Volume XXV, No. 1
The Independent Medical Business Newspaper
Preventing Medicare readmissions
Hospital pilot shows promising early results By William Neresian, MD, MHA, Barry Baines, MD, and Becky Schmidt, RN–BC
By Victor M. Montori, MD, MSc
FOOTPRINT to page 10
PRSRT STD U.S. POSTAGE
A call for minimally disruptive medicine
Detriot Lakes, MN Permit No. 2655
the health care footprint
he health care footprint has gotten oppressively large. For those who have limited access to health care, the burden of illness—symptoms, disability, and avoidance of activities to prevent symptoms—can significantly reduce quality of life, independence, the ability to care for loved ones and to pursue goals and dreams. Caring for these patients is the oldest calling of medicine: Alleviate suffering, palliate symptoms, and diagnose and cure the underlying cause. Reducing the burden of illness and returning the patient to health may leave a noticeable footprint (e.g., when an ICU admission or surgery is required), but it will be limited to the extent that the intervention is brief. For some patients, though, the health care footprint is ever-growing and never-ending. In particular for patients with chronic conditions, the goal often
educing hospital admissions, readmissions, and ED visits constitutes best care for patients and represents a key part of any serious effort to contain health care costs. Nationally, 20 percent of hospitalized Medicare patients are readmitted within 30 days. In February 2010, Fairview Physician Associates (FPA), UCare, and primary care physicians in the FPA network piloted a program to reduce Medicare readmissions at Fairview Southdale Hospital. FPA is an Edina-based network of approximately 1,200 physicians affiliated with Fairview Health Services. UCare is an independent, nonprofit health plan serving more than 200,000 members of Medicaid and Medicare programs in Minnesota and western Wisconsin. READMISSIONS to page 16
IN THIS ISSUE:
Patient education Page 18
One Heart, One Mind, One Universe May 8, 2011 at Mariucci Arena, University of Minnesota Medicine Buddha Empowerment: A Tibetan Cultural and Spiritual Ceremony Promoting Personal and Societal Healing featuring His Holiness the 14th Dalai Lama 9:30 - 11:30 a.m. Peace Through Inner Peace: A Public Address featuring His Holiness the 14th Dalai Lama 2:00 - 3:30 p.m. May 9, 2011 at University Radisson Hotel Second International Tibetan Medicine Conference: Healing Mind & Body 9:00 a.m. - 7:30 p.m. (* His Holiness is not expected to be in attendance.)
2 Days Only, 3 Events
The Minnesota Visit 2011 His Holiness the 14th Dalai Lama
A special invitation to health professionals: The Second International Tibetan Medicine Conference May 9, 2011 This event will bring to the Twin Cities the foremost practitioners of Tibetan medicine from the Men-Tsee-Khang, the Tibetan Medical Institute of His Holiness the Dalai Lama, in Dharamsala, India. By the end of the conference, participants will be able to meet the following objectives involving Tibetan Medicine: Examine the relationship between ethics, spirituality, and healing. Investigate participants' own unique constitution. Determine what lifestyle choices to make, based on participants' own constitution. Explain how to heal from the source and develop health through balance. Describe research about Tibetan medicine, as well as propose additional research needed. Apply teachings of Tibetan medicine personally and professionally.
etan Ame Tib r
For tickets and more information, visit www.dalailama.umn.edu or call 612-624-2345
un n Fo dation ica
APRIL 2011 Volume XXV, No. 1
FEATURES Shrinking the health care footprint A call for minimally disruptive medicine
MINNESOTA HEALTH CARE ROUNDTABLE
By Victor M. Montori, MD, MSc
Preventing Medicare readmissions Hospital pilot shows promising early results
1 T H I R T Y- F I F T H
By William Nersesian, MD, MHA, Barry Baines, MD, and Becky Schmidt, RN-BC
8 Ed Ehlinger, MD Minnesota Department of Health
COMPLEMENTARY AND ALTERNATIVE MEDICINE East meets West 26 By Charles Bransford, MD
INTERNATIONAL MEDICINE Forging links to improve care 28 By Lee Pyles, MD, James St. Louis, MD, and Andreas Tsakistos
INTERNATIONAL MEDICINE Building a global health portfolio 32 By John R. Finnegan Jr., PhD
SPECIAL FOCUS: PATIENT EDUCATION Helping patients get the message
By Anne Beschnett, MLIS
Patient literacy and effective care
By Marcie Parker, PhD, MA, MPA, CFLE
Improving health literacy in seniors
By Alisha Ellwood, MA, LMFT
Information, connection, comfort
By Kendall Munson
Background and focus: Until recently, when the word wellness came up in organized medicine it was regularly dismissed as pseudo-science. Our health care delivery system, or as many call it “sick care delivery system,” evolved in a way that doctors were not paid to keep patients well and thus wellness strangely fell outside the purview of medicine. Obviously it is better to stay healthy than try to fix complex and sometimes avoidable medical conditions. Selling servA changing focus in health care ices supporting this approach was often criticized for lack of randomized clinical trial April 28, 2011 research; inadequate licensing, 1:00 – 4:00 PM • Duluth Room credentialing, and oversight for practitioners; and many other Downtown Mpls. Hilton and Towers concerns. Wellness as an industry, with its wide diversity of methods and approaches, was kept at arm’s length by the medical establishment. Economics have forced this to change.
The Wellness Revolution
Objectives: We will explore the definition of wellness, why today there is a wellness revolution, and why doctors now embrace the concept. Examining multiple collection methodologies and sets of data, we will discuss how and why employers are driving this new approach to health care. We will consider privacy issues and many other challenges to an already overburdened administrative process posed by collecting and storing individual health care data in places such as work sites and health clubs. We will discuss the breadth of wellness initiatives, their pros and cons, and how they can lower the cost of health care while improving individual health status. Panelists include: N Julia Halberg, MD, MS, MPH, Vice President Global Health and Chief Medical Officer, General Mills N Karen L. Lawson, MD, Director Health Coaching, U of M Center for Spirituality and Healing
The Independent Medical Business Newspaper
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APRIL 2011 MINNESOTA PHYSICIAN
MDH Concerned Over Measles Reemerging In Hennepin County Health officials are urging parents to make sure their children are up to date on basic vaccinations after 10 cases of measles were found among children in Hennepin County in March. The news comes on the heels of a report that found a significant drop in rates of vaccination for children in Minnesota. The report, released by Childrenâ&#x20AC;&#x2122;s Hospitals and Clinics of Minnesota, found the state had dropped sharply in certain areas of vaccinations, due in some cases to myths and misinformation that led parents to decide against vaccinating children. Among the cases are Somali children who had not been vaccinated because of parental concerns about the vaccination for measles, mumps, and rubella (MMR). Officials with the Minnesota Department of Health (MDH) say in recent years the Somali community has seen a drop in MMR vacci-
nations because of concerns about safety. â&#x20AC;&#x153;Contrary to misinformation that may still be circulating, the measles vaccine is safe and effective. Without it, the risk of disease is real. Children can die from measles,â&#x20AC;? says Edward Ehlinger, MD, Minnesota commissioner of health. MDH officials say they are working closely with public health agencies to investigate cases of measles. Officials say the children in the early cases are recovering, though five of them had to be hospitalized. State officials have also alerted health care providers in Minnesota, particularly in the metro area, to be alert for patients with signs or symptoms of measles. Anyone who has concerns about their health should contact his or her health care provider, they add. â&#x20AC;&#x153;Measles can be a severe infection and is very contagious if a person without immunity is exposed to an infected person,â&#x20AC;? says Ruth Lynfield, MD, state epidemiologist. â&#x20AC;&#x153;We strongly urge parents and health care
providers to ensure that children have received appropriate vaccinations.â&#x20AC;?
Report: Treatment Decisions Vary by Locale in Minnesota A new Dartmouth Atlas report finds wide variations in elective surgery decisions in Minnesota. The report, the first in a series that will look at variation of treatment in individual states and regions, finds that decisions on how to treat medical conditions can vary widely depending on where a patient lives. â&#x20AC;&#x153;If you have gallstones and live in Wadena, you are three times more likely to have your gall bladder removed than if you live in Minneapolis,â&#x20AC;? the report says. â&#x20AC;&#x153;Variations of a similar magnitude were found across the state for other procedures as well. Among the largest 60 communities in Minnesota, we found fourfold variation in coronary angioplasty and stenting and more
than threefold variation in carotid endarterectomy, a procedure performed to prevent stroke.â&#x20AC;? Officials with the Dartmouth Atlas, which has become a leading authority on variations in practice and on how medical resources are distributed, say that the findings show the need for patients to be better informed about their choices and to work with clinicians on medical decisionmaking. â&#x20AC;&#x153;All too often, patients facing elective surgery are not given an opportunity to learn about the full range of options, and that each choice has unique risks and benefits. Many are not even aware that the decision about an elective procedure is actually a choice. Instead, they routinely delegate such important decisions to their clinicians, with the result being that patients often do not get the treatment they would prefer,â&#x20AC;? says David C. Goodman, MD, MS, report co-author and coprincipal investigator for the Dartmouth Atlas Project.
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MINNESOTA PHYSICIAN APRIL 2011
Residency Directors Fear Shift Limitations Could Impair Training Restrictions on hospital shifts for residents may be affecting the quality of their training, a Mayo Clinic survey suggests. Fatigue among residents, who traditionally have worked long hours in hospitals as part of their training, has become associated with patient safety issues. Last year, the Accreditation Council for Graduate Medical Education (ACGME) set new guidelines restricting residents to hospital shifts of no more than 16 hours. Mayo sent surveys to directors of residency programs around the county and found that many are concerned that the new limitations may compromise the quality of training for residents. Of the nearly 500 respondents from the fields of surgery, internal medicine, and pediatrics, 87 percent of program directors felt that the shortened shifts would interrupt the interactions between residents and hospitalized patients. “Many survey respondents expressed concern that the limits will decrease the continuity of care. As residents face more handoff of responsibilities within a 24-hour period, they have less opportunity to see and learn how patients’ care progresses,” says Darcy Reed, MD, MPH, a co-author of the study. The survey found that up to 78 percent of directors say the restricted shifts are likely to result in graduates who fall short in the key competency areas defined by the ACGME. Directors of surgery expressed the greatest concern. A strong majority of respondents from all areas, 65 percent, indicated they did not believe the restricted hours would reduce fatigue.
GOP Budget Plan Cuts Health Services GOP state legislators unveiled health and human services budgets recently, saying that deep cuts in health and human
services and aid to local government were necessary to address the state’s $5 billion budget deficit. GOP lawmakers and Gov. Mark Dayton have been at odds since the beginning of the session on how Minnesota should fix the state’s deficit, with Dayton proposing a mix of cuts and increased taxes on the wealthy, and GOP members insistent on avoiding tax hikes during a time of economic recovery. In the area of health and human services, the GOP plan calls for spending $1.6 billion less than projected costs for existing plans. Dayton’s budget calls for approximately $200 million in cuts to projected health spending in Minnesota. Sen. David Hann (R-Eden Prairie) emphasized that the GOP proposal represents 6 percent growth from current levels of spending on health programs. However, at a March 10 press conference, he acknowledged that the projected costs of health spending for current programs far outstrip what the GOP proposes. He said he hoped that legislators will find a way to minimize cuts to programs that serve vulnerable populations such as the disabled or those in nursing homes. “We’re going to do everything we can to try and protect the commitments we have made to people, but we are also looking at ways to do this in a way that is financially sustainable in the long term, so we are not back every year figuring out how to cope with double-digit increases,” he said. In a statement released the same day, a Dayton spokeswoman said the GOP plan would result in cuts to health care and education in Minnesota and would raise property taxes. “These cuts will hurt schoolchildren, taxpayers, businesses, and seniors,” the statement said. CAPSULES to page 6
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UCare Gives Back $30 Million to State Minneapolis-based UCare will give the state $30 million to help address Minnesota’s budget deficits, officials announced recently. The move comes at a time when the Legislature has raised questions about the finances of public health plans administered by health insurance companies. UCare officials note that they made money on public programs such as Medical Assistance in 2010, but say that such programs can be volatile. Ucare is calling for the state to work with insurers on a new financial oversight model that would share excess earnings with the state while protecting health plans from losses during lean years. State lawmakers have raised questions about recent profit margins for public plans administered by private health insurers such as UCare, Blue Cross and Blue Shield of Minn-
esota, HealthPartners, and Medica. Some policymakers have proposed taxing plans or creating a new system of oversight on administrative costs, saying that some of the dollars generated could go to helping the state with its budget problems. According to UCare Senior Vice President of Public Affairs and Marketing Ghita Worcester, her organization decided that under the current budget crunch, it was appropriate to return some money to the state. “We came forward at this time because they’re developing the budget, and we know there could be additional health cuts,” she says. “We said, ‘2010 was a good year for the health plan; what’s a fair amount of money for us to keep?’ The remainder over that we determined should be shared back to the state.” Worcester notes that her company is different from other health plans because it works entirely with public health programs, with both Medicaid and Medicare offerings. She adds
that UCare’s Medicare segment is not part of the company’s payback to the state. Gov. Mark Dayton has welcomed the UCare decision, saying that he has asked Department of Human Services Commissioner Lucinda Jesson to begin discussions with other health plans on whether they can follow UCare’s lead. However, the other state health plans do not seem to be rushing to join UCare in donating money to the state. Officials with Blue Cross, Health Partners, and Medica all said they were considering the idea but noted that each health plan has unique circumstances. “We all have different mixes of business,” says Medica spokesman Larry Bussey. He adds that Medica made only a small profit on government plans in 2010. HealthPartners and Blue Cross also released statements underlining the differences between their business models and that of UCare. Blue Cross said insurers and the state should have further discussion on payment systems, such as a
new model that Blue Cross has instituted with many providers in the state.
Federal Regulators Approve Dayton’s Medicaid Expansion Federal regulators have approved Gov. Mark Dayton’s request for an expansion of Medicaid in Minnesota. The approval was expected, as Dayton had made the expansion a campaign issue and state legislators had already discussed the move with officials from the Centers for Medicare & Medicaid Services. At the Feb. 17 announcement, Dayton said the move will cover 95,000 Minnesotans, create 20,000 jobs, and save the state money over the long run. Medicaid expansion is built into the federal Affordable Care Act and is scheduled to take effect fully in 2014, but states can elect to opt into the program early.
Upcoming CME Courses www.cmecourses.umn.edu Office of Continuing Medical Education U 612-626-7600 or 1-800-776-8636 U email: email@example.com
2011 CME SPRING COURSES 12th Annual Lillehei Symposium: Cardiovascular Care for Primary Care Practitioners April 18 – 19, 2011 “Bridging the Transition to Life after Cancer Treatment” Cancer Survivorship Conference April 29 – 30, 2011 North Central Chapter Infectious Disease Society of America (NCC-IDSA) Annual Meeting April 30, 2011 Bariatric Education Day May 25 – 26, 2011 Workshops in Clinical Hypnosis “Introductory and Advanced Sections” June 2 – 4, 2011 Topics and Advances in Pediatrics June 9 – 10, 2011 Advances in Breast, Endocrine, and Cancer Surgery June 16 – 18, 2011
2011 AHRQ National PBRN Research Conference June 22 – 24, 2011 Global Health Training August 1 – 26, 2011
UPCOMING FALL 2011 COURSES Psychiatry Review September, 2011 Pediatric Clinical Hypnosis September 15 – 17, 2011 Pediatric Trauma Summit September 22 – 23, 2011 Obstetrics, Gynecology, & Women’s Health Autumn Seminar September 23, 2011 Pain Management for Primary Care September 28, 2011 Practical Dermatology September 30 – October 1, 2011 Twin Cities Sports Medicine September 30 – October 1, 2011
Urology for Primary Care October 6, 2011 Transplant Immunosuppression “The Difficult Issues” October 12 – 15, 2011 Internal Medicine Review and Update November 2 – 4, 2011 Emerging Infections November 18, 2011
ON-LINE COURSES Courses available for AMA PRA category 1 credit. http://www.cme.umn.edu/online s Reducing Recurrent Preterm Birth s Travel Medicine s Healthcare for Immigrant & Refugee Populations s ECG of the Week s Adult Congenital Heart Disease All courses are held in the Twin Cities unless noted
Syed Shahkhan, MD, has joined the Noran Neurological Clinic and will practice at Noran’s Minneapolis and Burnsville offices. Shahkhan earned his medical degree from Deccan College of Medical Sciences in Hyderabad, India. He completed his neurology residency at the Oklahoma University Health Sciences Center and a fellowship in clinical neurophysiology at UT Southwestern Hospital in Texas. Prior to joining Syed Shahkhan, MD the Noran Clinic, Shahkhan was a neuromuscular specialist and general neurologist at the Minneapolis VA Medical Center from 2007 to 2010. Shahkhan is board-certified in clinical neurophysiology and neurology. Family practice physician Kevin R. Wentworth, MD, has joined Tri-County Health Care and will practice at Henning Medical Clinic. Wentworth attended the University of Minnesota, Minneapolis School of Medicine and completed his family medicine residency at the University of North Dakota. Joseph Lemker, MD, has joined the orthoKevin R. pedic surgery staff at Community Memorial Wentworth, MD Hospital in Cloquet. Lemker is board-certified in orthopedic surgery. He graduated from the St. Louis University School of Medicine and completed a residency in orthopedic surgery at St. Louis University Hospital and Clinic. He previously practiced with Essential Health East Region and Virginia Regional Medical Center. Lisa-Ann Wuermser, MD, has joined Courage Center’s Physicians’ Associates staff as part of the health care team treating people with disabilities and complex medical conditions. Wuermser specializes in physical medicine and rehabilitation. She has done extensive research in osteoporosis after paralysis, and has been Lisa-Ann Wuermser, MD part of a team developing physical medicine and rehabilitation and spinal cord injury treatment in Honduras and Vietnam for the past decade. Most recently, Wuermser practiced at the Mayo Clinic in Rochester. Among the recipients of the Arrowhead Regional Emergency Medical System’s 2011 awards are Christopher Delp, MD, FACEP, and Arne Vainio, MD. The two were awarded the Mark Rathke, MD, Medical Leadership Award, which is presented to a physician who has shown outstanding EMS leadership qualities within his or her community or region. Delp is an emergency medicine physician at St. Luke’s Hospital in Duluth; Vainio is a family practice physician at the Min-No-Aya-Win Human Services Clinic on the Fond du Lac Ojibwe Reservation in Cloquet. The awards program honors regional EMS providers for their hard work and dedication in providing emergency medical services to their communities in the Arrowhead region. Jessica Krog-Breeuwer, MD, has joined St. Luke’s Internal Medicine Associates, Duluth. Krog-Breeuwer received her medical degree from the University of Minnesota Medical School and completed her residency in internal medicine at Abbott Northwestern Hospital in Minneapolis. Thomas O’Connor, MD, has joined St. Luke’s Urology Associates. O’Connor received his medical degree from Cornell University Medical College in New York City. He completed his internship and residency in the Department of Urology at New York Hospital-Cornell University Medical Center, where he also was chief resident. Before joining St. Luke’s, O’Connor was clinical assistant professor of urology at the University of Tennessee Medical Center in Knoxville. Michael Butner, MD, a family medicine physician, has returned to Laurentian Medical Clinic, a St. Luke’s Clinic, in Mountain Iron. Butner is board-certified in family medicine. He received his medical degree from the University of Missouri– Columbia and completed his residencies at Mercy Medical Center and St. Luke’s Hospital in Cedar Rapids, Iowa.
REQUEST FOR NOMINATIONS
2011 HEALTH CARE ARCHITECTURE & DESIGN
HONOR ROLL NOMINATION CLOSING: FRIDAY, MAY 6, 2011 PUBLICATION DATE: JUNE 2011
Seeking Exceptionally Designed Health Facilities Minnesota Physician announces our annual Health Care Architecture & Design Honor Roll. We are seeking nominations of exceptionally designed health care facilities in Minnesota. The nominees selected for the honor roll will be featured in the June 2011 edition of Minnesota Physician, the region’s most widely read medical publication. Eligible facilities include any structure designed for patient care: hospitals, individual physician offices, clinics, outpatient centers, etc. Interiors, exteriors, expansions, renovations, and new structures are all eligible.
In order to qualify for nomination, the facility must have been designed, built or renovated since January 1, 2010. It also must be located within Minnesota (or near the state border within Wisconsin, North Dakota, South Dakota or Iowa). Color photographs are required. If you would like to nominate a facility, please fill out the nomination form below and submit the form, three to eight 300 resolution color photographs, and a brief project description by Friday, May 6, 2011. For more information, call (612) 728-8600.
2011 HEALTH CARE ARCHITECTURE & DESIGN HONOR ROLL NOMINATION FORM FACILITY NAME TYPE OF FACILITY LOCATION OWNERSHIP ORGANIZATION OWNER CONTACT NAME and PHONE OWNER ADDRESS CITY, STATE, ZIP ARCHITECT/INTERIOR DESIGN FIRM ARCHITECT CONTACT NAME and PHONE ARCHITECT ADDRESS CITY, STATE, ZIP ENGINEER CONTRACTOR COMPLETION DATE TOTAL COST SQUARE FEET NUMBER OF COLOR PHOTOS ENCLOSED [Note: Please include a caption for each photo] NOMINATION PROCEDURE: Send this form or a separate sheet with all the above information, a project description (150–250 words), and 300 resolution color 8”x10” digital or glossy photographs (no more than eight) to: Honor Roll Minnesota Physician Publishing, Inc. 2812 East 26th Street, Minneapolis, MN 55406 For further information, please phone (612) 728-8600, fax (612) 728-8601 or e-mail firstname.lastname@example.org.
Medicine, public health, and a new commissioner ■ What has been the biggest challenge in
getting to know the department and the scope of its work?
Ed Ehlinger, MD Minnesota Department of Health Edward Ehlinger, MD, MSPH, was named Minnesota commissioner of health by Gov. Mark Dayton on Dec. 31. Previously, Ehlinger served 16 years as director and chief health officer of Boynton Health Center at the University of Minnesota, where he was known nationally for his expertise in public health issues. Ehlinger has been the recipient of the Albert Justus Chesley Award from the Minnesota Public Health Association and the Physician Communicator Award from the Minnesota Medical Association. He also served as president of the Twin Cities Medical Society in 2010.
The biggest challenge is to see how a state agency functions. It is a large organization and it is in the context of state government, which is a different creature than city government or the university. It is in the midst of a political period that is unique in Minnesota, with both houses of the Legislature being Republican and the governor being Democratic. So the challenge has been to learn about a large agency in a very short time, get up to speed on the political and policy issues, and make decisions about the direction the department should go.
The last priority I have among these overarching priorities is to strengthen the local public health system. That is where the community engagement can occur, where the services can be provided at the local levels. We want to strengthen that state and local partnership as best we can. ■ When you say “community engagement,” what
do you mean?
The central corridor light rail is a good example of the kind of community engagement we need. The community in the central corridor has actively participated, engaged, and taken ownership of what is going on with light rail going down University Avenue. They have pushed to get a health impact assessment done in that communPublic health is ■ What are your top prioriity that looks at the health nonpartisan. That is not issues that are surrounding ties for the department? that development. That is a As a physician, we go under to say it is not political, good example of a communthe mantra: “First, do no ity stepping up and saying, but it is nonpartisan. harm.” The Minnesota “We need to be involved, we Department of Health is one own this as our problem, we of the premier state health need to be partners with the state agencies and the agencies in the country. My first priority is to city government to make sure that this happens in maintain that status and, if possible, enhance it. an appropriate way.” So that means maintaining all of those great pub-
lic health programs we have—the surveillance programs; the data collection programs; programs with water, food, infectious diseases, health promotion, acute and chronic diseases—while we start moving forward on a variety of other issues. One of my priorities is to see if we cannot integrate medicine and public health a lot more than has happened in the past. As I look at the history of medicine and public health, they were really linked hand and glove in the 19th century, but in the early 20th century they went on their own paths. Now we see that medical care by itself will not improve the health of the population, that we really do need to focus on the social determinants of health—the environmental, economic, educational, transportation issues. We need to bring medicine and public health back together. So that is going to be my focus. We need to look at how we are going to improve our medical care system, the quality, cost, and overall value of the system. We need to decrease the use of the system, not by putting up barriers but by decreasing chronic disease. So we need to start looking at obesity prevention, diabetes prevention, heart disease prevention—all of the chronic illnesses we can address by doing some public health interventions. Our goal with health reform is to improve the quality and efficiency of our medical care system. Another priority is to reduce disparities in the state. We will really work on health equity, because we have some of the largest disparities in the country in this state.
MINNESOTA PHYSICIAN APRIL 2011
■ I don’t think most people see light rail as having
a health impact. Light rail has a health impact in a variety of ways. One is that where light rail comes through an area, people get more physical activity. It decreases particulate matter in the air, it cuts down on asthma, but it also enhances economic development and it improves housing. Economics and housing certainly have a direct impact on health. Similarly, lots of bills in the Legislature have an impact on health even though they may not be health bills. The perfect example is smoking in cars. It is a transportation issue, but it is also a health issue. Education bills—the better you are educated, the healthier you are. We need to look at those things as health initiatives, not just as housing, education, or transportation issues. ■ What are your views on the federal health care
reform law? Minnesota has been dealing with health reform for several years. We have done a lot of things that are unique to this state: the data collection we have had for provider peer grouping, the development of health care homes, the development of an Accountable Care Organization (ACO) model. So Minnesota has been at the forefront of setting the stage for even more health reform activities. The Affordable Care Act has given us an opportunity to pull together some resources to expand what we are doing in Minnesota and gives us the opportunity to develop a health reform approach that is unique to Minnesota.
■ What are some possible solutions to the
suggestion that MDH has too many projects and too little funding? Public health is a complex and farreaching field. We cover many things. For example, there are public health issues related to the floods his spring. There are public health issues related to the obesity epidemic and the diabetes increases, mental health issues that affect large populations, disparities, infectious diseases, and the quality assurance that has to happen in our health care system. There is a broad range of activities that we have to do. We have a department that has a lot of expertise in all of these areas. The resources are under attack at the federal and state level, but those are services that need to be provided. If we do not have the resources to provide those services, the level of health in Minnesota is going to decline. ■ You’ve mentioned the political realities at
the Legislature. How do you deal with the tension between what public health professionals see as priorities and what the Legislature might see as priorities? Public health is nonpartisan. That is not to say it is not political, but it is nonpartisan. The bottom line is, what is good for the population in our state? The issues that have developed over the last couple of legislative sessions were really bipartisan. The provider
peer grouping, the health care homes—a lot of these reform initiatives came during the Pawlenty administration when there was a Democratic Legislature. So they really were bipartisan and good, sound approaches to health reform. Our role is to protect, maintain, and improve the health of Minnesotans. There are multiple ways of doing that. We need to be objective. We need to look at what the evidence tells us and argue that the evidence-based approach to improving health is what needs to happen. It is not a partisan issue—it is what the data say. ■ In what ways can physicians work more
closely with MDH? There are a variety of ways we can do this. One that I started when I was Twin Cities Medical Society president was to look at the Community Health Services medical consultants and enhance their role. Every community health agency, every health department has a medical consultant. The medical consultants really did not have a job description, did not know each other, and did not get much support and training from MDH. We are now making a real effort to give them some support so that physicians can understand public health and be actively involved in it. Then there are multiple task forces, committees, and work groups here at the
state Health Department that need physician involvement. We also need to educate physicians about the role public health plays in improving the health of their patients. We need to make sure we get physician involvement in data collection activities such as provider peer grouping, and what we do with that data, so that we do what is most effective and what is most efficient. ■ Do you get pushback on issues like the
data collection program? We get pushback on almost everything we do. There is never unanimity on anything that we do in public health. There are always vested interests. Even the Freedom to Breathe Act, for example. We see tobacco use as the major public health problem in our country, and yet we get pushback on clean air and smoking reduction. So on the data issues we get pushback, but that is where we really need the physician input. We need to be proactive in looking at medical care, evaluating its quality, evaluating its cost, and recommending how to improve it and make it more efficient. The data we are collecting will move us in that direction. It may not be a perfect instrument, but it is the next iteration of what we need to do.
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For many patients, the fundamental problem is not the burden of illness, but the burden of treatment.
Footprint from cover is not a cure, but rather controlling the condition and reducing the risk of long-term complications. There has been an explosion in chronic conditions, due in part to aging of the population; improvements in survival of previously lethal conditions, thanks to effective treatments; and, increasingly, defining conditions based on risk definitions. Examples of the latter include diabetes (defined as blood sugar levels above which patients are at high risk of retinopathy), hypertension (defined as blood pressure levels above which treatment reduces the risk of stroke), and dyslipidemia (defined as LDL cholesterol levels above which treatment reduces the risk of cardiovascular events). As a result, many patients, particularly older ones, carry multiple chronic conditions. Many of these people are fundamentally healthyâ&#x20AC;&#x201D;they have few symptoms and experience little illnessâ&#x20AC;&#x201D;but receive a large amount of health care: Medicare patients with five or
more chronic conditions account for almost 70 percent of health care expenditure. For them, the fundamental problem is not the burden of illness, but the burden of treatment. To understand the role of treatment as a burden, we have to understand what modern health care requires of clinicians and patients. Evidence-based guidelines define the care that is and is not recommended, but almost all of these documents focus on care of a single condition. They specify a maximum of care, requiring tests to diagnose, prognosticate, monitor, and trigger referrals and treatment; indicate measures to ascertain the quality of care performed; and propose treatments, dictating the outcomes that need to be achieved. These guidelines are problematic for a number of reasons: â&#x20AC;˘ The evidence on which they
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MINNESOTA PHYSICIAN APRIL 2011
are based is often corrupt (consider the revelations surrounding the safety of rosiglitazone or evidence of publication bias regarding antidepressants). â&#x20AC;˘ The guidelinesâ&#x20AC;&#x2122; writers are often specialists with narrow expertise and important financial relationships with corporations that stand to profit from adherence to the recommendations. â&#x20AC;˘ The recommendations fail to account for patient context, both internal (e.g., comorbidities, other treatments and their potential interactions with the new recommended ones) and external. While the internal context is the subject of â&#x20AC;&#x153;individualized medicine,â&#x20AC;? with its promise to identify safe and effective treatments through technologies such as pharmacogenomics, attention to the external context has received substantially less attention. To bring this into focus, letâ&#x20AC;&#x2122;s consider the fictionalized case of John, who resembles an increasing number of my own patients. John: a case study John is a 55-year-old accountant, husband, and father of two. He has diabetes, for which he takes metformin and glipizide (HbA1c 7.8 percent); dyslipidemia, for which he takes 40 mg of pravastatin (LDL 108 mg/dL); and hypertension, for which beta blockers were recently added to his thiazide diuretic because his office measures were above goal. After this addition, John experiences daily some orthostatic dizziness. His weight seems parked at 108 kg. He also has depression and chronic recurrent low back pain, as well as some neuropathic pain in both feet. To help address Johnâ&#x20AC;&#x2122;s problems and help him achieve guideline-recommended targets for patients with type 2 diabetes, Johnâ&#x20AC;&#x2122;s primary care clinician refers him to a tertiary center for evaluation by podiatry, dietitian, diabetes education, and
endocrinology. To attend these visits, John takes time off work and has a neighbor drive him to the medical center. There he is advised to cut back on carbohydrates, fats, salt, and calories; to take his pills regularly; to check his sugars twice per day; to exercise; and to check his feet daily. He also receives numerous tests, including an electromyogram that documents his neuropathy. John feels no one at the referral clinic pays much attention to his back difficulties when advising exercise; because of back stiffness and large abdominal obesity, he will have to ask his wife to take a look at his feet regularly. Despite comprehensive visits, his complaints of pain and difficulty sleeping remain largely unaddressed. One reason John cannot sleep very well is because of the situation at work. He used to be one of three accountants; through downsizing he remains the only accountant. He takes work home regularly, feels pressure to perform, and is noting that the numbers are not adding up. This causes him to worry that the company may be going underâ&#x20AC;&#x201D;and with it his job, his health insurance, his ability to pay his debt, and his mortgage. But paying his mortgage is not the main concern about his home situation. A few months ago, his daughter returned to live with them, bringing with her two beautiful granddaughters. The daughter came seeking refuge from her abusive husband and is drinking heavily. As John sits in his La-Z-Boy reviewing all these concerns, he opens a letter from his primary care physician. She works in a pay-for-performance environment with public reporting of disease-centered outcomes for her patient panel. In her letter, she says that his failure to accomplish the goals of diabetes care, despite all her efforts, requires that John seek care with another primary care clinician. FOOTPRINT to page 15
&OR YOUR PATIENTS WITH RELAPSING FORMS OF MULTIPLE SCLEROSIS
&GÂžDBDZ BU IBOE 1PUFOUJBM BU UIFJS ÂžOHFSUJQT Primary end point1:
Primary end point1: RELATIVE REDUCTION IN ANNUALIZED RELAPSE RATE vs interferon beta-1a IM (0.16 vs 0.33; P<0.001)
RELATIVE REDUCTION IN ANNUALIZED RELAPSE rate vs placebo (0.18 vs 0.40; P<0.001) Key secondary end point: s REDUCTION in the risk of 3-month confirmed
Key secondary end points: s 3IGNIFICANT REDUCTION in mean number
disability progression as measured by the EDSS compared with placebo (hazard ratio of disability progression [95% CI]: 0.70 [0.52-0.96]; P=0.02)
of new or newly enlarged T2 lesions compared with interferon beta-1a IM (1.6 vs 2.6; P=0.002)
s .O SIGNIFICANT DIFFERENCE in the time to 3-month confirmed disability progression between GILENYA and interferon beta-1a IM at 1 year (hazard ratio [95% CI]: 0.71 [0.42-1.21]; P=0.21) TRANSFORMS: A 1-year, randomized, double-blind, double-dummy, active-controlled (interferon beta-1a IM) phase III study in 1292 people with RRMS. At baseline, patients had a diagnosis of RRMS with at least 1 documented relapse during the previous year or at least 2 documented relapses during the previous 2 years. They had a score of 0.0 to 5.5 on the EDSS with a median score at baseline of 2.0. Previous therapy with either any type of interferon beta or glatiramer acetate was not a criterion for exclusion.
FREEDOMS: A 2-year, randomized, double-blind, placebocontrolled phase III study in 1272 people with RRMS. At baseline, patients had a diagnosis of RRMS with at least 1 documented relapse during the previous year or at least 2 documented relapses during the previous 2 years. They had a score of 0.0 to 5.5 on the EDSS with a median score at baseline of 2.0. Patients did not receive any interferon beta or glatiramer acetate for at least the previous 3 months and had not received any natalizumab for at least the previous 6 months.
GILENYA is a sphingosine 1-phosphate receptor modulator indicated for the treatment of patients with relapsing forms of multiple sclerosis (MS) to reduce the frequency of clinical exacerbations and to delay the accumulation of physical disability.
IMPORTANT SAFETY INFORMATION
Initiation of GILENYA treatment results in a decrease in heart rate and has resulted in transient (AV) conduction delays. Obtain baseline electrocardiogram before first dose if not recently available in those at higher risk for bradyarrhythmia. Observe all patients for signs and symptoms of bradycardia for 6 hours after the first dose. Patients receiving Class Ia or Class III antiarrhythmics, beta-blockers, calcium channel blockers, those with low heart rate, history of syncope, sick sinus syndrome, second degree or higher conduction block, ischemic heart disease, or congestive heart failure are at increased risk of developing bradycardia or heart blocks. First and second degree AV blocks following first dose have occurred. These conduction abnormalities were usually transient, asymptomatic, and resolved within the first 24 hours, but occasionally required treatment with atropine or isoproterenol. If GILENYA is discontinued for >2 weeks, the effects on heart rate and AV conduction may recur on reintroduction of treatment and the same precautions for initial dosing should apply. GILENYA may increase the risk of infections. A recent complete blood count should be available before initiating GILENYA. Suspension of GILENYA should be considered if a patient develops a serious infection. Monitor for signs and symptoms of infection during treatment and up to 2 months after discontinuation. Do not start GILENYA in patients with active acute or chronic infections. Two patients receiving a higher dose of GILENYA (1.25 mg) in conjunction with high-dose corticosteroid therapy died of herpetic infections. Concomitant use with antineoplastic, immunosuppressive or immune modulating therapies would be expected to increase the risk of immunosuppression. Before initiating GILENYA, patients without a history of chickenpox or without vaccination against varicella zoster virus (VZV) should be tested for antibodies to VZV. VZV vaccination of antibody-negative patients should be considered prior to commencing GILENYA treatment, following which GILENYA initiation should be postponed for 1 month. Macular edema can occur, with or without visual symptoms. An ophthalmologic evaluation should be performed before starting GILENYA and at 3 to 4 months after initiation. Monitor visual acuity at baseline and during routine patient evaluations. Patients with diabetes mellitus or history of uveitis are at increased risk and should have regular ophthalmologic evaluations. Decreases in pulmonary function tests can occur. Dose-dependent reductions in forced expiratory volume over 1 second (FEV1) and diffusion lung capacity for GILENYA is a trademark of Novartis AG.
carbon monoxide (DLCO) were observed in GILENYA patients as early as 1 month after initiation. The changes in FEV1 appear to be reversible after discontinuing GILENYA; however, there is insufficient information to determine the reversibility of DLCO. Obtain spirometry and DLCO when clinically indicated. Liver transaminases may increase. Recent liver transaminase and bilirubin levels should be available before initiating GILENYA. Elevations 3- and 5-fold the upper limit of normal occurred with GILENYA. Recurrence of liver transaminase elevations occurred with rechallenge in some patients. The majority of elevations occurred within 3 to 4 months and returned to normal within 2 months after discontinuing GILENYA. Assess liver enzymes if symptoms suggestive of hepatic injury develop. Discontinue GILENYA if significant liver injury is confirmed. GILENYA may cause fetal harm. Women of childbearing potential should use effective contraception during and for 2 months after stopping GILENYA. A registry for women who become pregnant during GILENYA treatment is available. Blood pressure should be monitored during treatment with GILENYA. An average increase of 2 mm Hg in systolic and 1 mm Hg in diastolic blood pressure was observed. GILENYA remains in the blood, and has pharmacodynamic effects, including decreased lymphocyte counts, for up to 2 months following the last dose. Lymphocyte counts generally return to normal range within 1 to 2 months of stopping therapy. Initiating other drugs during this period warrants the same considerations needed for concomitant administration. Carefully monitor patients concomitantly receiving Class Ia or Class III antiarrhythmics, beta-blockers or systemic ketoconazole. The use of live attenuated vaccines should be avoided during and for 2 months after stopping GILENYA. The most common adverse reactions with GILENYA (incidence >10% and >placebo) compared with placebo were headache (25% vs 23%), influenza (13% vs 10%), diarrhea (12% vs 7%), back pain (12% vs 7%), liver transaminase elevations (14% vs 5%), and cough (10% vs 8%). EDSS=Expanded Disability Status Scale. FREEDOMS=FTY720 Research Evaluating Effects of Daily Oral Therapy in Multiple Sclerosis. IM=intramuscular. RRMS=relapsing-remitting MS. TRANSFORMS=Trial Assessing Injectable Interferon vs FTY720 Oral in Relapsing-Remitting Multiple Sclerosis.
Please see Brief Summary of Prescribing Information on adjacent pages. Reference: 1. GILENYA [package insert]. East Hanover, NJ: Novartis Pharmaceuticals Corporation; 2010.
Novartis Pharmaceuticals Corporation East Hanover, New Jersey 07936-1080
Printed in the USA
Initial U.S. Approval: 2010 BRIEF SUMMARY: Please see package insert for full prescribing information. 1 INDICATIONS AND USAGE GILENYA is indicated for the treatment of patients with relapsing forms of multiple sclerosis (MS) to reduce the frequency of clinical exacerbations and to delay the accumulation of physical disability. 4 CONTRAINDICATIONS None 5 WARNINGS AND PRECAUTIONS 5.1 Bradyarrhythmia and Atrioventricular Blocks Reduction in heart rate Initiation of GILENYA treatment results in a decrease in heart rate [see Clinical Pharmacology (12.2) in the full prescribing information]. Observe all patients for a period of 6 hours for signs and symptoms of bradycardia. Should post-dose bradyarrhythmia-related symptoms occur, initiate appropriate management and continue observation until the symptoms have resolved. To identify underlying risk factors for bradycardia and atrioventricular (AV) block, if a recent electrocardiogram (i.e., within 6 months) is not available, obtain one in patients using anti-arrhythmics including beta-blockers and calcium channel blockers, those with cardiac risk factors, as described below, and those who on examination have a slow or irregular heart beat prior to starting GILENYA. Experience with GILENYA in patients receiving concurrent therapy with beta blockers or in those with a history of syncope is limited. GILENYA has not been studied in patients with sitting heart rate less than 55 bpm. GILENYA has not been studied in patients with second degree or higher AV block, sick sinus syndrome, prolonged QT interval, ischemic cardiac disease, or congestive heart failure. GILENYA has not been studied in patients with arrhythmias requiring treatment with Class Ia (e.g., quinidine, procainamide) or Class III (e.g., amiodarone, sotalol) antiarrhythmic drugs. Class Ia and Class III antiarrhythmic drugs have been associated with cases of torsades de pointes in patients with bradycardia. After the first dose of GILENYA, the heart rate decrease starts within an hour and the Day 1 decline is maximal at approximately 6 hours. Following the second dose a further decrease in heart rate may occur when compared to the heart rate prior to the second dose, but this change is of a smaller magnitude than that observed following the first dose. With continued dosing, the heart rate returns to baseline within one month of chronic treatment. The mean decrease in heart rate in patients on GILENYA 0.5 mg at 6 hours after the first dose was approximately 13 beats per minute (bpm). Heart rates below 40 bpm were rarely observed. Adverse reactions of bradycardia following the first dose were reported in 0.5% of patients receiving GILENYA 0.5 mg, but in no patient on placebo. Patients who experienced bradycardia were generally asymptomatic, but some patients experienced mild to moderate dizziness, fatigue, palpitations, and chest pain that resolved within the first 24 hours on treatment. Atrioventricular blocks Initiation of GILENYA treatment has resulted in transient AV conduction delays. In controlled clinical trials, adverse reactions of first degree AV block (prolonged PR interval on ECG) following the first dose were reported in 0.1% of patients receiving GILENYA 0.5 mg, but in no patient on placebo. Second degree AV blocks following the first dose were also identified in 0.1% of patients receiving GILENYA 0.5 mg, but in no patient on placebo. In a study of 698 patients with available 24-hour Holter monitoring data after their first dose (N=351 on GILENYA 0.5 mg and N=347 on placebo), second degree AV blocks, usually Mobitz type I (Wenckebach) were reported in 3.7% (N=13) of patients receiving GILENYA 0.5 mg and 2% (N=7) of patients on placebo. The conduction abnormalities were usually transient and asymptomatic, and resolved within the first 24 hours on treatment, but they occasionally required treatment with atropine or isoproterenol. One patient developed syncope and complete AV block following the first dose of fingolimod 1.25 mg (a dose higher than recommended) in an uncontrolled study. Re-initiation of therapy following discontinuation If GILENYA therapy is discontinued for more than two weeks the effects on heart rate and AV conduction may recur on reintroduction of GILENYA treatment and the same precautions as for initial dosing should apply. 5.2 Infections Risk of infections GILENYA causes a dose-dependent reduction in peripheral lymphocyte count to 20-30% of baseline values because of reversible sequestration of lymphocytes in lymphoid tissues. GILENYA may therefore increase the risk
MINNESOTA PHYSICIAN APRIL 2011
of infections, some serious in nature [see Clinical Pharmacology (12.2) in the full prescribing information]. Before initiating treatment with GILENYA, a recent CBC (i.e., within 6 months) should be available. Consider suspending treatment with GILENYA if a patient develops a serious infection, and reassess the benefits and risks prior to re-initiation of therapy. Because the elimination of fingolimod after discontinuation may take up to two months, continue monitoring for infections throughout this period. Instruct patients receiving GILENYA to report symptoms of infections to a physician. Patients with active acute or chronic infections should not start treatment until the infection(s) is resolved. Two patients died of herpetic infections during GILENYA controlled studies in the premarketing database (one disseminated primary herpes zoster and one herpes simplex encephalitis). In both cases, the patients were receiving a fingolimod dose (1.25 mg) higher than recommended for the treatment of MS (0.5 mg), and had received high dose corticosteroid therapy for suspected MS relapse. No deaths due to viral infections occurred in patients treated with GILENYA 0.5 mg in the premarketing database. In MS controlled studies, the overall rate of infections (72%) and serious infections (2%) with GILENYA 0.5 mg was similar to placebo. However, bronchitis and, to a lesser extent, pneumonia were more common in GILENYA-treated patients. Concomitant use with antineoplastic, immunosuppressive or immune modulating therapies GILENYA has not been administered concomitantly with antineoplastic, immunosuppressive or immune modulating therapies used for treatment of MS. Concomitant use of GILENYA with any of these therapies would be expected to increase the risk of immunosuppression [see Drug Interactions (7)]. Varicella zoster virus antibody testing/vaccination As for any immune modulating drug, before initiating GILENYA therapy, patients without a history of chickenpox or without vaccination against varicella zoster virus (VZV) should be tested for antibodies to VZV. VZV vaccination of antibody-negative patients should be considered prior to commencing treatment with GILENYA, following which initiation of treatment with GILENYA should be postponed for 1 month to allow the full effect of vaccination to occur. 5.3 Macular Edema In patients receiving GILENYA 0.5 mg, macular edema occurred in 0.4% of patients. An adequate ophthalmologic evaluation should be performed at baseline and 3-4 months after treatment initiation. If patients report visual disturbances at any time while on GILENYA therapy, additional ophthalmologic evaluation should be undertaken. In MS controlled studies involving 1204 patients treated with GILENYA 0.5 mg and 861 patients treated with placebo, macular edema with or without visual symptoms was reported in 0.4% of patients treated with GILENYA 0.5 mg and 0.1% of patients treated with placebo; it occurred predominantly in the first 3-4 months of therapy. Some patients presented with blurred vision or decreased visual acuity, but others were asymptomatic and diagnosed on routine ophthalmologic examination. Macular edema generally improved or resolved with or without treatment after drug discontinuation, but some patients had residual visual acuity loss even after resolution of macular edema. Continuation of GILENYA in patients who develop macular edema has not been evaluated. A decision on whether or not to discontinue GILENYA therapy should include an assessment of the potential benefits and risks for the individual patient. The risk of recurrence after rechallenge has not been evaluated. Macular edema in patients with history of uveitis or diabetes mellitus Patients with a history of uveitis and patients with diabetes mellitus are at increased risk of macular edema during GILENYA therapy. The incidence of macular edema is also increased in MS patients with a history of uveitis. The rate was approximately 20% in patients with a history of uveitis vs. 0.6% in those without a history of uveitis, in the combined experience with all doses of fingolimod. MS patients with diabetes mellitus or a history of uveitis should undergo an ophthalmologic evaluation prior to initiating GILENYA therapy and have regular follow-up ophthalmologic evaluations while receiving GILENYA therapy. GILENYA has not been tested in MS patients with diabetes mellitus. 5.4 Respiratory Effects Dose-dependent reductions in forced expiratory volume over 1 second (FEV1) and diffusion lung capacity for carbon monoxide (DLCO) were observed in patients treated with GILENYA as early as 1 month after treatment initiation. At Month 24, the reduction from baseline in the percent of predicted values for FEV1 was 3.1% for GILENYA 0.5 mg and 2% for placebo. For DLCO, the reductions from baseline in percent of predicted values at Month 24 were 3.8% for GILENYA 0.5 mg and 2.7% for placebo.
The changes in FEV1 appear to be reversible after treatment discontinuation. There is insufficient information to determine the reversibility of the decrease of DLCO after drug discontinuation. In MS controlled trials, dyspnea was reported in 5% of patients receiving GILENYA 0.5 mg and 4% of patients receiving placebo. Several patients discontinued GILENYA because of unexplained dyspnea during the extension (uncontrolled) studies. GILENYA has not been tested in MS patients with compromised respiratory function. Spirometric evaluation of respiratory function and evaluation of DLCO should be performed during therapy with GILENYA if clinically indicated. 5.5 Hepatic Effects Elevations of liver enzymes may occur in patients receiving GILENYA. Recent (i.e., within last 6 months) transaminase and bilirubin levels should be available before initiation of GILENYA therapy. During clinical trials, 3-fold the upper limit of normal (ULN) or greater elevation in liver transaminases occurred in 8% of patients treated with GILENYA 0.5 mg, as compared to 2% of patients on placebo. Elevations 5-fold the ULN occurred in 2% of patients on GILENYA and 1% of patients on placebo. In clinical trials, GILENYA was discontinued if the elevation exceeded 5 times the ULN. Recurrence of liver transaminase elevations occurred with rechallenge in some patients, supporting a relationship to drug. The majority of elevations occurred within 3-4 months. Serum transaminase levels returned to normal within approximately 2 months after discontinuation of GILENYA. Liver enzymes should be monitored in patients who develop symptoms suggestive of hepatic dysfunction, such as unexplained nausea, vomiting, abdominal pain, fatigue, anorexia, or jaundice and/or dark urine. GILENYA should be discontinued if significant liver injury is confirmed. Patients with pre-existing liver disease may be at increased risk of developing elevated liver enzymes when taking GILENYA. Because GILENYA exposure is doubled in patients with severe hepatic impairment, these patients should be closely monitored, as the risk of adverse reactions is greater [see Use in Specific Populations (8.5) and Clinical Pharmacology (12.3) in the full prescribing information]. 5.6 Fetal Risk Based on animal studies, GILENYA may cause fetal harm. Because it takes approximately 2 months to eliminate GILENYA from the body, women of childbearing potential should use effective contraception to avoid pregnancy during and for 2 months after stopping GILENYA treatment. 5.7 Blood Pressure Effects In MS clinical trials, patients treated with GILENYA 0.5 mg had an average increase of approximately 2 mmHg in systolic pressure, and approximately 1 mmHg in diastolic pressure, first detected after approximately 2 months of treatment initiation, and persisting with continued treatment. In controlled studies involving 854 MS patients on GILENYA 0.5 mg and 511 MS patients on placebo, hypertension was reported as an adverse reaction in 5% of patients on GILENYA 0.5 mg and in 3% of patients on placebo. Blood pressure should be monitored during treatment with GILENYA. 5.8 Immune System Effects Following GILENYA Discontinuation Fingolimod remains in the blood and has pharmacodynamic effects, including decreased lymphocyte counts, for up to 2 months following the last dose of GILENYA. Lymphocyte counts generally return to the normal range within 1-2 months of stopping therapy [see Clinical Pharmacology (12.2) in the full prescribing information]. Because of the continuing pharmacodynamic effects of fingolimod, initiating other drugs during this period warrants the same considerations needed for concomitant administration (e.g., risk of additive immunosuppressant effects) [see Drug Interactions (7)]. 6 ADVERSE REACTIONS The following serious adverse reactions are described elsewhere in labeling: • Bradyarrhythmia and atrioventricular blocks [see Warnings and Precautions (5.1)] • Infections [see Warnings and Precautions (5.2)] • Macular edema [see Warnings and Precautions (5.3)] • Respiratory effects [see Warnings and Precautions (5.4)] • Hepatic effects [see Warnings and Precautions (5.5)] The most frequent adverse reactions (incidence ≥10% and > placebo) for GILENYA 0.5 mg were headache, influenza, diarrhea, back pain, liver enzyme elevations, and cough. The only adverse event leading to treatment interruption reported at an incidence >1% for GILENYA 0.5 mg was serum transaminase elevations (3.8%). 6.1 Clinical Trials Experience A total of 1703 patients on GILENYA (0.5 or 1.25 mg once daily) constituted the safety population in the 2 controlled studies in patients with relapsing remitting MS (RRMS) [see Clinical Studies (14) in the full prescribing information].
Study 1 was a 2-year placebo-controlled clinical study in 1272 MS patients treated with GILENYA 0.5 mg (n=425), GILENYA 1.25 mg (n=429) or placebo (n=418). Table 1. Adverse Reactions in Study 1 (occurring in ≥1% of patients, and reported for GILENYA 0.5 mg at ≥1% higher rate than for placebo) Primary System Organ Class Preferred Term
GILENYA 0.5 mg N=425 %
Infections Influenza viral infections Herpes viral infections Bronchitis Sinusitis Gastroenteritis Tinea infections Cardiac disorders Bradycardia Nervous system disorders Headache Dizziness Paresthesia Migraine Gastrointestinal disorders Diarrhea General disorders and administration site conditions Asthenia Musculoskeletal and connective tissue disorders Back pain Skin and subcutaneous tissue disorders Alopecia Eczema Pruritus Investigations ALT/AST increased GGT increased Weight decreased Blood triglycerides increased Respiratory, thoracic and mediastinal disorders Cough Dyspnea Psychiatric disorders Depression Eye disorders Vision blurred Eye pain Vascular disorders Hypertension Blood and lymphatic system disorders Lymphopenia Leukopenia
Placebo N=418 %
13 9 8 7 5 4
10 8 4 5 3 1
25 7 5 5
23 6 4 1
4 3 3
2 2 1
14 5 5 3
5 1 3 1
Adverse reactions in Study 2, a 1-year active-controlled (vs. interferon beta-1a, n=431) study including 849 patients with MS treated with fingolimod, were generally similar to those in Study 1. Vascular Events Vascular events, including ischemic and hemorrhagic strokes, peripheral arterial occlusive disease and posterior reversible encephalopathy syndrome were reported in premarketing clinical trials in patients who received GILENYA doses (1.25-5 mg) higher than recommended for use in MS. No vascular events were observed with GILENYA 0.5 mg in the premarketing database. Lymphomas Cases of lymphoma (cutaneous T-cell lymphoproliferative disorders or diffuse B-cell lymphoma) were reported in premarketing clinical trials in MS patients receiving GILENYA at, or above, the recommended dose of 0.5 mg. Based on the small number of cases and short duration of exposure, the relationship to GILENYA remains uncertain. 7 DRUG INTERACTIONS Class Ia or Class III antiarrhythmic drugs GILENYA has not been studied in patients with arrhythmias requiring treatment with Class Ia (e.g., quinidine, procainamide) or Class III (e.g., amiodarone, sotalol) antiarrhythmic drugs. Class Ia and Class III antiarrhythmic drugs have been associated with cases of torsades de pointes in patients with bradycardia. Since initiation of GILENYA treatment results in decreased heart rate, patients on Class Ia or Class III antiarrhythmic drugs should be closely monitored [see Warnings and Precautions (5.1)].
Ketoconazole The blood levels of fingolimod and fingolimod-phosphate are increased by 1.7-fold when coadministered with ketoconazole. Patients who use GILENYA and systemic ketoconazole concomitantly should be closely monitored, as the risk of adverse reactions is greater. Vaccines Vaccination may be less effective during and for up to 2 months after discontinuation of treatment with GILENYA [see Clinical Pharmacology (12.2) in the full prescribing information]. The use of live attenuated vaccines should be avoided during and for 2 months after treatment with GILENYA because of the risk of infection. Antineoplastic, immunosuppressive or immunomodulating therapies Antineoplastic, immunosuppressive or immune modulating therapies are expected to increase the risk of immunosuppression. Use caution when switching patients from long-acting therapies with immune effects such as natalizumab or mitoxantrone. Heart rate-lowering drugs (e.g., beta blockers or diltiazem) Experience with GILENYA in patients receiving concurrent therapy with beta blockers is limited. These patients should be carefully monitored during initiation of therapy. When GILENYA is used with atenolol, there is an additional 15% reduction of heart rate upon GILENYA initiation, an effect not seen with diltiazem [see Warnings and Precautions (5.1)]. Laboratory test interaction Because GILENYA reduces blood lymphocyte counts via redistribution in secondary lymphoid organs, peripheral blood lymphocyte counts cannot be utilized to evaluate the lymphocyte subset status of a patient treated with GILENYA. A recent CBC should be available before initiating treatment with GILENYA. 8 USE IN SPECIFIC POPULATIONS 8.1 Pregnancy Pregnancy Category C There are no adequate and well-controlled studies in pregnant women. In oral studies conducted in rats and rabbits, fingolimod demonstrated developmental toxicity, including teratogenicity (rats) and embryolethality, when given to pregnant animals. In rats, the highest no-effect dose was less than the recommended human dose (RHD) of 0.5 mg/day on a body surface area (mg/m2) basis. The most common fetal visceral malformations in rats included persistent truncus arteriosus and ventricular septal defect. The receptor affected by fingolimod (sphingosine 1-phosphate receptor) is known to be involved in vascular formation during embryogenesis. Because it takes approximately 2 months to eliminate fingolimod from the body, potential risks to the fetus may persist after treatment ends [see Warnings and Precautions (5.7, 5.8)]. GILENYA should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.
8.2 Labor and Delivery The effects of GILENYA on labor and delivery are unknown. 8.3 Nursing Mothers Fingolimod is excreted in the milk of treated rats. It is not known whether this drug is excreted in human milk. Because many drugs are excreted in human milk and because of the potential for serious adverse reactions in nursing infants from GILENYA, a decision should be made whether to discontinue nursing or to discontinue the drug, taking into account the importance of the drug to the mother. 8.4 Pediatric Use The safety and effectiveness of GILENYA in pediatric patients with MS below the age of 18 have not been established. 8.5 Geriatric Use Clinical MS studies of GILENYA did not include sufficient numbers of patients aged 65 years and over to determine whether they respond differently than younger patients. GILENYA should be used with caution in patients aged 65 years and over, reflecting the greater frequency of decreased hepatic, or renal, function and of concomitant disease or other drug therapy. 8.6 Hepatic Impairment Because fingolimod, but not fingolimod-phosphate, exposure is doubled in patients with severe hepatic impairment, patients with severe hepatic impairment should be closely monitored, as the risk of adverse reactions may be greater [see Warnings and Precautions (5.5) and Clinical Pharmacology (12.3) in the full prescribing information]. No dose adjustment is needed in patients with mild or moderate hepatic impairment. 8.7 Renal Impairment The blood level of some GILENYA metabolites is increased (up to 13-fold) in patients with severe renal impairment [see Clinical Pharmacology (12.3) in the full prescribing information]. The toxicity of these metabolites has not been fully explored. The blood level of these metabolites has not been assessed in patients with mild or moderate renal impairment. 10 OVERDOSAGE No cases of overdosage have been reported. However, single doses up to 80-fold the recommended dose (0.5 mg) resulted in no clinically significant adverse reactions. At 40 mg, 5 of 6 subjects reported mild chest tightness or discomfort which was clinically consistent with small airway reactivity. Neither dialysis nor plasma exchange results in removal of fingolimod from the body. 16 STORAGE GILENYA capsules should be stored at 25°C (77°F); excursions permitted to 15-30°C (59-86°F). Protect from moisture.
Pregnancy Registry A pregnancy registry has been established to collect information about the effect of GILENYA use during pregnancy. Physicians are encouraged to enroll pregnant patients, or pregnant women may enroll themselves in the GILENYA pregnancy registry by calling 1-877-598-7237. Animal Data When fingolimod was orally administered to pregnant rats during the period of organogenesis (0, 0.03, 0.1, and 0.3 mg/kg/day or 0, 1, 3, and 10 mg/kg/day), increased incidences of fetal malformations and embryofetal deaths were observed at all but the lowest dose tested (0.03 mg/kg/day), which is less than the RHD on a mg/m2 basis. Oral administration to pregnant rabbits during organogenesis (0, 0.5, 1.5, and 5 mg/kg/day) resulted in increased incidences of embryo-fetal mortality and fetal growth retardation at the mid and high doses. The no-effect dose for these effects in rabbits (0.5 mg/kg/day) is approximately 20 times the RHD on a mg/m2 basis. When fingolimod was orally administered to female rats during pregnancy and lactation (0, 0.05, 0.15, and 0.5 mg/kg/day), pup survival was decreased at all doses and a neurobehavioral (learning) deficit was seen in offspring at the high dose. The low-effect dose of 0.05 mg/kg/day is similar to the RHD on a mg/m2 basis.
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Minimally disruptive medicine Footprint from page 10 John’s “failure” to achieve disease-specific outcomes despite his physician’s prescription intensification is usually interpreted as John “not taking personal responsibility” or being “noncompliant.” Most literature on nonadherence suggests that John’s nonadherence is intentional. This is often related to knowledge and beliefs about disease and treatment that are not correct and that lead patients to opt out of some aspect of the treatment program. Solutions to the problem of intentional nonadherence therefore focus on learning patients’ beliefs, educating patients about the condition and treatments, presenting them with the options available, having them invest in shared decision-making, and providing them with tools (such as pill boxes) to help them implement the agreed-upon plan of action. The burden of treatment for patients But intentional nonadherence is only part of the story. A discussion with John easily identifies his contextual challenges. The problem with John’s adherence to therapy, visits, tests, diet, exercise, etc., is that this “patient work” does not fit into his life. His physician, instead of co-creating a program that fits John’s external context, has chosen to intensify therapy. In referring John to the endocrinologist, she was thinking that perhaps John would be started on an injectable antihyperglycemic agent and a greater emphasis on self-management would make John check his sugars two or more times per day. Indeed, a study of how much time patients with diabetes spend taking care of their diabetes reveals that on average they spend 48 minutes per day but frequently miss recommended activities. An estimate of how much patients with diabetes ought to be doing places these demands at 122 minutes/day; accounting for administrative tasks such as setting up appointments and getting refills or insurance pre-authorizations increases the time to 143 minutes/day. Taking full care of his
Minimally disruptive medicine requires us to:
mendations and advice that patients accumulate from visiting different health professionals.
1. Establish prioritized patient goals. 2. Assess patient treatments, tests, visits, practices, and overall work the patient completes routinely and how each aligns with patient goals (assessment of patient workload), in the context of all the other work the patient completes routinely. 3. Assess patient capacity by determining significant others that can be enrolled and the available community resources to assist the patient, by determining the state of control of debilitating symptoms such as pain and depression, and by assessing work and financial pressures. 4. Reduce the burden of treatment by a. Stopping treatments, tests, and visits that are less likely to achieve top-priority patient goals. b. Simplifying treatment, tests, and visits to the least burdensome version that is still likely to achieve top-priority patient goals. c. Augmenting patient capacity by reducing symptoms, treating depression, enrolling family and community resources to delegate or assist with work, and assisting patients in dealing with work and financial difficulties. 5. Assess and document the overall burden of treatment, i.e., the imbalance between workload and capacity. diabetes would be a part-time job for John! Thus, this form of structurally induced nonadherence reflects the situation in which the patient’s capacity to take on the work of being a patient is exceeded by the treatment workload. It could result from reductions in patient capacity (through pain, depression, isolation, illness burden), from increment in treatment workload, or from both, especially for patients with multiple chronic conditions. Poorly coordinated, disease-focused care can result in treatment intensification for each condition, with each demanding its own lifestyle changes, tests, monitoring requirements, treatments, and visits—and resulting in large, inefficient increases in treatment burden. The solution to this form of nonadherence in patients with multiple chronic conditions requires that the focus of care shift from each of their conditions to the patient as a whole. In particular, clinicians must take stock of the patient’s capacity and workload. It turns out that there are limitations in our ability to assess both. Patients’ capacity results from their ability to enlist family, friends, co-workers, and others in the work of being a patient; their resilience in the face of illness; their literacy; their quality of life; and their functional capacity. These are not measured routinely in prac-
Applying principles of minimally disruptive medicine Clinicians seeking to improve outcomes for patients with multiple chronic conditions by reducing nonadherence should seek to reduce the burden of treatment, i.e., to optimize the balance between workload and capacity. In an article published in the British Medical Journal in 2009, along with Profs. May and Mair from the U.K., we called this type of practice “minimally disruptive medicine.” This approach would benefit from having a patient-reported measure of treatment burden. David Eton, PhD, is leading our research group in developing this measure in collaboration with colleagues at Mayo Clinic and Hennepin County Medical Center as well as research groups in England and Scotland. In seeking to reduce treatment burden, minimally disruptive medicine requires that clini-
tice. Nor do we know how effective patients are at conveying, and clinicians are at eliciting, a sense of the patient’s ever-changing capacity to do patient work. Treatment workload may be easier to assess, particularly in highly integrated health systems and with electronic medical records. But even the best records will not note the recom-
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FIGURE 1. Decreasing Medicare readmissions: workflow. Readmissions from cover Fairview employs one-third of FPA physician members, while the majority practice independently or with University of Minnesota Physicians. FPA has a standing contract with UCare to provide case management services to some 14,000 UCare Medicare Advantage enrollees.
Fairview Southdale Hospital 1. Patient clearly instructed to follow up with provider ASAP after discharge 2. Intensive patient education regarding medications by pharmacist 3. Discharge summary: Dictation, copies to primary care, specialists and FPA <3 days 4. Notify FPA of all admissions and discharges same day 5. Patient on Plexus software
Physicians 1. Allow appointments at patient’s convenience in <5 business days 2. Send clinic visit notes to FPA, documenting appointment in <5 business days and allowing for incentive pay
because of transportation issues. Finally, we believe that readmissions can be minimized only when hospitals, ambulatory care physicians, case man-
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Notification of med list
Plexus data shared
ys da es ess t o in e n us fic 5 b f f o it < y o vis tes t p s no men Co rifie r e y Ve ag pa an tive m n se ce Ca 0 in $5
FPA nurse case managers 1. Priority to recent discharges 2. Call <2 business days after discharge 3. System of regular follow-up calls at one week and at one month and other times as appropriate 4. Meds, devices, transport, caretakers, meals/nutrition, appointments, wellness, Advance Directive & POLST, depression assessment, vision/hearing assessment, disease-specific questioning 5. Copy of care plan to primary care and appropriate specialty physicians Regular communication
Our pilot project has several philosophical underpinnings. First, we believe that when patients are able to see their own primary care physicians very soon after discharge, and when the physician is given the necessary time, information, and compensation to best manage the patient, readmissions are prevented. Second, nurse case management and supplemental pharmacy education help obviate many simple but common problems that often lead to readmission. Examples include patient errors in taking medications or inability to keep clinic appointments
Patients receive coordinated interventions
Notification of admission and discharge
Skilled nursing facility LTC The pilot did not create any systematic new interaction with nursing facilities; this is seen as a valid area for action in the future
agers, and payers work together in partnership; any single entity would be hard-pressed to achieve the same results. Fairview Southdale Hospital was chosen for the pilot because the number of annual admissions was adequate for concerted case intervention and statistical analysis. The intervention components are summarized in Figure 1. • Every patient has an FPA nurse case manager. In most cases, a case manager speaks face-to-face with the patient in the hospital and by telephone afterward. Every patient is contacted within two business days of discharge. • Nurse case managers primarily focus on ensuring that patients understand and comply with their discharge plan: filling their prescriptions, understanding and taking their medications, scheduling and completing follow-up appointments, obtaining necessary laboratory tests, etc. While addressing the problem(s) that resulted in the hospitalization, case managers scrutinize all other patient needs as well. Additional needs might include advance care plan-
ning, transportation, safety, financial resources, immunizations (including flu shots), smoking cessation, need for weight loss and healthy exercise, depression assessment, and hearing and vision assessment. Hospitalists advise all patients to visit their primary care physicians as soon as possible after discharge. Discharge summaries are dictated on the day of discharge and sent to those primary care physicians within two business days. A pharmacist at Fairview Southdale Hospital spends about 20 additional minutes with each patient before discharge, providing education regarding medications and disease management. This supplemental education exceeds what Medicare usually requires for medication reconciliation. The hospital maintains a social services database on every patient. This is shared with the nurse case manager and might include such information as lack of English skills, transportation needs, nutrition needs, and level of family support. UCare pays $50 above the
usual reimbursement to clinics that are able to see patients for post-hospital checks within five business days. • Nurse case managers notify clinics the day patients are discharged so that patients can receive priority for clinic appointments. Project demonstrates reduction of readmissions
rate in the first nine months of the program. Patients with all diagnoses who were discharged to a SNF or long-term care had a 9.4 percent readmission rate. Although we have no baseline data for comparison with these latter two groups, we believe these readmission rates seem favorable when compared with state and national Medicare data.
Projected savings According to 2009 data comAccording to UCare data, FPA piled by UCare, 16.5 percent prevented approximately 30 of FPA Medicare Advantage percent of readmissions. For seniors were rehospitalized Fairview Southdale Hospital, within 30 days of discharge these results could translate to from Fairview Southdale a reduction of more than 30 Hospital. This retrospective readmissions a analysis includyear. UCare estied only patients mates that each with a discharge We believe that readmission diagnosis that costs approxiincluded diareadmissions can mately $10,000. betes, chronic obstructive pulbe minimized only If about 12 percent of readmismonary disease when hospitals, sions could be (COPD), or projheart disease, ambulatory care prevented, ect program even if these costs could be common probphysicians, recouped. lems were not case managers, In addition related to the to constituting primary reason and payers work better care, this for hospitalizaprogram could tion. Patients in together in save $300,000 a this group were partnership. year at this one discharged hospital, for home, to a UCare patients skilled nursing alone. Net savings would equal facility (SNF), or to long-term $240,000 after subtracting procare. After the first eight gram costs. It is estimated that months of the pilot project in if all patients at five Fairview 2010, using an “apples to metropolitan facilities received apples” comparison, UCare the same interventions, reported that 11.7 percent of patients had been readmitted— $680,000 a year could be saved on UCare Medicare Advantage a reduction of approximately seniors alone. Obviously, ex30 percent in readmissions. In tending the pilot program to general, patients with one or other insurers could yield more of these three diagnoses are sicker and would be expect- much greater savings. In light of project results so far, UCare ed to have higher readmission rates than patients without one agreed to extend the project as of Jan. 1, 2011, to patients at of these diagnoses. Fairview Ridges Hospital in We designed our program Burnsville. to intervene with patients who were discharged home (and Extending the pilot hence could be case-managed to other facilities and brought back to their priMany rehospitalizations among mary care physicians). FPA’s the Medicare population are own prospective data reveal due to factors that can be amethat patients with all diagnoses liorated by using nurse case who were discharged home had a 10.1 percent readmission managers and pharmacists to
educate and assist patients, and by expediting post-hospital follow-up visits with their primary care physicians. A pilot program at Fairview Southdale Hospital has prevented 30 percent of hospital readmissions in UCare Medicare Advantage seniors, generating considerable cost savings. Fairview and UCare
remain committed to this pilot project and are extending it to other facilities. William Nersesian, MD, MHA, is chief medical officer for Fairview Physician Associates. Barry Baines, MD, is the recently retired associate medical director of UCare. Becky Schmidt, RN–BC, is manager of care delivery and clinical operations for Fairview Physicians Associates.
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chronic or serious illness of their own or a family
is accurate and under-
focus looks at information resources, the state of health literacy among the general population and in those 65 and older, the need to bridge cultural and communication gaps in conveying treatment recommendations to patients, and the comfort that a Family Resource Center provides for parents of hospitalized children.
By Anne Beschnett, MLIS
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MINNESOTA PHYSICIAN APRIL 2011
Guide to Health Literacyâ&#x20AC;? (at www. health.gov/communica tion/literacy/quickguide/), poor health literacy skills can result in lower use of preventive services, higher hospitalization rates, and less effective management of chronic health conditions. Limited health literacy poses challenges
The National Assessment of Adult Literacy found that 36 percent of adults in the United States have only basic or below basic health literacy skills. This means that more than a third of American adults may have trouble following instructions on a prescription bottle or following care instructions, which can have a negative effect on their health. In fact, only 12 percent of the population has truly proficient health literacy skills. When it comes to health information and patient education, we rely heavily on written communication, from the monographs supplied with prescription drugs to the self-care instructions received after a surgical procedure. Much of this information is written at a level that is difficult for many patients to understand. For people who may have limited health literacy skills, understanding and processing the information provided could prove to be a challenge. If you are creating or evaluating patient education materials, it is important to build resources that will be easily understood by most people, regardless of their health literacy skills. Here are a few general tips to keep in mind: â&#x20AC;˘ Write at a sixth-grade reading level or lower. There are many tools available to help you assess the reading level of patient education materials, and several are mentioned in the materials listed below. â&#x20AC;˘ Avoid the use of medical jar-
gon or â&#x20AC;&#x153;doctor-speak.â&#x20AC;? There are word lists to help you determine appropriate language for the information you are trying to convey, such as the University of Michigan Libraries â&#x20AC;&#x153;Plain Language Medical Dictionaryâ&#x20AC;? (www.lib. umich.edu/plain-languagedictionary) and the Centers for Disease Control and Preventionâ&#x20AC;&#x2122;s â&#x20AC;&#x153;Plain Language Thesaurus for Health Communicationsâ&#x20AC;? (www.plain language.gov/populartopics/ health_literacy/Thesaurus_ V-10.doc). â&#x20AC;˘ Know your audience. Donâ&#x20AC;&#x2122;t just think about the information you are trying to convey, think about your audience too. The Centers for Disease Control and Prevention has information on health marketing (www.cdc.gov/healthmarket ing/resources.htm), which includes resources and tools to assist you in finding out more about your audience. â&#x20AC;˘ Avoid information overload. Keep your message clear and include only information that is important and necessary. â&#x20AC;˘ Pay attention to design. Use images that help convey information, use at least a 12-point serif font, and leave white space so it is easier to read. â&#x20AC;˘ Ask for feedback from your audience. Once you have created material, ask a few patients to evaluate it and get their opinion on how well you communicated your information. â&#x20AC;˘ Remember that patient education materials should complement the communication between patients and members of their health care team. Be sure to take the time to listen to your patientsâ&#x20AC;&#x2122; questions and address any concerns that arise during the office visit. Resources abound
These tips are just the beginning. Whether you are looking to create new patient education materials or simply improve upon existing materials, there are many resources readily available to help guide you through the process of creating appropriate patient education materials. You can find links to these resources and more at the
University of Minnesota’s BioMedical Library’s Resources for Patient Education Materials (at http://hsl.lib.umn.edu/ biomed/help/creating-patienteducation-materials). Many of the resources listed on this page are available at no cost (some only to U of M affiliates). The Centers for Disease Control and Prevention’s “Simply Put: A Guide to Creating Easy-to-Understand Materials,” provides information on producing user-friendly and evidencebased health communication materials. The guide includes information on communications planning, forming a clear message, overall design elements, a checklist for creating easy-toread materials, and formulas for calculating readability. This guide also includes important information on cultural considerations and translation issues. It is available at www.cdc.gov/ healthmarketing/pdf/Simply_Put _082010.pdf The Toolkit for Making Written Materials Clear and Effective is an 11-part document produced by the Centers for
Medicare & Medicaid Services (CMS). While the toolkit was developed for creating and assessing materials for the CMS audience, the fundamentals are universal in nature and can be applied to the general patient audience. The toolkit emphasizes using a reader-centered approach to develop and test patient education materials and includes information on developing materials for the Internet, using readability formulas, tips for writing materials for older adults, and before-and-after examples to illustrate best practices. It is available at www.cms. gov/WrittenMaterialsToolkit The American Medical Association’s “Health Literacy and Patient Safety: Help Patients Understand, A Manual for Clinicians” focuses on raising awareness of low health literacy and improving the health literacy skills of patients by strengthening both oral and written communication skills. There is a section that explains the principles for creating and using patient-friendly written materials, including the depth
and detail of the message, the complexity of the text, format, and user testing. The manual also includes basic background information on developing non-written patient education materials, such as graphic illustrations and audiovisual materials. It is at www.ama-assn.org/ ama1/pub/upload/mm/367/ healthlitclinicians.pdf The Agency for Healthcare Research and Quality’s “Health Literacy Universal Precautions Toolkit” is an extensive resource with a broad focus on strategies to address health literacy-related issues in your practice, including advice for producing patient education materials. The toolkit (at www. ahrq.gov/qual/literacy/ healthliteracytoolkit.pdf) presents information on designing easy-to-read materials, as well as how to use health education materials effectively within the context of a broader patient education strategy. If you are looking to assess or revise the patient education materials you already have, you may want to check out resources linked to from “Health Literacy
Studies: Assessing and Developing Health Materials” website from the Harvard School of Public Health. Its guidelines for assessing materials include advice on grade level assessment, how to adjust long sentences and multi-syllabic words, and how to examine the readability of the text, charts, and graphs. The guidelines for rewriting materials step you through the planning and analysis process and suggestions for improvement based on best practices. It is at www.hsph. harvard.edu/healthliteracy/ practice/innovative-actions/ index.html Taking the time to make sure that patient educational information conveys its message in a clear and understandable way is extremely important to your patients’ health and their ultimate outcomes. The tools above are excellent resources to ensure your patients understand the information you give them. Anne Beschnett, MLIS, is the outreach librarian at the University of Minnesota’s Health Sciences Libraries, Minneapolis.
he National Institutes of Health describes health literacy as “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.” Nearly half of all adults in the United States—90 million people—cannot understand or use the information shared by their health care providers. A 1999 American Medical Association report found that low health literacy affects a person’s health status more than any other factor, including education, income, employment, or race. Evidence shows that people with low health literacy typically fail to seek preventive care; are less likely to follow treatment plans; have increased rates of hospitalization and use of emergency services; and stay in the hospital longer than someone with higher health literacy. Seniors’ literacy at risk
According to the 2003 National Assessment of Adult Literacy from the U.S. Department of
A new program helps meet the needs of older adults By Alisha Ellwood, MA, LMFT Education, adults 65 and older had lower average health literacy than adults in younger age groups, with only 3 percent at the proficient level. Seniors may be at risk for many reasons, such as: • Physical limitations (poor eyesight and/or hearing, memory problems) • Passive learning style (learning more from TV or radio, watching or listening to whatever comes to them, than from actively pursuing knowledge through reading or research) • Living longer with complicated illnesses and increased selfcare requirements • Feeling ill at ease about questioning the doctor’s expertise
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E D U C AT I O N
Improving health literacy in seniors
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MINNESOTA PHYSICIAN APRIL 2011
Currently there are more than 36 million adults age 65 and over living in the United States. This age group represents 13 percent of the U.S. population but accounts for nearly 35 percent of all hospital stays, 34 percent of all prescription medication use, and 30 percent of all over-the-counter medication use. Twenty-five percent consider themselves in fair or poor health and 33 percent have limited activity due to a chronic condition. Limited health literacy in older adults has been associated with a twofold higher risk of death, even after adjusting for demographic, socioeconomic, and other factors. A study of 17,000 community-dwelling Medicare beneficiaries age 65 and over, living in low-income neighborhoods across all 50 states, found that 40 percent of respondents reported some kind of nonadherence to a medication regimen. Of those reporting three or more chronic conditions, more than half were not taking medicines as directed (Wilson et al., J Gen Intern Med, 2007). Another study reported that 48 percent of seniors with low health literacy didn’t understand “taking medicine every six hours” as part of their discharge instructions (Williams et al., JAMA, 1995). What all this means is that the population group with the highest prevalence of chronic disease and the greatest need for health care has the least ability to read and comprehend information needed to maintain health. Low health literacy negatively affects the health and wellbeing of seniors. Yet, there are few programs that address the specific health literacy needs of older adults, and there is a lack of evidence-based programs in particular.
HeLP MN Seniors
To address these issues, the Minnesota Health Literacy Partnership and the University of Minnesota Health Sciences Libraries, together with Boutwells Landing Senior Living community in Oak Park Heights, Minn., have created a program to improve the health literacy of older adults. The goal of the Health Literacy Program for Minnesota Seniors (HeLP MN Seniors) is to help seniors and their families improve communication with their health care providers and find and assess health information on the Internet so they can become active participants in the patient care partnership. Through the work of a multidisciplinary team of health sciences librarians, health literacy specialists, public health professionals, and senior care specialists, HeLP MN Seniors has developed a model healthliteracy training program for seniors. The team created a twopart workshop series focusing on clear communications with health care providers and seeking health information on the Internet. The workshop content was developed using existing health literacy/health information literacy curricula that was modified to meet the specific needs of older adults, such as addressing reluctance to speak up or question a medical professional, the importance of talking about lifestyle changes, and sharing examples that highlighted common health concerns of seniors. The curriculum was further customized based upon the findings of needs assessment focus groups, pre- and post-tests for workshops, and an outcomes assessment survey with participants. Needs assessment findings showed that seniors feel rushed when seeing their health care providers, may not make the most of their time with providers, and are concerned and interested in health and health care reform issues. Being informed and staying informed are seniors’ biggest concerns related to seeking health information. Their most-used information source is health care providers,
followed by information sheets and Internet resources. More than 30 seniors participated in the HeLP MN Seniors pilot program. Workshop evaluation results demonstrated an increased awareness of key steps to improving health literacy and consumer empowerment. Postworkshop survey results showed that participants used several workshop tools, including creating a visit plan and looking up something on MedlinePlus, and that participants were more empowered to ask questions and more successful in finding online health information. HeLP MN Seniors has successfully gathered evidence related to teaching health literacy skills to seniors through the use of formal evaluation tools, and has applied this information to the development of a model training program. The physician’s role in improving health literacy
How can you help the seniors you care for better understand health information? Slow down. Speaking slow-
ly allows patients time to hear, process, and understand information being discussed. Spending just a small amount of time focusing solely on the patient and patiently listening can help create a more patient-centered visit. When your patients feel they are being listened to, they may engage more in dialogue about their health. Use plain, nonmedical language. Explain things to patients in everyday language. Use words that everyone can understand. Limit your use of medical terminology and jargon. Try using analogies. Use information that you know about the patient to speak more at his level and using words that he will understand. Use visual aids. Pictures, diagrams, and models can be very helpful for patients. If you don’t have access to these, try to draw your own pictures. Simple pictures are best, so you don’t have to be an artist to help your patient understand. Limit the amount of information provided—and repeat it. Focus your communication
on the “must-know” items— what are the most important things this patient needs to leave with? Consider using the AskMe-3 technique that helps ensure your patient knows the answer to these three simple questions after any office visit: 1) What is my main problem? 2) What do I need to do? 3) Why is it important for me to do this? Use the “teach-back” technique. Do not ask the patient, “Do you understand?” Instead, ask the patient to demonstrate her understanding of what you said by explaining it back to you in her own words. Here’s an example: “I know your daughter is going to ask what we talked about today. What will you tell her?” Or ask the patient to show you what he will do when he gets home. If the patient does not explain correctly, take ownership that you have not provided adequate teaching (“I may not have been clear enough in my instructions, let me try again”) and explain it again using different techniques. Create a shame-free envi-
ronment: Encourage questions. Help the patient to open up and ask questions. Sit rather than stand and explain things to the patients while they are fully dressed if possible. Validate your patient’s experience; let her know that this information can be difficult to understand and that you’d be happy to answer her questions. To learn more about the HeLP MN Seniors program, visit the Minnesota Health Literacy Partnership website at www.healthliteracymn.org /resources/help-mn-seniors. Alisha Ellwood, MA, LMFT, a project manager in health care improvement at Blue Cross and Blue Shield of Minnesota, chairs the Minnesota Health Literacy Partnership. She speaks and provides training on health literacy at events throughout Minnesota. Ellwood holds a master’s degree in counseling psychology and is a licensed marriage and family therapist, practicing at BHSI Behavioral Health Services in Eagan.
E D U C AT I O N
Bridging cultural, communication gaps to improve treatments, outcomes By Marcie Parker, PhD, MA, MPA, CFLE
ratios, and measurements so that patients can understand the risks and benefits of treatment options and suggested prevention strategies. A study of the Short Test of Functional Health Literacy in Adults found that 20 percent of participants had inadequate health literacy skills, 30 percent had marginal health literacy skills, and 50 percent had adequate health literacy skills (Center for New North Carolinians, University of North Carolina at Greensboro, 2006). These rates of low and marginal literacy have major implications for health care treatment, outcomes, and costs.
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Patient literacy and effective care
atients bring with them to the clinic characteristics that may make it difficult, if not impossible, for physicians and staff to provide effective health care. An increasingly important example is health literacy—a patient’s ability to obtain, understand, and then use the information needed to make informed health care choices. Health literacy constitutes more than reading and writing skills. It involves the ability to understand complex vocabulary and concepts, including medical terms, probability, and risk; to share accurate personal information with providers, including health history and symptoms; to make decisions about basic behaviors such as diet, prevention, wellness, and exercise; to provide self-care and manage chronic diseases well; and to navigate a complex health care system, e.g., by filling out insurance forms and finding one’s way around a hospital. Health literacy skills also include the ability to understand numerical data, percentages,
MINNESOTA PHYSICIAN APRIL 2011
Implications of low health literacy
There is a strong correlation between low literacy and poor health outcomes, frequent medication errors, missed appointments, inability to navigate the hospital or find specialists, incomplete medical histories, and an inability to read and follow directions from the physician, nurse, or pharmacist. Patients with limited health literacy skills enter the health care system when they are sicker; are more likely to have chronic conditions such as high blood pressure, diabetes, asthma, HIV/AIDS, or TB; and are less able to manage these conditions successfully than patients with adequate health literacy. People with low health literacy skills are significantly more likely than those with adequate health literacy skills to report their health as poor. They have higher rates of hospitalization and use emergency services more often. As a consequence, there are much higher health care costs associated with patients with low health literacy. Low health literacy has been shown to lead to medical errors of all kinds, poorer outcomes, lower quality of life, and death or disability, costing the health care system at least $73 billion a year. A pilot study of the California Health Literacy Initiative found there is often a mismatch between the high literacy levels required to successfully obtain quality health care and the significantly lower literacy levels of many patients. In the study, many patients had a great deal of difficulty filling out paperwork: 80 percent could not complete the paperwork, and 45 percent said that filling out the paperwork was one of their greatest health literacy chal-
lenges—so much so that they were either delaying or avoiding medical care altogether. The California study also found that although most physicians are aware that many patients come to them with low health-literacy skills, physicians have not received any formal training in health literacy. Cultural differences and health literacy: the Hmong example
Patient literacy issues are further complicated when patients from different cultures do not understand basic principles of Western medicine. For example, Hmong transplant patients do not always understand they need to stay in the hospital and must take medications for the rest of their lives. Blood pressure medication, antibiotics, medications for any chronic condition— Hmong patients often stop taking all of these or share them with friends and family if they do not understand the need to take them for a full course of treatment or for life. In working with these patients for the first time, physicians may learn that for the Hmong, the primary cause of illness is soul loss; that there needs to be both a spiritual as well as a physical treatment (so the physician may need to work in concert with the Hmong shaman to get the desired result); and that Hmong see pregnancy and childbirth as normal events and therefore do not seek out prenatal/perinatal care and shun hospital deliveries. They have no word for mental illness and believe that addictions are bad habits that the person should be able to overcome. Hmong consider blood a limited and sacred fluid, so blood draws are an issue. Another belief is that someone who loses a body part (e.g., in surgery) may not be reincarnated or will come back with a disability at the site of the lost part. When Hmong have surgery, they may be concerned that the community will label them as disabled or unmarriageable and that the whole family may become socially isolated. For Hmong, hospitals are places where unhappy ghosts steal souls; the hospital is a place where you go to die.
Strategies for working with low-literacy patients • Write down patient instructions instead of giving only oral information. • Use teach-back instruction methods, asking patients to “teach back” what they have learned rather than simply repeating it. (“Can you tell me in your own words what we have discussed?”) • Provide materials written at the third- through fifthgrade reading level. • When possible, provide reading materials in the native language of patient populations. • Provide pill boxes or other devices to encourage medication compliance. • Use commonly understood terminology, e.g., “this keeps bones strong” rather than “this prevents osteoporosis.” • Use real-life examples for teaching (e.g., actual pill labels or food items for diabetes education). • Use diagrams, pictures, audiotaped instructions, or DVDs and interactive touch-screen computer programs where appropriate. • Offer sessions where RNs meet with a group of patients to go over instructions, medications, devices, and questions related to a chronic condition (e.g., diabetes). • Work with professional, certified, trained interpreters whenever possible. Using family members There is no word for “might” in the Hmong language, so if a physician says, “You might get cancer if you don’t stop smoking,” the family takes this to mean that the patient will definitely get cancer. Older, less
to help the patient understand instructions can lead to disruptions in the family hierarchy or may cause power struggles within the family, as well as breaches of confidentiality and withholding of information by family members. Whenever possible, work face-to-face with patients, as this engenders a stronger trust relationship with the physician. Work closely with hospital, long-term care, and community pharmacists, as low-literacy patients frequently turn to them as approachable and easy to understand in explaining what the physician wants. Support lay health advocates/advisers in churches and community classes to explain prevention, wellness, nutrition, high blood pressure, stroke, diabetes, heart attack, and the impact of chronic stress. Support efforts by non-English speakers to learn English and learn about the health care system, patients’ rights, consent forms, and ways to communicate with physicians about their needs. Take advantage of training in intercultural communication for health care providers. Support library outreach programs to help overcome low health literacy and to disseminate health information to targeted audiences.
acculturated Hmong believe that even talking about a medical problem with the physician ensures that they will experience the illness. At the same time, Hmong do not consider someone ill until he or she can no longer
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get out of bed and fulfill work and family obligations. [The corollary to this idea is that if there are no symptoms, the person is not ill.] These components of the Hmong belief system can lead to taking children out of the
hospital and ceasing to comply with medications or treatments for chronic conditions. These examples point up the many difficulties that health providers must bridge in order to improve patients’ health literacy. In working cross-culturally, especially with patients with literacy issues, the office visit will be much more effective if the physician can elicit, in a short amount of time, the basics of the patient’s worldview and disease/healing assumptions. What can physicians do?
In 2004, researchers Chew, Bradley, and Boyko developed three simple questions to screen for health literacy in the physician’s office to determine if patients are functioning at a fifth-grade level or lower: 1. How often do you have somebody help you read hospital materials? 2. How confident are you about filling out medical forms by yourself? 3. How often do you have problems learning about your LITERACY to page 38
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early every day, parents enter the Family Resource Center (FRC) at Children’s Hospitals and Clinics of Minnesota feeling overwhelmed by the heightened responsibilities of parenting a hospitalized child. They are looking for information and resources to help them understand and cope with their child’s recent diagnosis. They want answers. We work alongside doctors, nurses, and other practitioners to provide a continuum of services to help families navigate the health care experience and become active, informed participants in the healing process. Parents play a critical role in helping a child heal. At Children’s, an important part of our job is to care for the parents as well as children, helping with support, information, and comfort however we can. Avoiding “Dr. Google”
Whether the diagnosis is cancer, a broken leg, or the flu, when parents are faced with the news that there is something wrong
PAT I E N T
E D U C AT I O N
Information, connection, comfort Giving families with sick children a room of their own By Kendall Munson with their child, they want information. The FRC helps families find credible, current, researchbased references to complement and augment the education provided by caregivers. And family requests for information give us an opportunity to coach them on how to search for and evaluate information on the Internet. What we want to avoid is the “Dr. Google” phenomenon, where computer users do an Internet search of medical symptoms and find reams of unreliable or downright false information that spikes their anxiety and leads to misinformed assumptions. We want the health care journey to be a positive and knowledge-rich experience, one
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in which families become savvy health care consumers. To that end, the FRC offers books (written at various reading levels), brochures, DVDs, and access to peer-reviewed medical journals to help parents and family members make sense of the challenges they are facing. Many of these resources are available both in hard copy and online, so patient families can access them both inside and outside the hospital setting. As a supplement to our services, we can connect patient families with resources outside our hospital and clinic network and act as a clearinghouse for information. For instance, if the CDC releases an educational video on proper hand-washing and it fits our purposes, we add it to our library. We also work with community groups such as PACER Center, Arc, and Early Childhood Family Education to provide families with additional help. A welcoming space
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When the beeping and buzzing of a child’s hospital room becomes too much for family members to handle, the FRC gives them a momentary break from the clinical setting and the intensity they’re living with on a day-to-day basis. Many times, families simply come down for a cup of coffee and to check their email, but may quickly find themselves asking our staff questions and browsing our resource library. For a few moments, they can spend time in a place that may make them forget that they are in a hospital. Designed with the input of patient families, the FRC aims to create a comforting atmosphere. Indirect lighting, plenty of plants, soft music, and natural wood make it feel much more like a living room than a
hospital room. Services are constantly evaluated through feedback from families to ensure that the FRC is meeting the unique needs of the diverse populations we serve. To make it easy for families to have quiet time to relax or get work done, the FRC is also connected to the sibling play area. This area is specially designed for children, with a library of books (both educational and recreational) for kids, as well as toys, games, and other activities. Families find hope and healing
One of the best ways to illustrate the FRC’s role is to share a few personal stories of how families have used the center. Story #1: A few years ago, a 4-year-old boy was admitted to our Minneapolis hospital with a rare infectious disease. Doctors had to use a new, experimental drug to save the boy’s life but, sadly, his legs and arms had to be amputated. During the boy’s hospital stay, his grandmother made many trips to the FRC, spending hours locating the latest research and information on her grandson’s disorder. We were able to walk her through this process so she could learn about the newest technologies pertaining to amputation and prosthetics. It was a world she knew little about, but she was desperate to learn as much as she could about the world in which her grandson would live. While most of her visits were focused on finding information, there were other times when she came to the FRC simply to escape. She knew she had to be a pillar of strength for her family, but she also needed private moments to sit, reflect, and grieve. She later explained that her visits helped keep her pain in check, rather than letting it engulf her. She said she needed the support of the FRC just as much as her grandson needed his medical care. Story #2: A boy was admitted to Children’s to undergo complex spinal fusion surgery. During his time in our hospital, his mother struggled to stay in touch with family and friends, making call after call to update everyone about her son’s condi-
Services available at the Family Resource Center tion. She wished there were a better way. She was a novice computer user but the FRC staff helped her set up and maintain a CaringBridge site. She could communicate with family and friends about her sonâ&#x20AC;&#x2122;s condition without making endless phone calls. Since her sonâ&#x20AC;&#x2122;s condition was so unusual, the FRC staff helped point her in the direction of research that was easily understandable and that she could share on her sonâ&#x20AC;&#x2122;s CaringBridge site. She and the visitors to the site took heart in knowing that the information came from a credible, reliable and research-based source. She was even able to share a photo of the metal rod used in her sonâ&#x20AC;&#x2122;s surgery. During this motherâ&#x20AC;&#x2122;s exhausting hospital experience, the FRC staffâ&#x20AC;&#x2122;s help with these otherwise simple tasks lightened her load so she could concentrate on her son. Story #3: A young boy from Iran, afflicted with a rare heart defect, traveled with his father
â&#x20AC;˘ Library services, including reference and research assistance â&#x20AC;˘ Laptop computer checkout and PCs for Internet and email access and other business applications (in partnership with the in-hospital Geek Squad Precinct) â&#x20AC;˘ CaringBridge, an Internet service that helps parents create personalized, secure web pages to share their childâ&#x20AC;&#x2122;s health care journey â&#x20AC;˘ Fax, photocopy, and TTY machines â&#x20AC;˘ Financial counseling and assistance with applications for Medical Assistance and other health care programs, Charity Care, Supplemental Security Income, and billing concerns â&#x20AC;˘ Beverages, snacks, and donated materials for leisure activities such as magazines, novels, cross-stitch kits, and knitting supplies â&#x20AC;˘ Information about community-based agencies that support children and families as well as local hotels, restaurants, parks, bus lines, and recreational activities across the world to have openheart surgery not available in his home country. Without a support network of family and friends, the boyâ&#x20AC;&#x2122;s father began to feel isolated. Soon after he arrived, however, he was referred to the FRC and he quickly became a regular. We tried to make him feel as much at home as possible. The Family Resource Center became a place where he could come to find a sense of community. Having found his niche within Childrenâ&#x20AC;&#x2122;s, he told us how eager he was to stay up to date
on the latest news from his home country. We collaborated with our IT department to load computers in the FRC with Persian fonts so he could check the news in his native tongue. He came in every day and was able to stay connected and feel more at ease despite being so far away from home. Empowering families
One of the educational methods Childrenâ&#x20AC;&#x2122;s is passionate about throughout the hospital is teachback, using the â&#x20AC;&#x153;see one, do one, teach oneâ&#x20AC;? method. Care pro-
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Kendall Munson is coordinator of the Family Resource Center at Childrenâ&#x20AC;&#x2122;s Hospitals & Clinics of Minnesotaâ&#x20AC;&#x2122;s Minneapolis and St. Paul hospitals.
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viders demonstrate a technique or skill to a family member, who demonstrates it back and then, in turn, can teach it to other members of the family. In this way, we help prepare families to care for their child properly and feel comfortable with the transition from hospital to home. This is especially important for parents of children with complex or chronic health issues. In many ways, the FRC exists to make families feel comfortable: comfortable asking questions about their childâ&#x20AC;&#x2122;s condition; comfortable finding quality information; comfortable in a home away from home; comfortable leaving our care and finally going home. With the help of the FRC, patient families become champions of their loved oneâ&#x20AC;&#x2122;s health care journey and can work alongside providers to ensure the best possible care.
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haramsala, India, Dalai Lama’s compound, January 2006 I am a 55-year-old internist from Stillwater, Minn., sitting on the edge of a new life. Actually, I am sitting on a boulder on the edge of a cliff not too far from my apartment at the Dalai Lama’s compound. It is early morning. Behind and to my left are the massive graywhite peaks of the Himalayas, backlit by the sun. To my right is a grove of beautiful scrub pines giving off that unmistakable smell of pine that is the same the world over. Behind and above the pines stands one of numerous stupas (mound-like structures containing Buddhist relics) that dot the Tibetans-inexile landscape. There are thousands of prayer flags attached to each stupa and they give off a gentle fluttering sound as they send off endless prayers of compassion to our world. Accompanying this quiet fluttering and the gentle squeaking of prayer wheels is an intense sense of peace and quiet. I look off to the steppes of northern India and
The intersection of two approaches to the practice of medicine By Charles Bransford, MD see an infinite layer of clouds. The color is a muted purple with ever-changing shades of indigo and blue. I can see forever. Soaring on the clouds are eagles and hawks seemingly oblivious to any need for hunting, but rather simply enjoying the pleas-
Maslow would say I was having a “peak experience” and it would be absolutely true. This scene remains as real and intense an experience for me today as it was five years ago.
Over time I came to think that looking at another culture’s health care system could give us insights into our own. ure of flight and being lifted up by ever-changing currents of air—Sunday drivers. I have found my Shangri-La, the place I have looked for since reading James Hilton’s “Lost Horizon” as a child. The eminent psychologist Abraham
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MINNESOTA PHYSICIAN APRIL 2011
The road to Tibet: glimpsing another medical culture
I have practiced traditional allopathic medicine in Stillwater since 1981. Throughout my practice, I have experienced the wonders of our health care system—from the discovery of the cause of Lyme disease, which turned out to be an ongoing epidemic in our area, to the miracle of giving streptokinase to a young man having a massive myocardial infarction before my eyes, and watching the infarction stop in its tracks. These medical advances required years of research by thousands of individuals and show the potential strength of our health care system. Yet, I have also seen the thousands of people we simply have not been able to help—because of cancer, chronic fatigue, fibromyalgia, headaches, irritable bowel syndrome, depression, anxiety, and chronic pain, among many other illnesses. Over time I came to think that looking at another culture’s health care system could give us insights into our own. When I traveled to the Dalai Lama’s compound in 2006, it was as a student in a graduate-level course on Tibetan medicine that was offered by the University of Minnesota and led by Miriam Cameron, PhD, of the Center for Spirituality and Healing. We brought needed medical sup-
plies (antibiotics, oxygen saturation monitors, EKG machine, bandages, etc.) to the Tibetans. In return, we were given the gift of education from the Dalai Lama’s leading physicians at the Men-Tsee-Khang, often called “the Harvard of Tibetan medicine.” The Tibetan doctors had preserved as much as they could of their rich 2,000+-year heritage by transporting their ancient texts from Tibet, across the Himalayas, to Dharamsala, where they proudly house them in a museum. They freely shared their ancient, accumulated knowledge with us. Tibetan medicine shares elements of Chinese, ayurvedic, and yogic systems of care but has evolved in its own unique way, in part because of its isolating geography. Tibetan medicine is a holistic philosophy of care combining psychological, spiritual, and physical components. It holds that for each person, good health is achieved by understanding those components and how to keep them in balance. Physicians prescribe diets, meditations, types of yoga and exercise, and specialized herbs. (In Tibet, it is common for doctors to grow their own herbal remedies. They know which ones have the best growing season, richest soil, etc.— kind of like cultivating grapes for a fine wine.) A fundamental principle of Tibetan medicine is that in order to treat their patients, doctors must live the balanced life they preach. The Buddhist philosophy is deeply embedded in the daily life of the doctors (and other medical staff), with prayers at the temple as well as prayers for individual patients. This deeply spiritual approach to medical practice aids Tibetan doctors in making an emotional and spiritual bond with their patients. They are experts in physical diagnosis, intuition, empathy, and making a “heart connection.” In Minnesota: applying new knowledge, experience
In both small and large ways, my experience with Tibetan medicine, beginning five years ago, changed the way I practice medicine in the here and now:
Conference to bring Tibetan medicine to Minnesota 1. I stopped wearing my white coat. I just became tired of explaining the “white coat syndrome” to all my anxious, hypertensive patients. There is a vast array of positive and negative cultural mythologies attached to the white coat, let alone the power differential it implies. Communication is tough enough without it. 2. Somehow, the Tibetan doctors gave me the courage to pursue a second subspecialty that I had been deeply drawn to, but didn’t quite have the courage to actually do—hospice and palliative care medicine. Tibetan doctors and the Tibetan culture do a wonderful job with death and dying. Here in the U.S., we have a long way to go in coming to grips with death. After World War II, my parents’ generation wanted to protect their children from death, and they were quite successful. Unfortunately, this has left us with a society that doesn’t understand the dying process. My patients and their families don’t know what the experience of death is like. This leads to a multitude of unnecessary treatments at the end of life that increase both medical expense and individual suffering. When I ask patients if they know they are dying, they will typically say no, and I believe them. Tibetans have a better internal understanding of death. 3. I began to study and practice mind/body medicine. My passion is yoga. At Stillwater medical group, we offer mind/body groups every season to our patients and staff. In these groups we develop our own personal healing stories through practices such as life maps, guided imagery, yoga, and meditation. We incorporate lots of music and poetry. Tenzin Nambul (a Tibetan doctor and friend) attended one of our groups. He said he would like to start a similar group back in Dharamsala, as it had never occurred to him to actually talk about his own personal meditation experience with other people. They
Minnesota is home to the second-largest population of Tibetan immigrants (after New York City). It is also the home of the University of Minnesota’s Center for Spirituality and Healing and the Tibetan Healing Initiative, which is expanding the center’s work involving Tibetan medicine and yoga in four areas: research, education, outreach, and integrated care. On May 9, the Second International Tibetan Medicine Conference: Healing Mind & Body will be held at the University of Minnesota with the express purpose of introducing Tibetan medicine to the Minnesota medical community. The conference will bring practitioners of Tibetan medicine from the Men-Tsee-Khang (the Tibetan Medical Institute of His Holiness the Dalai Lama), in Dharamsala, together with Minnesota health practitioners. The event will be co-hosted by the Tibetan American Foundation of Minnesota and the U of M’s Center for Spirituality & Healing in collaboration with the Men-Tsee-Khang. Continuing education units will be available for the conference. More information about the conference is available at www.dalailama.umn.edu/may9/home.html. just do it; it is part of their soul. 4. Being with the Tibetan doctors, practicing meditation and yoga, and studying their healing system have changed the way I relate to and experience my patients. Tibetan medicine/culture has helped to change my consciousness, by opening me up to an awareness of the collective unconscious of humanity. The most superficial layers of the collective unconscious hold all the rules of our culture—stop at red lights, shake hands when you meet someone, keep a certain physical distance, form a line when more then one person is waiting for something. It is all the cultural traditions we follow without thinking on a physical, psychological, and spiritual level. Below that is this wonderfully complex collective unconscious that we all share. At its deepest level, the collective unconscious is the reservoir of our human experiences as a species, a kind of knowledge we are all born with (think of the universal myths and symbols that psychiatrist Carl Jung elegantly described in his writings). At the center of our consciousness resides the calmness we were born into, called “nonjudgmental awareness” (or, in Western psychology, mindfulness). It is in the collective unconscious that so much medical healing occurs—and it is in this very place that putting two healing systems together can be so valuable. For myself, the practice of meditation and yoga
has made it easier for me to slip in and out of my collective unconscious and share it with my patients. I think we go to a common place together that gives healing a better chance to germinate. Broaden your perspective
The remarkable culture of Tibetan medicine has a great deal to offer us Western practitioners. The upcoming Second International Tibetan Medicine
Conference, to be held May 9 at the University of Minnesota (see sidebar), offers an opportunity for physicians and other health care providers to learn what Tibetan medicine is all about. At a roundtable discussion that I am chairing, each member of the panel will have a unique perspective on the interplay of Western and Tibetan medicine. The panel will include traditional Tibetan doctor, a Tibetan who is a family practice physician at Hennepin County Medical Center, a Tibetan doctor who is studying Western medicine, and me—a Western physician with a strong interest in integrating Tibetan medical tradition into my medical practice in Minnesota. Think about attending the conference. It’s certain to broaden your own perspective on how East and West meet in the practice of medicine. Charles Bransford, MD, is an internal medicine and hospice/palliative care physician at Lakeview Health System in Stillwater, Minn.
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I N T E R N AT I O N A L
Forging links to improve care
irst Hospital of Lanzhou University is the premier health care facility in western China’s Gansu Province, which is home to 30.7 million people. The 1,050-bed hospital is in Lanzhou, a city of approximately 3 million people. Children’s HeartLink, a nonprofit organization based in Minneapolis, works with health care centers in underserved regions of the world to promote sustainable and accessible cardiac care for children with congenital or acquired heart disease. Over the past 10 years, these two groups have forged a partnership dedicated to improving cardiac care for the children of Gansu Province. Children’s HeartLink currently works with partner sites in eight countries: Brazil, China, India, Kenya, Malaysia, South Africa, Ukraine, and Vietnam. Unlike traditional medical missions, Children’s HeartLink’s cardiac training visits focus on teaching, mentoring, and developing a strategic plan to foster sustainable improvement by local cardiac teams. Children’s
Collaborative efforts focus on pediatric cardiology By Lee Pyles, MD, James St. Louis, MD, and Andreas Tsakistos
HeartLink pays the travel expenses for medical staff to conduct the training, and the medical team members volunteer their time.
addition to maturing to the status of an established pediatric cardiovascular center. Over the past 10 years, Children’s HeartLink has collaborated
A shared goal of the partnership is to position the First Hospital of Lanzhou University to become a training program for other health centers in the region. Children’s HeartLink has begun a dialogue with its centers around the world to encourage them to work toward becoming a regional or national training center as the ultimate goal, in
with First Hospital of Lanzhou University to improve the knowledge and technical skills of the local cardiac team and to help them transform their program into a sustainable regional center of excellence in pediatric cardiac care. A shared goal of the partnership is to position the hospital to become a training program for other health centers in the region, thereby extending quality cardiac care to more children in need. A volunteer cardiac training team
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In October 2010, a team from the University of Minnesota Amplatz Children’s Hospital Heart Center completed a fiveday cardiac training visit to First Hospital. This trip was the first Children’s HeartLink visit for a full medical team from the University of Minnesota. It was led by James St. Louis, MD, a pediatric cardiac surgeon with University of Minnesota Physicians (UMP) and an associate professor in the Division of Cardiothoracic and Vascular Surgery at the University of Minnesota. For UMP pediatric cardiologist Lee Pyles, MD, this was a third trip to Lanzhou. Also part of the volunteer team was Jeff Paurus, MS, RN, a
nursing instructor at University of Minnesota Amplatz Children’s Hospital and at Minneapolis Community and Technical College. Paurus has traveled to Lanzhou many times over the past eight years to volunteer in the hospital’s pediatric cardiac intensive care unit. Other members of the volunteer team included Raj Sarpal, MD, cardiac anesthesia; Marie Steiner, MD, pediatric critical care; Kris Nielsen, CCP, perfusion; Karen Robeck, RN, pediatric critical care; Paul Paulisch, RN, pediatric critical care; and Cindy Hacker, RRT, pediatric respiratory therapist. Pediatric cardiovascular surgery at First Hospital
First Hospital hosts the leading pediatric cardiac surgery program in this part of China, performing 250 to 350 surgeries each year. These operations include closure of atrial and ventricular septal defect (ASD/VSD), repair of tetralogy of Fallot (TOF), semilunar (aortic and pulmonary) valvuloplasties, and repair of coarctation of the aorta. No newborn surgeries are performed, as in China these surgeries are currently limited to centers in large cities such as Beijing and Shanghai. The youngest child to routinely undergo a corrective operation, such as VSD, at First Hospital is 8 months of age. The surgical success rates are excellent and Lanzhou staff would like to perform more complex operations. First Hospital intends to expand its surgical program capabilities to include correcting congenital cardiac anomalies in newborns. Another of the hospital’s goals is to develop a strategic plan for its surgical program that will encompass training opportunities, program development, and quality improvement. The 2010 training visit to Lanzhou
In comparison with past visits, measurable improvements in various aspects of pediatric cardiac care were noted during this recent visit. First Hospital’s intensive-care nursing showed continued improvement, and the surgical group showed progres-
The International Quality Improvement Collaborative sive growth in complexity and numbers of operations. The echocardiography physician team also had expanded, and the team’s expertise is steadily improving. In preparation for the 2010 training, and prior to the arrival of the volunteer team, the First Hospital echocardiography group evaluated 19 patients— with no detection of major anatomic diagnostic errors. In repeat echocardiographic exams of the same 19 patients by the University of Minnesota Amplatz Children’s Hospital team, two patients showed minor variations and one child exhibited elevated pulmonary vascular resistance prohibitive for operative VSD closure. [It should be noted that some physiologic assessments and interpretations of the hemodynamic estimates from echocardiography were modified.] During the 2010 visit, the two hospital teams focused on two specific surgeries: atrioventricular canal defect and repair of VSD in younger infants. Dr. St. Louis demonstrated a repair of a partial atrioventricular canal defect for the First Hospital surgeons and, along with Dr. Pyles, demonstrated how they review a child’s status at the conclusion of an operation with the aid of transesophageal echocardiography. In a morning series of didactic lectures, Dr. St. Louis shared with the First Hospital surgeons his approach to atrioventricular canal defect, including choice of operative technique and troubleshooting in the operating room. The University of Minnesota Amplatz Children’s Hospital pediatric intensive care team—including Marie Steiner, MD, Cindy Hacker, RRT, and the nurses—lectured on postoperative care provided to children the week following surgery. [The lectures were translated by First Hospital staff surgeon Tang Hanbo, MD, with assistance from Quan Ni, PhD, of Minnesota-based Inspire Medical.] In addition to working with the hospital’s cardiac health care providers on specific procedures, the University of Minnesota Amplatz Children’s Hospital team compiled a group report
A group of cardiac centers from around the world have banded together under the leadership of Children’s Hospital Boston to monitor, track, and share aggregate data regarding their outcomes, and to collectively explore opportunities for quality improvement. The centers review results and discuss the issues of infection control and 30-day operative outcomes. Initially, five international centers collaborated to submit data to this database at Children’s Hospital Boston. Currently, 14 sites participate in the collaborative. Bistra Zheleva, assistant director of international programs at Children’s HeartLink, and Dr. Pyles are participating in the advisory committee for the project. Children’s HeartLink is sponsoring five additional surgical programs that began to submit data in 2010. The data submission includes standard components such as surgical procedure, age, weight, survival, and length of stay, as well as wound-infection rates. Children’s Hospital Boston is also providing educational webbased seminars for participating sites throughout the year to facilitate distance learning, dialogue, and dissemination of knowledge and skills. The webinars are part of learning modules focusing on three key drivers of reducing 30-day mortality in pediatric cardiac surgery: team-based practice through nurse empowerment, reducing surgical-site infections, and safe perioperative practice. for First Hospital that outlined the hospital’s strengths, weaknesses, and areas for improvement. To further improve cardiac surgery at First Hospital, the volunteer team also introduced the International Quality Improvement Collaborative (see sidebar) and encouraged the First Hospital surgical group to participate in the program. Further plans for the cardiac surgery program
During the 2010 visit, the First Hospital surgical group presented the strategic plan it had developed over the past year, as an outgrowth of a strategic planning process that was conducted during the 2009 visit. To expand the range of operations it can provide, the First Hospital group will plan and offer additional training for key personnel—in China, at University of Minnesota Amplatz Children’s Hospital, and elsewhere. These trainings will expand and enhance First Hospital’s expertise in diagnosis of congenital heart disease by providing more in-depth knowledge of diagnostic modalities, including echocardiography, cardiac catheterization, cardiac magnetic resonance imaging, and computed tomography. Because the First Hospital pediatric cardiac surgery team has not operated on newborns to date, additional trainings will focus on cardiac surgery for infants under 6 months of age (including neonates and in-
fants). These training sessions will include information on extracorporeal perfusion technology, anesthesiology, and pediatric and neonatal critical care.
renewed. The process of evaluating best practices at home and advising the developing center to institute improvements produces constructive introspection. The volunteers unanimously report they receive much more than they give. The downside of a weeklong medical training visit is the feeling that many more children could be helped if the volunteer team could stay longer. The goal of the training partnership with First Hospital’s pediatric cardiac surgery team is to bring that desire closer to reality. Lee Pyles, MD, is a pediatric cardiologist with University of Minnesota Physicians (UMP) and an associate professor of pediatrics and emergency medicine at the University of Minnesota. James St. Louis, MD, is a pediatric cardiac surgeon with UMP and an associate professor in the Division of Cardiothoracic and Vascular Surgery at the University of Minnesota. Andreas Tsakistos is international programs coordinator at Children’s HeartLink.
Post-visit: rewards and reflection
From a personal perspective, the volunteers reported they came home energized, focused and
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Footprint from page 15 cians take an unusual step in today’s medical practice: Stop guideline-mandated interventions. Consider, for example, self-monitoring of blood sugar levels. The best available evidence, as recently summarized by the American Diabetes Association Standards of Care for 2011, indicates that this practice is of benefit, albeit small, for patients with type 2 diabetes taking insulin (to improve the safety of this treatment) and for patients who find value in seeing the impact of changes in their lifestyle or treatment on sugar levels (to improve the efficacy of this treatment). Thus, the routine use of self-monitoring increases the workload importantly—and for many patients, including John, it will not produce a big enough benefit to justify it. John’s situation would require that his clinician engage him in identifying John’s goals and prioritizing the available treatments according to his ability to achieve those goals. The goals need to be stated in ways
that patients can conceptualize and “own”: We should not discuss LDL, HbA1c, or bone density. Rather, we should focus on what we call patient-important outcomes: living independently, being able to care for loved ones, being able to live unhindered by complications of the diseases or treatments, avoiding premature death. Our research group reported in JAMA in 2010 that only 1 in 20 trials in diabetes report the effect of treatments on patientimportant outcomes, so clinicians may not know whether recommended treatments could help John until trials measuring patient-important outcomes are completed and published. For example, since 2008 it has become clear that tight glycemic control is unlikely to favorably affect John’s quality of life, life span, or risk of most diabetes complications. This type of research could help John’s physi-
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MINNESOTA PHYSICIAN APRIL 2011
cian answer important questions: What treatments would help John accomplish his goals? What other treatments are less likely to help and could be discontinued or deployed only after John has mustered greater capacity? Changing the way we practice medicine The agenda of minimally disruptive medicine should sound like the good medicine we all want to practice: judicious use of evidence-based interventions that are consistent with the patient’s context, values, and preferences. However, the medicine we actually practice today is the medicine of overtesting and overtreatment in pursuit of diseasecentered outcomes to ensure that we score high on reported measures of “quality of care,” that we get certified as “providers,” and that we get bonuses in pay-for-performance schemes. These costly practices contribute to health care inflation, yet also to the well-being of the health care industry. Everyone appears to benefit—except patients like John. The practice of minimally disruptive medicine (see sidebar on p. 15) could be placed in the center of medical home initiatives. We see optimizing health care to fit the patient as a key function of medical homes, one in which the clinician should not be alone. We see roles for social workers (who could help John deal with his mortgage and work challenges and get help for his daughter by harnessing community resources), pharmacists (to modify the medicines to once-a-day preparations, discontinue the large-dose vitamin D preparation, and stop the proton pump inhibitor that appears no longer necessary), primary care nurses (to ensure appointments are consolidated and scheduled conveniently around John’s schedule so he can avoid taking time off work), and other team members (care managers to ensure adequate treatment of depression, counselors in the
community who can help patients develop resilience through mindfulness meditation). Where better to do this than in the context of true patient-centered medical homes? In the era of evidence-based medicine, minimally disruptive medicine brings to the fore the difficult challenges of caring for patients and the skills necessary to diagnose the context—both internal and external—and to engage patients in a shared approach to designing their treatment program. This form of personalized medicine seeks to optimize the treatment workload, enhance patient capacity, and reduce the burden of illness and the burden of treatment, while in pursuit of the patient’s goals for care and life. Minimally disruptive medicine seeks to swing the pendulum back from disease-centered optimization of systems and quality that pit clinicians against patients who “fail” to achieve quality metrics. We hypothesize that minimally disruptive medicine will move us closer to a patient-centered practice that can improve health professionals’ satisfaction by realigning clinician goals with patient goals, improve outcomes and efficiency by improving adherence to effective therapy, and allow clinicians to fundamentally care for and about the patient. Everything else will follow—including a smaller health care footprint. To engage in discussions about minimally disruptive medicine or partner with us to explore this concept, visit http://minimallydisruptive medicine.org. Victor M. Montori, MD, MSc, is a professor of medicine in the Department of Medicine and director of health care delivery research for the Knowledge and Evaluation Research Unit in the Department of Health Sciences Research at the Mayo Clinic, Rochester. Acknowledgment: I would like to thank my colleagues Nilay Shah, Carl May, Frances Mair, Annie LeBlanc, Nathan Shippee, David Eton, Kathleen Yost, Katie Gallacher, Mark Linzer, and the growing community of thought and hope that is advancing minimally disruptive medicine and working to reduce the health care footprint. I hope to have presented correctly the best of their ideas, but the flaws here are only my own.
Minneapolis VA Medical Center Internal Medicine or Family Practice Physician The Minneapolis Veterans Affairs Health Care System (MVAMC) is seeking BE/BC Family Practice or Internal Medicine primary care providers at several community-based outpatient clinics to provide primary care services during daytime hours Monday through Friday (no weekend duties or night call). Locations include Superior,Wisconsin; Rice Lake,Wisconsin; Rochester, Minnesota; and two Twin Cities metro area clinics, Maplewood and a new clinic in the Northwest Metro area. Competitive salary, recruitment incentive possible, and performance pay. Send CV and application to: Veterans Affairs Medical Center Human Resources Management Service Attention: Brittany Buck One Veterans Drive, Minneapolis, MN 55417 or, e-mail Brittany.Buck@va.gov
Opportunities available in the following specialty: Olmsted Medical Center, a 150-clinician multi-specialty clinic with 10 outlying branch clinics and a 61 bed hospital, continues to experience significant growth.
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of Registration and a minimum two years of direct work or intern experience. • ER is staffed 24/7 by skilled PAs • OB is required; C-section training is a bonus • Guaranteed competitive salary Mille Lacs Health System is an integrated healthcare organization that tends to the lifelong healthcare needs of all its patients. Come live where there is excellent hunting, fishing, and cross-country skiing. Practice medicine where your skills and experience can be fully utilized, and where you can make a difference.
Please send inquiries to; Rob Stiles; 320-532-2606 email@example.com or Dr. Tom Bracken; firstname.lastname@example.org ONAMIA • ISLE • HILLMAN • GARRISON • MILACA
Come home. Where organizational strength lies in the diversity of people who call SANFORD HEALTH – home. Sanford Health – Fargo Region is redefining health care. Serving northwestern Minnesota and eastern North Dakota, we offer innovative technology, support of a multi-specialty organization, and dependable colleagues. Excellent practice opportunities exist in family-oriented communities that offer year-round outdoor activities, cultural events, and superior education districts that will allow you to balance your work & life. Our employment model features competitive salaries, a comprehensive benefits package, paid malpractice insurance, and a generous relocation allowance. Contact: Kathryn Norby, MHA Physician Recruiter Phone: (701) 280-4851 Kathryn.Norby@sanfordhealth.org
Cardiology Dermatology ENT Emergency Medicine Family Medicine Gastroenterology Hospitalists Internal Medicine Neurology Occupational Medicine Oncology Orthopedic Surgery Pediatric Specialties Psychiatry Pulmonology (Sleep) Rheumatology Urology
I N T E R N AT I O N A L
alk with public health leaders today and you will likely hear something like this: “Global health is public health. Public health is global health.” Our notion of “global” is forged in the blazing pace of the 21st century in which all nations share the same chronic diseases, and pandemics can spread worldwide in hours. But Minnesota has a 140-year history of working to improve the health of the state, the nation, and the world. In 1862, Congress passed and President Lincoln signed what would turn out to be one of the important pieces of 19thcentury lawmaking: the Morrill Land Grant Act. The idea was that public universities in undeveloped parts of the country would generate knowledge and learning to create flourishing economies of educated, healthy, and prosperous people. After the Civil War, the University of Minnesota responded to the Morrill “tonic,” emerging in the 1870s with its first permanent faculty and president, William W. Folwell. It set about the mis-
Building a global health portfolio Expanding on the legacy of Minnesota’s public health pioneers By John R. Finnegan Jr., PhD
sion of helping to transform Minnesota, which it has been doing ever since. Health was an important element of this mission. Folwell, a Civil War veteran, appointed his comrade-in-arms, Dr. Charles N. Hewitt, as the first professor of public health in the university (and, very likely, in the nation). Hewitt was a physician, innovator, and global thinker who pushed the boundaries of prevention and public health. He visited Louis Pasteur in France and Robert Koch, who helped frame the “germ theory” of disease, in Germany. Hewitt built relationships with scientific colleagues back East in the U.S., and initiated vaccine production
in Minnesota and one of the first disease surveillance systems in the country. As a university faculty member, the founding secretary of the State Board of Health (forerunner of today’s Minnesota Department of Health), and an early member of the Minnesota State Medical Society (MMA forerunner) that sponsored the public health legislation, Hewitt was a key leader. He and others created the organizational infrastructure that established Minnesota as a bellwether for health innovation. From the beginning, global connections were important. Zip forward to the present. Most developing nations of the 21st century know very well that
research universities and higher education are important pathways out of the poverty trap. And they want to partner with the best systems of higher education, especially the land-grants like the University of Minnesota that haven’t forgotten their mission to transform learning into impact on people’s lives. Launching the “One Health” initiative
While the university has been “global” for a long time, today it is engaged in formal planning about how best to shape its strengths in partnership with global and peer institutions. What is emerging in these discussions so far is the idea of global “portfolios” with a broad, inclusive focus on four areas key to human development and achievement: food, health, education, and economic development and sustainability. Within each portfolio, one can already find many projects, programs, and initiatives that faculty across the university have been pursuing for many years with PORTFOLIO to page 34
Minneapolis VA Medical Center Look for the friendly doctor in a MN based physician staffing service ...
Physicians: • Let us do your scheduling & credentialing • Paid Malpractice • Physician Friendly • Choose where and when you want to work • Competitve Rates • Courteous Staff
Clients: • Prevent loss of revenue • BC/BE physicians • Competitive rates • Quality coverage • Malpractice coverage paid by us
P-763-682-5906/F-763-684-0243 email@example.com www.whitesellmedstaff.com
MINNESOTA PHYSICIAN APRIL 2011
Medical Director of Community-Based Outpatient Clinics The Minneapolis VA Medical Center (MVAMC), affiliated with the University of Minnesota, is seeking a dynamic leader for the position of Medical Director of the Community-Based Outpatient Clinics (CBOCs).The Director supervises the clinical operations and providers of 10 clinics throughout Minnesota and Wisconsin, and oversees the development of several new clinics in both metropolitan and rural settings.We seek a physician with experience in ambulatory medicine and administration who will provide leadership and clinical duties for the CBOCs.The CBOCs provide primary care, and mental health care onsite and through telemedicine to more than 20,000 veterans.This position would include an academic appointment at the University of Minnesota. Applicants must be board-certified in Internal Medicine and experience working in VA facilities is preferred. Competitive salary, recruitment incentive, and benefits with performance pay. Send CV and application to: Human Resources Management Service Attention: Brittany Buck MVAMC One Veterans Drive Minneapolis, MN 55417 or, e-mail Brittany.Buck@va.gov For additional information, please call 612-725-2060. Equal Opportunity Employer
NO ONE GOES THROUGH MEDICAL SCHOOL TO PR AC TICE INSUR ANCE.
Remember graduating from college and passing your MCATs, then spending the next four years of your life getting through classes like clinical epidemiology, neurology and radiology so you could practice medicine? Today’s financially driven managed care environments make having a practice difficult. Hurrying patients in and out of the office to make a quota and going into negotiations to prescribe treatments that don’t coincide with a patient’s policy aren’t practicing medicine. We’d like to prescribe a solution: Move your profession to the United States Air Force. Get back to what’s important — practicing medicine.
Physician-owned, multi-specialty group practice with 100+ providers, has an exceptional opportunity for a BC/BE Neurologist to join two others. You will see patients with a full spectrum of disease states and have an opportunity to participate in clinical trials. We provide staff and support for EMG, Lumbar Punctures, Polysomnograpy, Botox, Occipital Block and a full-time, plus a registered EEG technologist. We offer a first year income guarantee with a production incentive income thereafter; service area 300,000; great payer mix; $6,600 annual CME business allowance; potential shareholder status after one year; 401(k); profit sharing. Our picturesque community, population 50,000+ provides a great setting to practice medicine and raise a family plus year-round indoor/outdoor recreational at nearby lakes and resorts; excellent public and private schools with award winning academics and sports teams; state university, two colleges, community college, business school with combined enrollment of over 18,000; shopping mall with four anchor stores and new retail construction. Just over an hour from Minneapolis/St. Paul southern metro; easy access to international airport. No J-1 openings. Contact Dennis Davito, Director of Physician Placement, Mankato Clinic, 1230 East Main Street, P.O. Box 8674, Mankato, MN, 56002-8674; phone: 507-389-8654; fax: 507-625-4353; email: firstname.lastname@example.org.
1-800-588-5260 ©2009 Paid for by the U.S. Air Force. All rights reserved.
Family Practice Urgent Care Dynamic, independent 3 location, single-specialty practice in northwest Minneapolis suburbs is seeking additional associates for its Rogers site and has Full Time/ Part Time shifts in the Crystal and Rogers Urgent Care. • • • • •
Partnership opportunity after 2 years Competitive salary with incentives Excellent benefits, 401k/employer paid pension Practice at one site/one hospital Physician-owned
Please contact or fax CV to: Joel Sagedahl, M.D. 1495 Highway 101 North, Plymouth, MN 55447 763-504-6600 • Fax 763-504-6622
Sioux Falls VA Medical Center “A Hospital for Heroes” Working with and for America’s Veterans is a privilege and we pride ourselves on the quality of care we provide. In return for your commitment to quality health care for our nation’s Veterans, the VA offers an incomparable benefits package. They all come together at the Sioux Falls VA Medical Center.
• Pulmonologist • Orthopedic Surgeon • Oncologist
To be a part of our proud tradition, contact:
Human Resources Mgmt. Service P O Box 5046 Sioux Falls SD 57117 605-333-6852
Visit our website at www.NWFPC.com
www.siouxfalls.va.gov APRIL 2011
At left: University of Minnesota students and faculty stop in a fishing village on Uganda's Lake Edward, within the Queen Elizabeth National Park, and see "One Health" in action (note the elephant in the background). Middle: University of Minnesota students studying at a Global Health Institute in Uganda last August make a stop at the equator, which cuts across the lower one-third of the country. At right: University of Minnesota students visit a community hospital in Fort Portal, Uganda, located about 200 miles west of the capital Kampala. It is one of only three hospitals as RESPOND will work to: serving the local area's 2 million people.
Portfolio from page 32 global partners. But the institutional planning happening today brings the potential of connecting and synergizing disparate activities, improving our effectiveness as global university partners and sharpening our considerable assets in tackling some of the greatest challenges facing the world. Hewitt’s legacy launching global health at Minnesota is
well captured in this process. To illustrate, let me share an example of a recent major initiative in the University of Minnesota global health portfolio. In late 2009, when the University of Minnesota was among a team of recipients of a five-year, $185 million contract from the U.S. Agency for International Development (USAID), the College of Veterinary Medicine (CVM) and the School of Public Health (SPH) were poised
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MINNESOTA PHYSICIAN APRIL 2011
to take a leadership role in training multidisciplinary teams of health professionals to prepare for and respond to emerging disease outbreaks. The initiative from USAID directed the planning to take place with local partners in several “hot spots” around the globe where the conditions are ripe for an animalborne disease to make the jump to humans. Specifically, over the course of the five-year project, the team on the project known
• improve the training and response capacity for zoonotic disease outbreak identification, investigation, analysis, and control within countries and regions • strive to improve the coordination among public and private interests involved in an outbreak • support in-country outbreak response activities PORTFOLIO to page 36
Growing multi-specialty group practice in Northern Minnesota is looking for a BC/BE Family Practice Physician, Internal Medicine Physician, Emergency Room Physician, OB/GYN Physician, Urologist as well as an Orthopaedic Surgeon. Join an existing group practice and take over existing practices from departing physicians. Grand Itasca Clinic & Hospital in Grand Rapids, Minnesota has recently opened a new state of the art clinic & hospital. Excellent salary guarantee with outstanding income potential, full benefits and sign-on bonus. Community located in the beautiful northern Minnesota lakes area.
Contact: Gail Anderson (218) 999-1447 email@example.com.
Mercy Medical Center-North Iowa is at the center of a 9 hospital/ 44 clinic premier rural health care delivery network. Enhance your personal and professional life with low cost of living, competitive compensation and benefits, and a financially stable and growing health system. Practice where your skills are appreciated. Live where you and yours will flourish as you become rooted in a lifestyle second to none!
- Family Medicine (OB) - Pediatrics - Neurology - Occupational Medicine - Family Medicine - Ophthalmology - Neurosurgery
- Hospitalist (IM) - Psychiatry - Urology - Chief Medical Informatics Officer - Family Medicine Faculty - Emergency Medicine
- Rheumatology - Hematology/ Oncology - Bariatric Surgery - Vascular Surgery - Palliative Medicine Fellowship Director - Hospice Director
Contact Denise Siemers, Physican Recruitment Mercy Medical Center â&#x20AC;&#x201C; North Iowa Phone: (888) 877-5551 or (641) 428-5551 CV to: PRACTICE@mercyhealth.com
Portfolio from page 34 • introduce new technologies to help improve a country’s response to an outbreak It’s clear from everything we know about emerging diseases that a multi-disciplinary approach is critical. The new framework we are using is called “One Health.” It merges the interests of human and animal health and the environmental conditions within which they interact to shape health for good or ill. The interaction of human and animal health in the environment is a complex “dynamic adaptive system” that requires interdisciplinary collaborations and communications in all aspects of health, from clinical to population and community approaches. While the specifics of One Health are formative in how it is brought to bear on global challenges, we think the potential benefits of collaboration with global partners in building capacity are immense— on both sides. One of the first activities we undertook through the USAID
initiative was a two-week Global Health Institute last August in Kampala, Uganda, one of the initiative’s hot spots. Along with faculty colleagues from the U of M’s CVM and School of Nursing, and from Makerere University, in Kampala, SPH faculty taught a host of courses spanning zoonotic disease, epidemiology, applied biostatistics, risk communication, participatory research, and global public health. [A video from the Global Health Institute is at www.sph .umn.edu/outreach/go /gouganda.asp.] Twelve U of M students from the schools of public health, nursing, and veterinary medicine joined 65 students and junior faculty from universities in seven East African countries at the institute, which was sponsored, in part, by the U of M. During the institute, participants traveled to rural Uganda to visit Queen Elizabeth National Park, a health center, and a fishing village on Lake George—where they witnessed an orphaned wild elephant living and mixing with villagers (see
Bringing the best to you
photo on p. 34). The situation puts the villagers in danger of being trampled by an unpredictable wild animal, as well as mutual exposure to pathogens. Closer to the topic of emerging diseases was the sight of water buffalo and hippos practically sitting on fishing canoes. This proximity obviously creates many opportunities for the wild, the domestic, and the human to interact, raising the potential to spread disease or even to incubate new ones. Getting up close and personal with this human-animalenvironment interchange “hot spot” illustrated the value of approaching the prevention of emerging infectious disease through a One Health lens. It was a true “aha!” moment for Minnesota participants as well as their African counterparts. And it was gratifying for the faculty members from the U.S. and Africa to witness the exchange of ideas and solutions among the participants. Indeed, we have much to learn from our African colleagues. We have much to share, too.
Reaffirming the land-grant mission
From the beginning, Minnesota medical and public health pioneers like Charles Hewitt recognized that health is global: What happens in the villages and cities of Africa and other places will sooner or later shape what happens in the villages and cities of Minnesota. Just ask our Latino, Asian, and African immigrants and refugees who have enriched this state with their cultures, hard work, and dreams. Higher education helped transform our nation in areas such as health. Now we can “pay it forward” to assist others in building the capacity they need to sustain a healthy, educated, and prosperous people. In these global engagement efforts, we are reaffirming our own landgrant mission around the world through research, learning, and service. John R. Finnegan Jr., PhD, is dean of the University of Minnesota School of Public Health.
Come to the Alexandria Lakes Area... • Dermatology • Emergency Medicine • Family Medicine • Internal Mdicine • Pediatrics
1c``S\b =^^]`bc\WbWSa W\( 4O[WZg ;SRWQW\S 7\bS`\OZ ;SRWQW\S >SRWOb`WQa Stillwater Medical Group is an 85 Physician multi-specialty group practice affiliated with Lakeview Hospital. For more than 50 years we have been providing comprehensive healthcare services in the beautiful St. Croix River Valley in Stillwater, MN. The historic town of Stillwater is located just east of the Twin Cities metro area and offers excellent recreation as well as a small town feel.
Broadway Medical Center is a rapidly growing, independent, physician-owned multi-specialty group practice with over 35 caregivers in 10 different medical specialties. We are located in Alexandria, MN; a beautiful and growing community with tremendous recreational opportunities. Welcome! Contact Daniel J. Jones, MHA at Broadway Medical Center 1527 Broadway Street, Alexandria, MN 56308 (320) 762-6841 or e-mail firstname.lastname@example.org
1527 Broadway Street, Alexandria, MN 56308
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Patti Lewis, Human Resources Stillwater Medical Group | 1500 Curve Crest Boulevard | Stillwater MN 55082 email: email@example.com | www.stillwatermedicalgroup.com
MINNESOTA PHYSICIAN APRIL 2011
To learn more about our practice, please visit our website at www.broadwaymedicalcenter.com
Allina Hospitals & Clinics in Minnesota/Western Wisconsin Allina Hospitals & Clinics is known for its clinical quality, and an award-winning EMR. At Allina, physician leadership and involvement drive our success. The Clinic and Community Division features the Allina Medical Clinic, Aspen Medical Group, and Quello Clinics, as well as Home and Community Services. Our clinics, as well as our 11 hospitals, are located in the Twin Cities metro area, throughout Minnesota, and in western Wisconsin.
Full- or part-time urban, suburban, and rural openings are available in the following specialties: t "MMFSHZ t %FSNBUPMPHZ t %JTUSJDU .FEJDBM %JSFDUPS t &NFSHFODZ .FEJDJOF t &OEPDSJOPMPHZ t 'BNJMZ .FEJDJOF t (FOFSBM 4VSHFSZ t (FSJBUSJDT JODMVEJOH .FEJDBM %JSFDUPS
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Allina offers a competitive benefits and salary package. For more information, please contact: Kaitlin Osborn Allina Physician Recruitment Toll-free: 1-800-248-4921 Email: Kaitlin.Osborn@allina.com Fax: 612-262-4163 Website: allina.com/physiciancareers EOE
11-8253 ÂŠ2011 ALLINA HEALTH SYSTEM. ÂŽA REGISTERED TRADEMARK OF ALLINA HEALTH SYSTEM
St. Cloud VA Medical Center is accepting applications for the following full or part-time positions:
â&#x20AC;˘ Internal Medicine
(Nursing Homeâ&#x20AC;&#x201D; St. Cloud, Brainerd)
(Nursing Homeâ&#x20AC;&#x201D;St. Cloud)
â&#x20AC;˘ Family Practice
â&#x20AC;˘ Neurology (St. Cloud)
â&#x20AC;˘ Psychiatrist (St. Cloud) â&#x20AC;˘ ENT
â&#x20AC;˘ Dermatology (St. Cloud) â&#x20AC;˘ Disability Examiner (IM or FP) (St. Cloud)
US Citizenship required or candidates must have proper authorization to work in the US. Physician applicants should be BC/BE. Applicant(s) selected for a position may be eligible for an award up to the maximum limitation under the provision of the Education Debt Reduction Program. Possible relocation bonus. EEO Employer.
Excellent benefit package including: Favorable lifestyle 26 days vacation CME days
Competitive salary 13 days sick leave Liability insurance
The perfect match of career and lifestyle. Affiliated Community Medical Centers is a physician owned multi-specialty group with 11 affiliate sites located in western and southwestern Minnesota. ACMC is the perfect match for healthcare providers who are looking for an exceptional practice opportunity and a high quality of life. Current opportunities available for BE/BC physicians in the following specialties: â&#x20AC;˘ Family Medicine â&#x20AC;˘ General Surgery â&#x20AC;˘ Geriatrician/ Outpatient Internal Medicine â&#x20AC;˘ Hospitalist â&#x20AC;˘ Infectious Disease
â&#x20AC;˘ Internal Medicine â&#x20AC;˘ Oncology â&#x20AC;˘ Orthopedic Surgery â&#x20AC;˘ Pain Management â&#x20AC;˘ Psychiatry
For additional information, please contact: Kari Bredberg, Physician Recruitment firstname.lastname@example.org, 320-231-6366 Julayne Mayer, Physician Recruitment email@example.com, 320-231-5052 www.acmc.com
Practice Well. Live Well.
Lake Region Healthcare is located in a magnificent, rural, and family-friendly setting in Minnesota lakes country where we aim to be the stateâ&#x20AC;&#x2122;s preeminent regional health care partner. Our award winning patient care and uncommon medical specialties set us apart from other regional health care groups. Lake Regionâ&#x20AC;&#x2122;s physicians and their families also enjoy an unmatched quality of professional and personal life. Current opportunities including competitive salary and benefit packages available for BE/BC physicians are: â&#x20AC;˘ Internal Medicine â&#x20AC;˘ Internal Medicine â&#x20AC;˘ Pediatrics â&#x20AC;˘ Pediatrics
â&#x20AC;˘ Family Medicine â&#x20AC;˘ Urology â&#x20AC;˘ Family Medicine â&#x20AC;˘ General Surgery â&#x20AC;˘ Psychiatrist â&#x20AC;˘ General Surgery
For more information contact
Barb Miller, Physician Recruiter firstname.lastname@example.org â&#x20AC;˘ (218) 736-8227
712 Cascade St. S. Fergus Falls, MN 736-8000 | (800) 439-6424
Interested applicants can mail or email your CV to VAMC Sharon Schmitz (Sharon.email@example.com) 4801 Veterans Drive, St. Cloud, MN 56303 Or fax: 320-255-6436 or Telephone: 320-252-1670, extension 6618
â&#x20AC;˘ Pediatrics â&#x20AC;˘ Pulmonary/ Critical Care â&#x20AC;˘ Radiation Oncology â&#x20AC;˘ Rheumatology
Lake Region Healthcare is an Equal Opportunity Employer. EOE
Health literacy resources Literacy from page 23 medical condition because of difficulty understanding written information? It may be useful for office staff to gather some key cultural information from patients prior to the visit. Arthur Kleinman, MD, of Harvard Medical School, has developed a cultural assessment to help physicians gather firsthand knowledge from patients to better understand their explanation for the cause, severity, treatment needs, and prognosis of their illness or injury. In cases where the patient’s worldview could affect treatment efficacy, Kleinman recommends asking eight questions: 1. What do you think caused the problem? 2. Why do you think it happened when it did? 3. What do you think your sickness does to you? How does it work? 4. How severe is your sickness? Will it have a short course? 5. What kind of treatment do you think you should receive?
Health Literacy: Help Your Patients Understand: A Continuing Medical Education (CME) Program that Provides Tools to Enhance Patient Care, Improve Office Productivity, and Reduce Healthcare Costs (2003, American Medical Association Foundation and American Medical Association) This program, available as a manual for clinicians (available for downloading at www.ama-assn.org/ama/pub/about-ama/amafoundation/our-programs/public-health/health-literacy-program/ health-literacy-kit.page), carries 2.5 hours of CME credit. Physicians will learn to understand the scope of the health literacy problem; recognize health system barriers faced by patients with low literacy; improve methods of oral and written communication; and incorporate possible strategies to create a shame-free environment. Other resources for health care practitioners: • www.nlm.nih.gov/archive//20061214/pubs/cbm/hliteracy.html U.S. National Library of Medicine, National Institutes of Health, Health Literacy Bibliographies • http://lincs.ed.gov/ Literacy Information and Communication Systems (part of the National Institute for Literacy) • www.lacnyc.org/profdev/healthlit NYC Health Literacy Initiative, a nonprofit organization dedicated to supporting and promoting the expansion of quality literacy services in New York • www.hsph.harvard.edu/healthliteracy/index.html Web page of Health Literacy Studies in the Harvard School of Public Health • www.pfizerhealthliteracy.com Website for physicians and other providers, dedicated to promoting clear health communication 6. What are the most important results you hope to receive from this treatment? 7. What are the chief problems your sickness has caused for you?
CME Conferences 2011
8. What do you fear most about your sickness? (Kleinman, A., Eisenberg, L., & Good, B. (1978). Culture, illness, and care: Clinical lessons from anthropologic and crosscultural research. Annals of Internal Medicine, 88(2), 251-258)
Why it matters
Health literacy matters. The MetLife Health Literacy Initiative points out that at least 46 percent of Americans lack the functional literacy to navigate the health care system, and these levels may be much higher for non-native English speakers. Patients who cannot understand disease processes, wellness, and prevention cannot participate in early detection efforts or comply with therapeutic counsel. Knowing how to identify patients who have low health literacy and then implementing strategies to help break down the literacy and cultural barriers are key to helping these patients, who often have difficulty managing their conditions and actively participating in their care. The sidebar lists strategies for working with patients who have low or marginal health literacy. Marcie Parker, PhD, MA, MPA, CFLE, is a health care consultant in private practice and a certified family life educator in Excelsior, Minn.
Pediatric Fundamental Critical Care Support May 19 - 20, 2011
Fundamental Critical Care Support July 14 - 15 and October 13 - 14, 2011
29th Annual Strategies in Primary Care Medicine September 22 - 23, 2011
Pediatric Conference • Urgent Care Focus: October 28, 2011 • Pediatric Update: October 29, 2011
12th Annual Women’s Health Conference November 4, 2011
Emergency Medicine and Trauma Update • Beyond the Golden Hour November 17, 2011
Otolaryngology Conference November 18, 2011 Education that measurably improves patient care.
MINNESOTA PHYSICIAN APRIL 2011
33rd Annual Cardiovascular Conference December 1 - 2, 2011
Youâ&#x20AC;&#x2122;re always there for them.
Weâ&#x20AC;&#x2122;re always here for you. We have defended and supported the individual needs of health professionals for more than 30 years. And nobody is more personally committed to protecting you from the risks you face every day. To learn more, call 800-328-5532 or visit MMICGroup.com
Protecting Yo Y Your ur Peace of Mind
You wouldnâ&#x20AC;&#x2122;t give a 2-year-old a drink, so why would you give one to an unborn child? As a physician, itâ&#x20AC;&#x2122;s your responsibility to let her know: the U.S. Surgeon General Advisory says no amount of alcohol is safe during pregnancy. Share 049: Zero Alcohol For Nine Months.