knowledge regarding genomics in medicine.

Shari Baldinger, MS, CGC is a certified genetic counselor who specializes in cancer risks assessment and cancer gene testing. She started genetic counseling services at many of the metro hospitals and has been providing these services for over 30 years. She now is the Manager of Genetic Counseling Services for the oncology service line at Allina Health. Her passion to help families identify and manage familial cancer risks brings great satisfaction. It often has resulted in early diagnosis of cancer when

The Journal of the Twin Cities Medical Society

it is most successfully treated or cancer risk reduction so it never occurs in the first place.

Empowering her patients to make informed choices is the goal! She can be reached at: Phone: 612-863-3536• shari.baldinger@allina.com.

If a patient answers YES to any ONE of the following, a referral to genetics is warranted: Do any of the following apply to you or a close family member-blood relative (parent, sibling, child, aunt, uncle, niece, nephew, or grandparent)?

• Three or more relatives on the same side of family (either your mother’s side or your father’s side) with breast cancer (Y/N) • Breast cancer at 50 or younger and at least one other relative on same side of family with breast cancer (Y/N) • Ovarian cancer at any age (Y/N) • Male breast cancer (Y/N) • Breast cancer at age 45 or younger (Y/N) • Breast cancer and Jewish ancestry (Y/N) If patient says yes to any of the following (a, b, or c) a referral to genetics is warranted: a. Do you have a first-degree relative (mother, father, brother, sister or child) with any of the following conditions diagnosed before age 50?

• * Colon or rectal cancer (Y/N) • * Cancer of the uterus, ovary, stomach, small intestine, urinary tract (kidney, ureter, bladder), bile ducts, pancreas or brain (Y/N) b. Have you had any of the following conditions diagnosed before age 50?

• Colon or rectal cancer (Y/N) • Colon or rectal polyps (Y/N) c. Do you have three or more relatives with a history of colon or rectal cancer?

(This includes parents, brothers, sisters, children, grandparents, aunts, uncles and cousins) (Y/N) Resources: Minnesota Genetic Counselors Association: http://mygenepool.org/; National Society of genetic counselors: http://nsgc.org/; n engl j med 370; 25 nejm.org June 19, 2014.

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Buzz Topics:

Vectorborne Diseases of Minnesota When the snow melts and the air temperatures rise, Minnesotans are quick to flock outdoors and engage in the countless outdoor activities our state has to offer. As we hit summer, it is a great time to remind medical providers of the local tick and mosquitoborne diseases (collectively known as vectorborne diseases) that Minnesota residents are at risk for when they are working or recreating outdoors. Medical providers should not only have a basic knowledge of these diseases to effectively care for symptomatic patients, but should also be able to provide vectorborne disease prevention education to patients. This article will highlight the most common vectorborne diseases endemic to Minnesota, their seasonal and geographical risk factors, and recommendations for avoiding them. Please see the insets for quickreference information on each disease, and visit the Minnesota Department of Health (MDH), http://www.health.state.mn.us/ divs/idepc/dtopics/vectorborne/, or Centers for Disease Control Prevention (CDC), http://www.cdc.gov/ncezid/dvbd/, websites for more detailed, disease-specific information on symptoms, diagnosis and treatment.

Tickborne Diseases of MN Tickborne diseases represent the majority of vectorborne disease reports in Minnesota.

The three most common tickborne diseases in Minnesota, in descending order of reporting frequency, are Lyme disease, human anaplasmosis, and babesiosis. These tickborne diseases are endemic to Minnesota and are transmitted to humans through a bite from an infected blacklegged tick, also referred to as the deer tick. Blacklegged ticks are found in wooded or brushy areas throughout much

By Franny Dorr, MPH

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of the state, and are most active during the warm months of the year. Risk for tickborne disease is highest from May through July when the immature life-stage of the blacklegged tick called the nymph is most active.

Blacklegged tick nymphs are very small, about the size of a poppy seed, and are difficult to detect on the body. Roughly onethird of adult blacklegged ticks and about 20 percent of blacklegged tick nymphs are infected with the bacteria that causes Lyme disease. All life-stages of blacklegged ticks are infected with other pathogens at much lower rates. During the warm months of the year, medical providers should keep tickborne diseases in mind for patients who are symptomatic and have a history of exposure to a wooded or brushy area within the previous month. Many people do not remember having a tick bite, so having the appropriate exposure history is important when considering a tickborne disease diagnosis.

Symptoms of Lyme disease, human Tickborne Disease Case Counts in Minnesota 2014

2010-2014

Human Anaplasmosis

448

3,090

Babesiosis

49

257

Lyme Disease

895

5,717

anaplasmosis and babesiosis are similar and nonspecific, but will typically develop within a few days to two weeks following a tick bite, and sometimes longer for Lyme disease and babesiosis. Nonspecific symptoms of these tickborne diseases include fever, headache, arthralgia, myalgia, fatigue and malaise.

Most patients with Lyme disease (up to 80 percent) will develop a rash at the site of the tick bite, but may develop other symptoms in absence of the rash. While rarely fatal, both human anaplasmosis and babesiosis can become serious in elderly or immunocompromised patients. While blood blanks routinely screen all blood donations for West Nile virus, they don’t routinely screen for human anaplasmosis or babesiosis. Although rare, transfusion-associated cases of these diseases have occurred in Minnesota patients.

Medical providers should be aware of this transmission potential in patients who have received transfusions.

Mosquitoborne Diseases of MN Mosquitoborne diseases are reported less frequently than tickborne diseases in Minnesota, but are still a major concern as they have the potential to cause serious illness, long-term sequelae, or death. The most common endemic mosquitoborne pathogens in Minnesota, listed in descending order of reporting frequency, are West Nile virus (WNV), La Crosse encephalitis virus (LAC), and Jamestown Canyon virus (JCV).

Risk for mosquitoborne disease is highest Mosquitoborne Disease Case Counts in Minnesota West Nile virus

La Crosse encephalitis virus Jamestown Canyon virus

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2010-2014

4

15

4

5

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Quick-Reference Table of Endemic Tickborne Diseases in Minnesota

Disease

Clinical Picture Early Infection

Spreading rash, arthralgia, myalgia, fatigue

Disseminated Infection

Multiple rashes, large joint swelling, Bell’s palsy, carditis, meningitis

Lyme disease

Diagnosis

Treatment

History of tick bite or exposure to wooded area within previous 30 days AND Two-tiered test: EIA screen and if positive, follow with Western blot serology

Antibiotics as indicated by the Infectious Diseases Society of America (www.idsociety. org); long-term antibiotic therapy not recommended

Human anaplasmosis

Fever, headache, myalgia, leukopenia, thrombocytopenia

History of tick bite or exposure to wooded area within previous 2 weeks; PCR, serology, smear

Empiric treatment with doxycycline

Babesiosis

Fever, headache, myalgia, arthralgia, loss of appetite, anemia

History of tick bite or exposure to wooded area within previous 60 days; PCR, serology, smear

Treatment not recommended if asymptomatic; Atovaquone + azithromycin for mild cases; Clindamycin + quinine for severe cases

Quick-Reference Table of Endemic Mosquitoborne Diseases in Minnesota Disease West Nile virus* La Crosse encephalitis virus** Jamestown Canyon virus

Mild

fever with headache, myalgia, arthralgia, vomiting, diarrhea, rash fever, headache, nausea, lethargy fever, headache, flu-like illness

*severe illness most common in elderly adults

during Minnesota’s warmest months, from July through September.

The majority of the 51 mosquito species found in Minnesota either do not bite humans or are just pests, but a few species are capable of spreading disease to humans. The mosquito that transmits WNV is Culex tarsalis. Culex tarsalis is most active during the hours of dawn and dusk, and is predominant in agricultural areas, especially the western half of the state. The mosquito that vectors LAC virus is Aedes triseriatus, also known as the “treehole mosquito.” This mosquito feeds during the day, prefers shaded and wooded areas, and breeds in tree holes or other small water-holding containers. This mosquito is most common in hardwood forests in southeastern Minnesota, especially along the Mississippi river valley. JCV is vectored by several different Aedes species.

Most people that become infected with WNV, LAC, or JCV will be asymptomatic, but a small proportion of those infected will develop a febrile illness including but not limited to headache, myalgia, arthralgia, nausea and lethargy. An even smaller proportion of symptomatic infections will develop severe illness that may progress rapidly. Severe illness in WNV cases typically occur in elderly or immunocompromised patients. Medical providers should note that the median age of LAC cases in Minnesota is MetroDoctors

Clinical Picture

Severe

high fever, severe headache, neck stiffness, CNS involvement

high fever, severe headache, CNS involvement

high fever, severe headache, CNS involvement

Diagnosis

Treatment

serology, PCR

supportive care

serology, PCR

supportive care

Contact MDH to facilitate testing

supportive care

**illness almost exclusively in children

6 years old (range, <1 – 49 years old in 139 total cases from 1985-2014). Severe cases of mosquitoborne disease involve encephalitis or meningitis. There are no specific treatments for mosquitoborne disease illness, only supportive care.

Vectorborne Disease Prevention The most effective way to avoid a vectorborne disease is to prevent tick and mosquito bites. Recommended repellents include those that contain up to 30 percent DEET, which can be applied to skin or clothing. For those who spend a lot time in tick or mosquito habitat, products that contain permethrin are also recommended. Permethrin is a repellent and a pesticide and cannot be applied to the skin, but is used to treat clothing and gear. A single application lasts through multiple uses and washings. Medical providers should encourage patients to avoid outdoor activity around dusk and dawn to reduce risk of WNV, and avoid outdoor activity in wooded areas during the day to reduce risk of LAC. Additionally, removing or frequently emptying water holding containers throughout a property (old tires, empty flower pots, etc.) can greatly reduce breeding habitat for mosquitoes. Trails in or along wooded areas should be mowed with the edge brush cut back to avoid contact with ticks. Performing a daily tick check is also

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highly recommended after spending time in a tick habitat. The sooner a tick is removed, the less risk for a tickborne disease.

Medical providers are in a unique and advantageous position to not only care for patients with symptoms of vectorborne disease, but also to educate patients on seasonal and geographical risks as well as prevention measures. Minnesota has a lot of outdoor experiences to offer residents and visitors during warm weather months, and with the help of medical providers, hopefully a vectorborne disease will not be one of them.

Reporting Vectorborne Diseases All tick and mosquitoborne diseases must be reported to MDH. Reports need to include demographic, clinical and laboratory information. To report cases, please download case report forms at http://www.health.state. mn.us/divs/idepc/dtopics/reportable/forms/ tickborneform.html for tickborne diseases, and www.health.state.mn.us/divs/idepc/ dtopics/reportable/forms/arboviralform. html for mosquitoborne diseases. Contact the vectorborne diseases epidemiology staff with any questions at (651) 201-5414.

Franny Dorr, MPH is an epidemiologist in the Vectorborne Diseases Unit at the Minnesota Department of Health. She received her Masters of Public Health at the University of Minnesota.

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U.S. Adult Immunization Rates are Not Good...Please Help

I

n contrast to our success in vaccinating our nation’s children — achieving coverage levels of more than 90% for recommended vaccines by kindergarten entry — we’ve not done anywhere near as well with vaccinating adults. This is clearly reflected in these sobering vaccinepreventable disease prevalence statistics for U.S. adults: • CDC statistics indicate that 3,000 to 49,000 influenza-related deaths occurred annually from 1976-2006, with variation depending on how severe the season is,1 with 80%-90% of these deaths occurring among adults age 65 years and older.2 • In 2013, there were 33,900 reported cases of invasive pneumococcal disease with 3,700 deaths, nearly all of which occurred in adults.3 • Approximately 24,000 cases of pertussis (whooping cough) were reported in 2014; more than 20% of those identified were adults age 20 years and older.4 • Annually, more than one million cases of zoster (shingles) occur in the United States.5 These disease statistics suggest that U.S. adults are not receiving routinely recommended vaccinations, and this is borne out in additional surveillance data.

National Vaccine Coverage Rates for Adults are Poor

In February 2016, CDC released “Surveillance of Vaccination Coverage Among Adult Populations — United States, 2014,”6 a report covering how we are doing

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July/August 2016

as a nation with providing our adult population with recommended vaccines. As highlighted below, the unfortunate bottom-line answer is, “We’re doing poorly.”

Note the years in which the named vaccines were recommended by CDC; they are included as an indicator of how slow our progress has been.

• Tetanus, diphtheria, acellular pertussis (Tdap) vaccine: Only 20% of adults have received Tdap, recommended since 2008 as a one-time vaccination for all adults 19 years of age and older, regardless of when the last Td dose was given.

• Zoster (shingles) vaccine (ZOS): Only 28% of adults in the recommended age range (60 years and older) have received zoster vaccine. It has been recommended since 2009.

• Pneumococcal vaccines (i.e., pneumococcal polysaccharide [PPSV23, Pneumovax 23] and pneumococcal conjugate [PCV13, Prevnar 13] vaccines): The pneumococcal vaccine coverage rate (primarily PPSV23 at the time these statistics were collected) for adults age 65 years and older was 61% overall, across all racial/ethnic groups. Coverage among whites was 65%; blacks, 50%; Hispanics, 45%; and Asians, 48%. PPSV23 became routinely recommended in 1984 for adults age 65 and older. In 2014, CDC also added PCV13 at this age, with the two types of pneumococcal vaccine doses spaced one year apart.

• Influenza vaccine: For 2013–14, only 43% of adults age 19 years and older received the vaccine, with a 71.5% coverage level for adults age 65 and

•

older. This vaccine has been recommended for all adults since 2010.

Human papillomavirus (HPV) vaccine: Only 38% of women in the recommended age group (through age 26 years) have received one or more doses. And only 13% of men in the recommended age group (through age 21 years) have received one or more doses. A three-dose series has been recommended for females since 2007 and for males since 2011.

Why are the Coverage Levels so Low?

Many barriers to adult immunization have been identified. Patient and provider issues, as well as healthcare system challenges,7 contribute to low vaccination rates.

Here are some examples: • Lack of public knowledge that vaccines are recommended for adults.

• Lack of access to, and utilization of, healthcare services by adults.

• Too few providers recommending vaccinations.

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The Journal of the Twin Cities Medical Society

•

•

•

•

Many healthcare professionals not staying current on vaccine recommendations.

The complexity of vaccination recommendations and schedules for adults, including the guidance based on riskgroup categories.

Financial impediments to vaccination, e.g., uncertainty as to whether insurance reimbursement will be forthcoming.

Acute and chronic medical management taking precedence over preventive services.

How You Can Help Overcome Low Vaccination Rates Among Adults

The National Vaccine Advisory Committee (NVAC), an expert body that advises the Department of Health and Human Services, has developed national standards with the goal of improving adult vaccination coverage for all vaccines recommended by the Advisory Committee on Immunization Practices (ACIP). In 2014, NVAC published “Standards for Adult Immunization Practice.”7 These recommendations call on all healthcare providers — whether they provide vaccinations in their healthcare settings or not — to take steps to help ensure that their adult patients are fully immunized. The four “Practice Standards for All Healthcare Professionals” are: 1. ASSESS the vaccination status of your patients at every clinical encounter. For providers to do this, they and their clinic staff need to stay informed about the latest CDC vaccine recommendations for adults.

2. STRONGLY RECOMMEND needed vaccines for your patients.

Clinicians are known to be the most valued and trusted source of health information for adults. Research shows that most adults believe vaccines are important and that a recommendation from their healthcare professional is a key predictor of whether patients get needed vaccines.

3. ADMINISTER recommended vaccines or REFER patients to a vaccination provider. Make vaccination MetroDoctors

services in your practice as convenient as possible for patients. If you do not stock certain vaccines or if you do not provide vaccines at all, refer your patients to a specific provider known to have the needed vaccines available.

HealthMap Vaccine Finder is a free, online service where users can search for locations that offer immunizations. Enter your zip code at http:// vaccine.healthmap.org.

4. DOCUMENT the vaccines your patients receive, whether they are administered by you or elsewhere.

Place that information in your state immunization registry, if you have one available, and Minnesota does. Also, be sure to give your patients a record of their vaccinations. This is particularly helpful when they see different providers for different health needs.

If you send them to another provider, follow up with your patients to make sure they received the vaccines you recommended.

Resources to assist providers with implementation of these standards for adult immunization practice are available at www.cdc.gov/vaccines/hcp/patient-ed/ adults/for-practice/standards/index.html.

So—Which Vaccines Are Recommended for Adults, and on What Schedule?

Each February, the Centers for Disease Control and Prevention (CDC) releases its “Recommended Immunization Schedule for Adults Aged 19 Years or Older,”8 complete with tables and explanatory footnotes that describe the details of each recommended vaccine. The schedule is available online at www.cdc.gov/vaccines/schedules/ downloads/adult/adult-combined-schedule.pdf. These CDC recommendations are endorsed by the American Academy of Family Physicians, the American College of Physicians, the American College of Obstetricians and Gynecologists, and the American College of Nurse-Midwives.

Need Help? The Immunization Action Coalition Can Assist!

The Immunization Action Coalition (IAC), a national nonprofit organization

The Journal of the Twin Cities Medical Society

based in St. Paul, Minnesota, is the nation’s leading immunization education organization. Its two main websites, www. immunize.org for healthcare professionals and www.vaccineinformation.org for the general public, average more than 30,000 visitors daily. Immunize.org, is the “goto” destination for busy practitioners who want up-to-date, ready-to-print CDCreviewed educational materials on U.S. vaccine recommendations and schedules, as well as guidance on vaccine administration, and much more. IAC has worked in close collaboration with CDC on vaccination education since the early 1990s and has been the recipient of continuous CDC funding for its work since 1995.

Visit www.immunize.org/handouts to access more than 250 free ready-to-copy educational materials — all of which are carefully constructed to be clear, concise, accurate, and useful in medical practice settings. More than 3.5 million PDF copies of staff and patient educational materials were downloaded over the past 12 months. The website includes a wealth of adult immunization content.

Your Patients are Counting on You

Adult patients rely on their healthcare providers to keep them informed about how to protect their health. This includes providing guidance on recommended vaccines. Based on the national statistics for adult vaccination coverage, it is likely that you have adult patients in your practice who are behind schedule on one or more recommended vaccines, such as Tdap, zoster, pneumococcal conjugate or polysaccharide vaccine, or HPV vaccine. You and your staff can help your patients determine which vaccines they need now and when the next ones are due. Even if you do not provide vaccination services in your practice, it is still important to obtain your patient’s vaccination history, determine which vaccines they need, and then direct them to another provider, such as a local pharmacy, that will administer needed immunization.

(Continued on page 26) July/August 2016

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Saint Therese Rehab

Better Balance for a Better Life

The STR Balance program incorporates state-of-the-art balance assessments and training techniques to help your patients live a better life. STR offers: • Comprehensive Balance Evaluations • 1:1 Personal Training • Specially Trained Therapists • Computerized NeuroCom Balance • Inpatient/Outpatient Therapy Services Systems

To learn more call 763.531.5435 or visit sttheresemn.org/str.

U.S. Adult Immunization Rates (Continued from page 25)

To determine which vaccines a particular patient needs, refer to CDC’s Recommended Adult Immunization Schedule at www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf or consult IAC’s “Summary of Recommendations for Adult Immunization” available at www.immunize.org/catg.d/p2011.pdf.

A simple patient handout on the adult immunization schedule is available from IAC for you to download and copy at www. immunize.org/catg.d/p4030.pdf.

Please let us know how IAC might assist you with improving your adult vaccination coverage. We are here to help.

Email us at admin@immunize.org.

Dr. Deborah Wexler is a family physician and founder and executive director of the Immunization Action Coalition (IAC), a nonprofit organization located in St. Paul, Minnesota.

IAC’s mission is to increase immunization rates by providing U.S. healthcare professionals and their patients with practical, concise, and up-to-date immunization information.

IAC is a national leader in immunization education, with its websites serving more than 30,000 visitors per day and its email news service being sent to 50,000 subscribers each week.

Sources: 1.

CDC. “Estimates of Deaths Associated with Seasonal Influenza—United States, 1976–2007.”

MMWR. 010;59(33): 1057–1062.

2.

Kostova, D., et al. “Influenza Illness and Hospitalizations Averted by Influenza Vaccination in the United States, 2005–2011.” http://journals. plos.org/plosone/article?id=10.1371/journal. pone.0066312.

3.

CDC. Active Bacterial Core Surveillance. www. cdc.gov/abcs/reports-findings/survreports/ spneu13.pdf.

4.

CDC. 2014 Provisional Pertussis Surveillance Report. www.cdc.gov/pertussis/downloads/ pertuss-surv-report-2014.pdf.

5.

CDC. “Prevention of Herpes Zoster.” MMWR 2008. 57(RR 5): 1–30.

6.

CDC. “Surveillance of Vaccination Coverage Among Adult Populations—United States, 2014.” Surveillance Summaries / February 5, 2016 / 65(1);1–36. www.cdc.gov/mmwr/volumes/65/ss/ss6501a1.htm.

7.

“Recommendations from the National Vaccine Advisory Committee: Standards for Adult Immunization Practice.” Public Health Reports, March-April 2014. www.publichealthreports. org/issueopen.cfm?articleID=3145.

8.

CDC. Advisory Committee on Immunization Practices Recommended Immunization Schedule for Adults Aged 19 Years or Older—United States, 2016. www.cdc.gov/mmwr/volumes/65/ wr/mm6504a5.htm.

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Future Physicians Hone End-of-Life Skills

“Advance Care Planning: What a Physician Needs to Know” is the title of an Honoring Choices orientation session for fourth year medical students at the University of Minnesota. Started one year ago, the coordinators — Colin Turner, M.D., Andrew Olson, M.D., and Karen Peterson, Honoring Choices Executive Director — recently met to evaluate the program in preparation for the second year.

Each month fourth year students entering a 4-week ICU rotation spend a day in orientation. Along with learning about ventilators and cross-coverage practices, they are introduced to Advance Care Planning (ACP) as well as the complexities of Family Care Conferences for acutely ill patients.

This session is jointly presented by an Honoring Choices representative and a palliative care physician. Students are introduced to why ACP and communication are especially important in an ICU setting, and given the opportunity to practice newly-introduced skills in two role-play exercises, with immediate feedback from the session presenters.

“This has honestly been one of the most rewarding projects that I’ve done in my academic career,” shares Dr. Turner.

“The students are always engaged in this work, and ask absolutely fantastic questions.

Most are just hungry for education and the skills of how to have these conversations.

It’s been an amazing opportunity to make even just a little growth in student skills, no matter what specialty of medicine they ultimately end up in.”

As part of the session, students are asked to reflect on how communication with family members can affect satisfaction with care, and the emotional wellbeing of all involved. A brief video on

By Karen Peterson MetroDoctors

Jennifer Kuyava, M.D., Palliative Care at North Memorial (standing) works with medical students learning about Advance Care Planning.

how to organize and navigate successful care conferences, along with a checklist to use during their first few conferences, gives them grounding in how to maximize the effectiveness of these meetings. In addition, students are walked through a typical healthcare directive and the Minnesota POLST form to gain familiarity with the information included as well as how to assist patients in completing the documents.

Finally, screenshots of EMRs are shared to help the students identify where and how to find information on their patients’ code status and treatment preferences.

Jennifer Kuyava, M.D., is a palliative care physician at North Memorial as well as a member of the Honoring Choices Advisory Council. She represents Honoring Choices in the orientation session. “It has been an honor to be granted the opportunity to teach the medical students through Honoring Choices. I have been so impressed with the students’ interest in learning about advance care planning, as

The Journal of the Twin Cities Medical Society

well as their willingness to role play scenarios that involve difficult conversations.

I am also just so proud that our medical school (I graduated in 2010) is leading the way in exposing students to palliative care.

In the end, this all adds up to better patient and family satisfaction and better patient care.”

Few medical schools offer significant training in ACP, despite the need described in the 2014 Institute of Medicine report “Dying in America.” Recognizing the importance of this topic for emerging physicians, curriculum coordinator for the ICU orientation Andrew Olson, M.D., just agreed to expand the time spent on the topic from 90 minutes to 2 hours. When he introduces the topic to students he explains how vital this is to their career development. “Learning about your patients’ values, goals and preferences and how you, as their doctor, can honor them is one of the most important parts of your medical education — regardless of what you are planning on specializing in.”

Karen Peterson is the Executive Director of Honoring Choices Minnesota.

Colin Turner, M.D., Hospitalist and Palliative Care at Regions (right) coaches medical students on effective communication techniques on end-of-life issues.

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Twin Cities Medical Society Foundation— Your Physician Foundation Who We Are

Twin Cities Medical Society Foundation is the philanthropic arm of the Twin Cities Medical Society and has a rich history of responding to the needs of the community. Initiating a mass immunization effort aimed at rubella was one of its initial projects in the 1970s; today the Foundation’s priority is to provide funding to organizations that offer health care services and connection to available resources to our underserved residents.

Mission

Twin Cities Medical Society Foundation is a physician-led philanthropic organization that strives to improve the health and wellbeing of the community through strategic initiatives.

Impact

Honoring Choices Minnesota® is the stalwart public health initiative of the Twin Cities Medical Society Foundation, working in collaboration with organizations throughout Minnesota and the nation to promote advance care planning. Who will speak for you if you can’t speak for yourself?

Advance care planning is all about thinking and talking about that question well before the need arises. Honoring Choices Minnesota® helps people understand what advance care planning is, why it matters, and how to begin the conversation. www. honoringchoices.org.

Recent beneficiaries of Twin Cities Medical Society Foundation grant dollars include: • Africa Solutions — Healthy Lifestyles Health Education Project.

• Greater Minneapolis Crisis Nursery — Pediatric Assessment and 28

July/August 2016

•

• • • •

Medical Management Program.

Minnesota Mental Health Community Foundation — Fast-Tracker Program.

Minnesota Visiting Nurses Agency — JumpStart Screens.

North Metro Pediatrics — Healthy Beginnings Program.

Phillips Neighborhood Clinic — Clinic Operations: lab tests and medications.

Physicians Serving Physicians — A peer program that provides support to physicians, families and colleagues who are affected by addiction.

Awards

Twin Cities Medical Society Foundation is honored to provide four awards to our medical and health care community: • Boeckmann Community Service Award — This award is given to a member of the Twin Cities Medical Society who is considered an “unsung physician hero” having served in a voluntary capacity in the leadership and development of special community projects or programs; has participated in civic or service organizations/ groups; has participated in educational, charitable, church or other projects; or has held public office.

• Charles Bolles Bolles-Rogers Award — First awarded in 1952, candidates for the award are nominated by their colleagues at Twin Cities area hospitals and clinics for contributions to medical research, achievement or leadership in medicine and considered to be an outstanding physician by his or her peers.

• Shotwell Award — Presented to a

•

person within the state of Minnesota for a noteworthy effort in the field of health care, including dedicated service to mankind; significant breakthrough in some form of research or significant contribution to the field of medicine; or innovations and/or improvements in health care delivery.

This award is not limited to physicians or other professionals in the health care field.

Twin Cities Medical Society Foundation Scholarship — Awarded to a third year University of Minnesota Medical Student. The recipient is selected by the University of Minnesota Foundation in recognition of proven leadership and achievement.

Funding

Funding for the Twin Cities Medical Society Foundation has come through various donations including, most notably, the legacy of Dr. Eduard Boeckmann, a man remembered for his charitable contributions to medicine and unimpeachable character to practice, and for the development of surgical catgut treated with pyoktanin. The manufacture and proceeds from this suture were donated to the Ramsey County Medical Society to support and cover the expense of a medical library. Following the closing of the library, these funds were transferred to the Boeckmann Fund maintained today by the Foundation.

Other legacy gifts, donations in honor of or in memory of a colleague, friend or family member, and an annual appeal to the Twin Cities Medical Society members continue to provide the basis for grant dollar allocations.

MetroDoctors

The Journal of the Twin Cities Medical Society

Your Contributions are Welcomed!

Donations to the Twin Cities Medical Society Foundation can be made at any time throughout the year, and particularly in honor or memory of a colleague, friend and/or family member. Please make your check payable to TCMSF and mail to Twin Cities Medical Society Foundation, 1300 Godward Street NE, Suite 2000, Minneapolis, MN 55413. Online donations can be made at www.metrodoctors.com; click on the Foundation tab. If you wish to designate your gift please include a brief note. Gifts are used to support the mission to improve the health and wellbeing of the community.

2016 Board of Directors

Members of the Twin Cities Medical Society Foundation Board of Directors are appointed by the Twin Cities Medical Society Board of Directors and serve two-year terms.

2016 Senior Physicians Summer Outing Join us for the 2016 Senior Physicians Summer outing on Tuesday, July 12, 2016 from 11:30 pm-1:00 pm at the Science Museum of Minnesota. There will be lunch and a presentation given by David Hilden, M.D., MPH, FACP on Medicine and the Media. After the presentation guests are welcome to explore the Science Museum at no additional cost or check out the Omni Theater/Mummies exhibit at a discounted rate. Register by Monday, July 4 to reserve your spot!

Can’t make it? There are two other events happening this year; visit www.metrodoctors.com for more information.

Officers:

Chris Johnson, M.D., Chair James Jordan, M.D., Vice-Chair Elisabeth Hurliman, M.D., Secretary Robert Moravec, M.D., Treasurer

CAREER OPPORTUNITIES

See Additional Career Opportunities on page 30.

Directors:

Thomas Dosland, M.D. Mark Engasser, M.D. Solveig Hagen, medical student Gretchen Hoff, medical student Christopher Jackson, M.D. Kathryn Justesen, M.D. Henri Minette, J.D. Richard D. Schmidt, M.D. Peter Stiles, M.D. James Struve, M.D. Andrew Thomas, M.D. Sue Schettle, CEO Questions?

Please contact Twin Cities Medical Society Foundation at (612) 623-2893; nbauer@ metrodoctors.com.

You focus on taking care of patients.

We’ll take care of the rest.

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July/August 2016

29

CAREER OPPORTUNITIES

See Additional Career Opportunities on page 31.

In Memoriam LEO de SOUZA, M.D., orthopedic surgeon, passed away on March 22, 2016.

THOMAS E. JOHNSON, M.D., radiologist, passed away on April 2, 2016. He was the first to introduce interventional radiology into private practice.

GEORGE W. LUND, M.D., pediatric cardiologist, passed away on April 24, 2016. He was a founder of the St. Louis Park Medical Center.

GLEN D. NELSON, M.D., general surgeon, health care leader, entrepreneur and philanthropist, passed away on May 14, 2016.

Visit TCMS at www.metrodoctors.com

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and new career opportunities! healthpartners.com 30

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CAREER OPPORTUNITIES

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31

LUMINARY of Twin Cities Medicine

By Marvin S. Segal, M.D.

WILLIAM KEITH HENRY, M.D. Many clinicians have had the gratifying experience of saving a life. Just think of how truly monumental it would be to have been instrumental in saving literally thousands of lives! Our Luminary has felt this pleasing emotion throughout his long and dedicated career.

Dr. Keith Henry was born, raised and initially educated in Illinois. He was Chief Resident during an internal medicine residency at Barnes/Washington University in St. Louis.

His grand rounds presentation on immunodeficiency piqued his interest and zeroed him in on his future life-long involvement with the Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS). He then accompanied his physician wife to the Twin Cities and completed an infectious disease fellowship at the U of M. Keith’s numerous and legendary accomplishments include his successful attack upon the dreadful visual morbidity in AIDS patients due to Cytomegalovirus retinal disease via an intra-vitreous injection of Ganciclovir as described in his classical 1987 American Journal of Ophthalmology article, and his clinical research efforts which richly contributed to the effective and efficient utilization of antiviral agents in HIV — often preventing or reversing AIDS related illnesses and death.

Regarding the 31 years he has headed HIV/AIDS programs at Regions Hospital and HCMC, Dr. Henry frankly states that the first decade of that service was exceedingly difficult both for the stricken patients and for their frustrated caregivers who had few “weapons.” AIDS patients’ massive array of immune related complications usually resulted in death.

Low T-cell numbers caused clinicians to wonder just when the inevitable “next lethal shoe would drop.” He helped his patients deal with the stigma of the disease by providing wellmeaning comfort care and sensitive understanding. In those days, Keith occasionally invited his own children to accompany him on hospital rounds in hopes of blunting rampant and frightening misinformation, and to emphasize to med center employees and others the low likelihood of disease transmission. He willingly ventured out to make house calls on patients in need — though never submitted charges for this aspect of direct patient care, and sometimes paid from his own pocket for needed medications for those who couldn’t afford them.

In the mid-1990s, HIV testing availability and the emergence of antiviral medication “cocktails” respectively resulted in earlier interventional care and a remarkable 90+% decline 32

July/August 2016

in AIDS related death. Though fully realizing that the battle he had been waging was by-no-means over, Dr. Henry states, “I then transitioned to a much better mood.”

Henry’s work has resulted in a superb world-wide reputation as he’s carried the messages achieved through his direct clinical care and numerous clinical research endeavors: over 120 peer reviewed articles; another 100+ published book chapters, communications and multicenter research study results; over 800 AIDS related lectures to professional and civic groups; consultancies and grant receipts with such far reaching organizations and sites from the Minnesota Department of Health and Human Services, the National Institutes of Health, Centers for Disease Control to the country of India and the continent of Africa. He’s been a reviewer for over a dozen professional journals, and his recognitions and awards are abundant: AOA academic fraternity election; American College of Physician Fellowship, U of M Medical School Professorship and multiple Top Researcher and Outstanding Clinician designations.

This modest physician clearly remembers and easily recounts specifics of numerous clinical experiences — always referring to his patients using first name only — both the early sad and frequent failures and the more recent remarkable successes. While giving much credit to his “team-care” colleagues — whom he refers to as “special and blessed,” he imparts the impression that his work is certainly not completed, and that there is much more to accomplish. His legions of grateful patients, his profession and our society are indeed fortunate to have this brilliant, tireless and devoted Luminary in our midst.

This last page series is intended to honor esteemed colleagues who have contributed significantly to Twin Cities medicine.

Please forward names of physicians you would like considered for this recognition to Nancy Bauer, managing editor, nbauer@metrodoctors.com.

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The Journal of the Twin Cities Medical Society

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