Volume XXV, No. 5
The Independent Medical Business Newspaper
Health care administration Recognizing outstanding achievement
MEDICAL HOMES to page 10
By Mary Sue Beran, MD, MPH; Elizabeth A. Kind, MS, RN; Cheryl E. Craft, RN; and Jinnet B. Fowles, PhD
PRSRT STD U.S. POSTAGE
Easing the burden of primary care
Detriot Lakes, MN Permit No. 2655
round the country, fewer physicians are graduating from medical schools with an interest in primary care practice. This trend occurs in the setting of an aging baby boomer population, an increase in the number of individuals with chronic disease, and an influx of newer, more complex medication regimens for common chronic illnesses such as diabetes. In addition, studies have documented that physician satisfaction in primary care is decreasing. The medical home primary-care redesign has the potential to help primary care physicians work at the top of their skill level and transfer non-physician work to appropriate levels of support staff. This work redistribution is important not only for preventing physician burnout but also
very seven years, Minnesota Physician recognizes health care administrators who have exhibited exceptional leadership and enhanced the effectiveness of health care delivery in their practices. As in the past, we solicited nominations from their peers and the Minnesota Medical Group Management Association. Among the guidelines for consideration were how the individual’s work contributed to the organization’s growth; dedication to improving health care delivery; and participation in professional association activities. (We did not include physician administrators.) Many health care administrators clearly are doing excellent work in their organizations and communities, and we were unable to include all of those who were nominated for this feature. The 23 administrators profiled here represent a cross-section of the excellent work being done throughout the state in a range of administrative positions and types of health care organizations—from small, independent clinics to hospitals, clinic networks, and large ADMINISTRATION to page 20
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AUGUST 2011 Volume XXV, No. 5
MINNESOTA HEALTH CARE ROUNDTABLE Medical homes Easing the burden of primary care
By Mary Sue Beran, MD, MPH; Elizabeth A. Kind, MS, RN; Cheryl E. Craft, RN; and Jinnet B. Fowles, PhD T H I R T Y- S I X T H
Health care administration Recognizing outstanding achievement
Recognizing health care administrators
8 Sona Mehring
PROFESSIONAL UPDATE: NEUROLOGY Normal pressure hydrocephalus 26 By Charles R. Watts, MD, PhD, and Edward G. Hames III, MD, PhD
MENTAL HEALTH First-episode psychosis
By Claudia Campo-Soria
CARDIOLOGY All heart
By Daniel J. Garry, MD, PhD
HOSPITALS Blood transfusion practices
Accountable Care Organizations Accountable to Whom? Thursday, October 13, 2011 1:00 – 4:00 PM • Duluth Room Downtown Mpls. Hilton and Towers
By Seymour Handler, MD
PROFESSIONAL UPDATE: NEUROLOGY Diagnosing Alzheimer’s disease 16 By David S. Knopman, MD
The Independent Medical Business Newspaper
Background and focus: Created as part of national health care reform, accountable care organizations (ACOs) are now part of every health care policy discussion. As defined by the 111th Congress, ACOs are organizations that include physicians, hospitals, and other health care organizations with the legal structure to receive and distribute payments to participating physicians and hospitals to provide care coordination, invest in infrastructure and redesign care processes, and reward high-quality and efficient services.
Exactly what this means is unclear, and a confusing array of levels and qualifications for ACOs has been proposed. With 2012 as a start date for Medicare reimbursement through ACOs, Congress is developing firm definitions at this time. Some say ACOs turn physicians into insurance companies; others say they are a way for physicians to take a leadership role in fixing a broken system. As health care organizations race to join, create, or redefine themselves as ACOs, they all face more questions than answers. Objectives: We will review the history, goals, and rationale behind the ACO model. We will review the latest federal guidelines defining what an ACO can be. We will discuss how the ACO will affect health insurance companies, employers, and the pharmaceutical industry. We will illustrate what must not be allowed to happen if the model is expected to succeed. We will examine who decides if ACOs are successful and how those decisions will be made. We will explore why so many people, representing very different perspectives on health care, are opposed to the idea and what can be done for it to achieve its best potential.
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Please send me tickets at $95.00 per ticket. Mail orders to Minnesota Physician Publishing, 2812 East 26th Street, Minneapolis, MN 55406. Tickets may also be ordered by phone (612) 728-8600 or fax (612) 728-8601.
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J Check enclosed J Bill me J Credit card (Visa,Mastercard, American Express, or Discover) Minnesota Physician is published once a month by Minnesota Physician Publishing, Inc. Our address is 2812 East 26th Street, Minneapolis, MN 55406; phone (612) 728-8600; fax (612) 728-8601; email firstname.lastname@example.org. We welcome the submission of manuscripts and letters for possible publication. All views and opinions expressed by authors of published articles are solely those of the authors and do not necessarily represent or express the views of Minnesota Physician Publishing, Inc., or this publication. The contents herein are believed accurate but are not intended to replace legal, tax, business, or other professional advice and counsel. No part of this publication may be reprinted or reproduced without written permission of the publisher. Annual subscriptions (12 issues) are $48.00. Individual issues are $5.00.
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AUGUST 2011 MINNESOTA PHYSICIAN
State Ranks 32nd In Obesity Report Minnesota ranks as the 32nd most obese state in the country, according to an annual report on obesity in the United States. â€œF as in Fat: How Obesity Threatens Americaâ€™s Future 2010â€? was released by Trust for Americaâ€™s Health (TFAH) and the Robert Wood Johnson Foundation. It found that adult obesity rates increased in 28 states last year, including Minnesota, with obesity rates dropping in only the District of Columbia. Officials say the ongoing obesity epidemic also has troubling racial, regional, and income disparities. For example, 10 out of the 11 states with the highest obesity rates were in the South, with Mississippi having the highest rates for all adults (33.8 percent) for the sixth year in a row. â€œObesity is one of the biggest public health challenges the country has ever faced, and troubling disparities exist based on race, ethnicity, region, and income,â€? said Jeffrey Levi, PhD,
executive director of TFAH. â€œThis report shows that the country has taken bold steps to address the obesity crisis in recent years, but the nation's response has yet to fully match the magnitude of the problem. Millions of Americans still face barriersâ€”like the high cost of healthy foods and lack of access to safe places to be physically activeâ€”that make healthy choices challenging.â€? The report says Minnesota could do more to address the obesity epidemic by taking steps such as setting nutritional standards for school meals or for food sold in schools through vending machines. The state also lacks requirements for body mass index (BMI) screenings of children and adolescents or other forms of weight-related assessments in schools. The report also credits Minnesota with passing â€œComplete Streetsâ€? legislation, which aims to encourage more healthy activities by promoting safe access to streets for pedestrians, bicyclists, and transit riders.
Minnesota HMOs See Record Profits Despite a troubled economy and rising health care costs, HMOs in Minnesota saw their most profitable year ever in 2010, a new report from Allan Baumgarten shows. The record profits were a result of strong margins on both government and private plans, the report says. In addition, health plan enrollment grew for the second consecutive year. The new report, part of the twice-yearly analysis on hospitals and health plans in Minnesota provided by Baumgarten, focuses on HMO plans in Minnesota, and finds that HMOs and county Medicaid plans in Minnesota had a net income of $264 million, or 3.6 percent of operating revenues of $7.3 billion. The report found a net income from operations of $194 million plus investment income of $69.8 million. Baumgarten notes that in the past 15 years, HMOs in Minnesota had posted a 3 per-
cent margin only once. The data show the health insurance companies overall had strong results. Blue Cross and Blue Shield of Minnesota had a net income after taxes of $100 million, and its Blue Plus plan had a profit margin of 6.9 percent in 2010. Medica Insurance company had a net income of $44 million. And HealthPartnersâ€™ health plans showed a 3.7 percent margin for 2010. As in past years, health plans showed good profits on state government plans, the report says. â€œIn 2010, state public programs (Medical Assistance and MinnesotaCare are the largest) accounted for about 46 percent of revenues but 78 percent of health plan profits,â€? the report says. â€œOn average HMOs collected $77 more in premiums from the state per member per month than they paid out in medical expenses. Losses on MinnesotaCare offset part of that profit.â€? These findings are likely to add to the debate on whether Minnesota should regulate pub-
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lic HMOs more closely since they are funded by the state but run by private health insurance companies. Last year, legislators debated the idea of requiring more public accounting of HMO finances, and Gov. Mark Dayton took several steps to address the perception that private HMOs were profiting from administering state plans at a time when the government faced a budget crisis. One of those steps was a one-year deal that will require health plans to give back to the state any profits above 1 percent from public health plans in 2011. The report says that although enrollment in employer-based HMOs continues to decline, overall enrollment in HMOs increased, driven largely by growth in Medicare and Medicaid plans. The report also finds that health premiums in Minnesota are growing faster than medical claims, inflation, and the overall economy. The average premium increase for HMO employer-based plans was 7.6 percent in 2010, which is down from 9.5 percent in 2009 and 8.6 percent in 2008. Medical expenses increased in 2010 by 4 percent.
DHS Website to Report on Quality Measurements The Minnesota Department of Human Services (DHS) has launched a website that gives the public easy access to measurements of the agency’s performance in priority areas such as home health care, access to insurance, and effective use of hospital services. The DHS “dashboard” is designed to be a user-friendly tool that will show DHS goals and how well the agency is doing in meeting those goals, officials say. The effort is one of several launched after Gov. Mark Dayton called for additional steps to make government services transparent and accountable. “The Department of Human Services is committed to giving Minnesotans the best
possible value for their public dollars,” says DHS Commissioner Lucinda Jesson. “The dashboard is one easy way for Minnesotans to check on both our priorities and our progress.” Officials say that over the past six months, the agency has begun to compile data and mark goals for areas of major importance in its different service areas. Depending on the measure, goals are set annually, quarterly, or by specific dates. More information is available at the dashboard website, dashboard.dhs.state.mn.us.
MN Report Finds Disparities Persist in Quality of Care A report from MN Community Measurement finds that disparities in health care have narrowed in Minnesota but remain a problem. The new report, produced in collaboration with the Minnesota Department of Human Services, looks at the quality of care provided to people in public plans compared with people with employerbased insurance. It finds that in nine of 12 areas of measurement, health care quality scores are lower for people with public program coverage versus those with private coverage. “Although the report shows that there has been some narrowing of disparities in quality of care, serious gaps still remain,” says Human Services Commissioner Lucinda Jesson. “Reports like this are vital both for helping us focus on where we need to improve as well as for helping the public keep us accountable for that improvement. As we move forward with our payment and delivery system reforms, tracking improvement in disparities reduction will be an area we keep our eye on.” CAPSULES to page 6
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“Building Blocks for Better Health” speakers include national and state experts on health care reform and working with populations facing significant health disparities The conference offers: • Management and public policy sessions covering operational and administrative issues • Clinical sessions on chronic disease management, care integration and reducing health disparities • Continuing education credit $175 early bird (by 10.7.11) $225 after Brought to you by:
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Capsules from page 5
Beacon Program Tracks Flu Vaccination Efforts A project designed to encourage people to get vaccinated for influenza and to improve flu shot reporting in southeastern Minnesota was successful, officials with Mayo Clinic say. The Beacon Program in southeast Minnesota is one of 17 Beacon initiatives nationwide. Created by the U.S. Department of Health and Human Services to better use information technology in health care delivery, the Beacon Program is run in Minnesota by Mayo Clinic, Winona Health Systems, and Olmsted Medical Center. The influenza program targeted people with type 2 diabetes and children with asthma. The Beacon Program sent letters to people within those groups stressing the importance of getting vaccinated for influenza and asking recipients to report where they had been vaccinated.
The study found that while more than half of the letter recipients had gotten flu shots prior to the letter, an additional 50 people were vaccinated after receiving the letter. “It was important that we were able to get some of our targeted population vaccinated through our proactive letter effort,” says Lacey Hart, program director of SE MN Beacon Community. “But even more valuable for our group was the realization that there were some real gaps in who was actually reporting immunization data to the Minnesota Immunization Information Connection’s database.” Officials say next plans are to assess reporting practices of various immunization providers and focus on educating and communicating with them.
Allina, Life Time Announce Partnership To Promote Fitness Allina Hospitals and Clinics and Life Time Fitness have created a
new partnership that will promote wellness, health education, and fitness in Minnesota. The new initiative was announced by top executives of the two groups at a press conference on June 30 at Allina’s Mercy Hospital in Coon Rapids. They said the collaboration will consist of several elements that stress wellness and health promotion, both at the two companies and in the communities they serve. The first element will be myHealthCheck, a Life Time health and wellness assessment program, which will be available to Allina’s physicians, nurses, and other employees of the health system. Allina staff also will connect with Life Time locations to provide medical education to Life Time members and staff, and medical services for athletic events sponsored by Life Time. The two groups will work together to promote health and fitness expertise in health care delivery, promote health and wellness programs, and improve access to preventive health and well-
ness services. Officials stressed the importance of wellness in the workplace and said the introduction of myHealthCheck will promote the adoption of improved health and wellness practices for Allina employees, supported by measurable health assessments and employee incentives. “Historically, the health care industry has focused almost exclusively on illness,” says Kenneth Paulus, president and CEO of Allina Hospitals and Clinics. “While this has resulted in outstanding acute care, little focus has been placed upon the impact of preventive health and fitness measures on the health of the community. Core to the launch of our partnership is the introduction of Life Time’s myHealthCheck wellness program to our employees. The comprehensive nature of this program makes it an outstanding solution for Allina and we believe the results provided to our employees will translate into actionable behavior change.”
Penny Wheeler, MD, chief clinical officer of Allina Hospitals & Clinics, and Pamela Jo Johnson, MPH, PhD, of Allina’s Center for Healthcare Innovation, have been selected to participate in a yearlong executive leadership program designed to tackle racial and ethnic disparities in health care. The Disparities Leadership Program is the first program of its kind in the nation for health care leaders and is led by the Disparities Solutions Center at Massachusetts General Hospital in Boston. Wheeler and Johnson are two of only 34 individuals from 16 health care organizations from around the United States to be selected for the 2011–2012 Disparities Leadership Program. Jason Alexander, MD, vascular surgeon with the Minneapolis Heart Institute at Abbott Northwestern Hospital, has begun seeing patients at the Alexandria (Minn.) Clinic. He also Penny Wheeler, MD provides care at Minneapolis Heart Institute’s Minneapolis and Waconia locations, and at Children’s Hospital in Minneapolis. He attended the University of Minnesota Medical School and completed his residency at Huntington Memorial Hospital in Pasadena, Calif., followed by a fellowship at the Vascular and Endovascular Surgery division of the University of Southern California. Alexander is a former site director of the general surgery residency program at University of California, San Francisco–East Bay. Joseph Petronio, MD, has joined the neurosurgery practice at Children’s Hospitals & Clinics of Minnesota and will lead the neuroJoseph Petronio, MD surgery program at Children’s–St. Paul. Petronio has performed neurosurgery at Children’s and other Twin Cities hospitals since 1999. A graduate of Northwestern University Medical School in Chicago, Petronio completed residencies at the Hospital of the University of Pennsylvania, Philadelphia, and Children’s Hospital of Philadelphia. He completed a clinical fellowship in neuro-oncology and a postdoctoral fellowship in the molecular biology of brain tumors at the University of California, San Francisco. Petronio also completed a fellowship in pediatric neurosurgery and an additional postdoctoral fellowship in the molecular biology of brain tumors at the University of Utah. A major focus of his practice will be treating hydrocephalus and related disorders, as well as the treatment and management of epilepsy and of brain, spine, and skull tumors. Lee W. Wattenberg, MD, has received the 2011 American Association for Cancer Research (AACR) Award for Lifetime Achievement in Cancer Prevention Research for his role in launching the field of chemoprevention and his work to understand the potential mechanisms of action of chemopreventive compounds. Wattenberg is a professor at the Masonic Cancer Center at the University of Minnesota and past president of the AACR. The AACR award cited Wattenberg as a “trendsetting, innovative cancer research leader whose early thinking and insights in cancer prevention put the spotlight on the potential of the field to save lives from cancer.” Michael Verneris, MD, of the University of Minnesota Masonic Cancer Center, has received the Relentless for a Cure Award from the Minnesota chapter of the Leukemia and Lymphoma Society. The award is given “in recognition of excellence in service that has improved the quality of life of patients and families.” Hennepin County Medical Center (HCMC) has named Jon Cole, MD, as the new medical director of the Hennepin Regional Poison Center. Cole will replace Dave Roberts, MD, who has led the center since 2004 but is reducing his hours in anticipation of retirement. The Poison Center serves as a statewide poison control center that Minnesota residents can call 24 hours a day. Cole, a staff physician at HCMC’s emergency department, completed his emergency medicine residency at HCMC and recently completed a two-year toxicology fellowship at Regions Hospital and Hennepin Regional Poison Center.
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CaringBridge: a way to connect with those who care ■ What is CaringBridge?
■ How do people find out about CaringBridge?
CaringBridge provides a personal space where people can communicate to their friends and family about a significant health challenge. It helps the patient and the caregiver let everybody know what’s going on, but just as importantly it “bridges” back the love and support that they can have while they’re going through their health journey.
About 60 percent find out through word of mouth, through families telling families, friends telling friends. The other 40 percent find out through the health care experience itself. We do a lot of very proactive outreach to health care professionals through conferences, to hospitals, and to other agencies that are associated with health, like the American Cancer Society. We have a program called “Recommend CaringBridge”—you can find it at caringbridge.org. It’s targeted toward health care professionals, to give them tips not only on CaringBridge but also on other information to help patients and their families as they’re going through a crisis. We also do outreach to professionals such as social workers, chaplains, and hospital administrators.
■ Have you learned anything from your members
about how they like to be treated by doctors, for instance, in presenting medical information? Sona Mehring CaringBridge Sona Mehring is the founder and CEO of CaringBridge, an online resource that allows patients and families to create personalized websites to keep others informed about serious health events. Since CaringBridge was founded in 1997, more than 273,000 personal sites have been created, and 1.7 billion visits have been made to CaringBridge websites. The Eagan-based nonprofit company has 67 employees and 72 volunteers. Mehring is a member of the Minnesota Council of Nonprofits, the National Health Council, Women Business Leaders of the U.S. Health Care Industry Foundation, and the National Health Marketing Leadership Roundtable.
We don’t ask a lot of specific questions of families about physician relationships. However, by and large, patients and caregivers who use CaringBridge do seek out additional information and like to be able to ask their physicians about other information they’re receiving, either by their own research or research from other sources. ■ Is there a perception that CaringBridge is only There’s the idea of the “e-patient”; while not all for terminal patients? Can you address this? of the people who use CaringBridge are technologiI do think that is a perception, because it is true cally savvy, they do have the electronic world availthat for the last 14 years, CaringBridge has focused able to them. I think most patients and caregivers on acute events: a diagnosis of do look up information on their cancer, a car accident, a premaown and physicians should be To me, a service ture birth. And certainly the able to speak to that. majority of those events do not like this should ■ What have you learned about end up as end-of-life, but there what your members do and do be integrated into are some that do. not want to hear from family It is for serious conditions, every care plan. members or friends? though. As we continue to look at what CaringBridge can do and What I’ve heard from patients how it can have a broader impact, we are looking and caregivers is that the last thing they really to have a wider variety of things that people can do want to hear is, “Everything will be all right.” They to help amplify the kind of care that’s needed durfeel that’s patronizing. They do want to hear love, ing a health experience. We’ve made progress in support, and compassion. And they do want to be having it be much broader than that. able to be helped, in a number of ways—whether People use CaringBridge for many years, somethrough the messages that people leave or the times—if it was an end-of-life event—almost as a proactiveness of friends and family helping out, on memorial. But more often than not, it’s used as a everything from logistics to whatever it takes, even celebration: the five-year anniversary of being a fundraiser. cancer-free, things like that. Even with premature What CaringBridge allows them to do is break birth—there can be lifelong complications, but down the barriers so that friends and families more than that there’s just the miracle of these very know what’s happening and can have an ongoing premature infants. Some people have even posted understanding of what that family’s going through. pictures of when they enroll in their first day of ■ It seems like a very focused form of social kindergarten—it becomes almost a kind of legacy. networking. ■ Have there been studies that provide data on It is. CaringBridge started in 1997, light years the effectiveness of services like CaringBridge in ahead of the social networking term—even a year helping patients? before Google was founded! We’ve commissioned some studies, not medical, Bringing together friends and family is not a double-blind studies, but ones to show how much new idea when someone’s going through an imporCaringBridge helps. A couple studies have docutant event. What CaringBridge does is lend new mented that well over 80 percent of the people technology, i.e., the Internet, to allow those connecusing CaringBridge feel it helps them heal, and 90 tions to happen any time, around the clock, percent indicated it is easy to use, saves time and whether you’re across the street or around the emotional energy, and helps not only them but an world. So it brings together that circle of friends entire network of individuals to understand the sitand family in a very easy-to-use, accessible manner. uation and to have a very positive experience.
MINNESOTA PHYSICIAN AUGUST 2011
■ Tell us about the relationship of this serv-
ice with the health care delivery system. To me, a service like this should be integrated into every care plan. It should be prescribed just as much as any medicine. Physicians and their support teams should ask, “How are you going to let others know what’s going on? How are you going to gain support from your family and friends?” Those are important questions to ask, and a service like CaringBridge helps provide that. It’s part of a more holistic approach. ■ Data privacy is a huge concern for physi-
cians. How can they participate in an organization that makes sensitive health care data as public as yours does? That is something we have not solved. With CaringBridge, the families are providing their own content; it’s user–generated content. So that does not fall within the HIPAA umbrella because it’s not the physician or the staff that’s speaking about this health or medical information. I do know that many times patients bring in their CaringBridge journal to let the physician know. But it certainly isn’t replacing the dialogue between the physician and that patient. ■ Do you ever wish there was a day where
a CaringBridge member is talking to their community and the physician weighs in
and says, “Here’s what I think?” That doesn’t happen now, right? No, it is not that type of forum. That would be a different kind of service, and one that would be under the HIPAA guidelines. But I think using CaringBridge as a portal or a conduit into other important health systems, everything from patient medical records to virtual visits with their doctor—that is a very real and tangible future that CaringBridge could support. ■ What else do you see in the future for
CaringBridge? As social networks have exploded in the last three to four years, the opportunity to really bring caring as a part of the social network is something we want to do, and go beyond that significant health challenge. It should be broader than that, and there should be times in life where staying connected with your friends and families for other caring reasons is a great option. We’d like to broaden the continuum of where CaringBridge-type services can be used, as well as continue to deepen what we do today. So a care calendar where people could do some type of scheduling is a possibility. Maybe more ways to have a private journal or a private conversation—we’re looking at things like that to deepen the current CaringBridge experiences.
■ What advice can you give physicians
to share with patients with significant health challenges? Empower patients by letting them know about CaringBridge. Shrinking away from the informed patient is not the way to go. You need to empower patients and honor that they feel empowered, because they are the ones in control of their treatment and their experience. ■ Do you encounter physicians who say,
“Oh, you heard this on the Internet. ...” Do they put up walls about that? I haven’t experienced this personally; most of the physicians I come across are very positive towards this. But at various conferences and seminars there is a backlash around the empowered patient. Because, you know, you can Google anything, and sometimes it’s false information. So there is that image of doctors who don’t want their patients to go out and find out information on their own—they want to provide that, because it’s more credible. They’re coming from their own knowledge base, versus opening up to another knowledge base. So they’re losing a lot of control. And I can relate to that, but again, I think an empowered patient is going to be a more positive, more active patient.
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Medical homes from cover for promoting physician and patient satisfaction. Previous studies have reported mixed physician views on implementing the medical home model in their clinic. Our research group sought to understand the physician perspective at an exploratory level to gain
tion would be primarily related to working with the chronic disease nurses in caring for medically complex patients over other aspects of the care redesign.
Participants and methods In 2007, one internal medicine clinic that is part of a large, multispecialty group practice
of our research study, the clinic had 17 physicians and one nurse practitioner and saw approximately 17,000 patients each year. Key components of the medical home that shaped reorganization of the clinic were patient-centered care with 24-hour access and communication, patient tracking and dis-
Physicians reported increased satisfaction with their practices after implementation of the medical home model. insights into how the medical home model affects physician practice on a personal, daily level. Our main hypothesis was that physicians would report increased satisfaction with their practice after implementation of the medical home. The secondary hypothesis was that the increase in physician satisfac-
within Park Nicollet Health Services reorganized as a medical home. The medical home pilot was implemented in phases, with key components taken from National Committee for Quality Assurance and the Minnesota State Department of Health criteria for medical home certification. At the time
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7:00 am - 8:45am Breakfast, Presentation by Panel Members and Discussion
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MINNESOTA PHYSICIAN AUGUST 2011
ease registry management, care management and coordination, patient self-management support, electronic prescribing, test and referral tracking, and performance reporting and quality improvement. Because the pilot clinic was part of a large multispecialty group, some components of the medical home, such as 24-hour access and communication and electronic prescribing, were already part of the daily workings of the clinic. Among the practical changes in implementing the medical home at the clinic were a restructuring of the physicians’ and nurses’ work spaces into co-located care teams consisting of four physicians, one chronic disease nurse, one department assistant, one medical information nurse, and two or three medical assistants. A care coordinator worked with all four of the clinic teams to identify and assist with barriers to care such as transportation issues and mental health problems. The goal for each team was to know and care for a set population of patients. Prior to restructuring into teams, the clinic had functioned as one large group. In addition to the restructuring, chronic disease nurses were trained to assist with care for the medically complex patients for each team. These nurses received individualized training in chronic disease
management and motivational interviewing. Patients are referred to the chronic disease nurses at the discretion of the physician, typically at the time of a physician visit. Eligible patients are those with hypertension, type 2 diabetes, congestive heart failure, or coronary artery disease. The nurses also assist physicians with management of patient registries. These registries focus on type 2 diabetes, hypertension, and coronary artery disease and are designed to track performance measures such as the proportion of a physician’s patients who meet blood pressure or hemoglobin A1c goals. Interview script. We asked physicians questions about the key components of the medical home model as well as about work culture and job satisfaction. The interview script was designed to be interactive, with open-ended questions and variation in discussions based on physician responses. Data collection. Between October 2009 and April 2010, we contacted all 17 physicians in the department by email and invited them to be interviewed. Three of the 17 physicians did not respond to our request after three attempts, and therefore were not interviewed. Two interviewers from a team of three experienced interviewers conducted hour-long, in-person interviews with 14 physicians. Interviews were taped, transcribed, and imported into a qualitative analysis software database.
Results Definition. When we asked physicians to define the medical home, we found that many believed the term was vague and difficult to define. They had a much easier time defining good primary care; a recurring theme was that the medical home design facilitated better care. As the following interview excerpts illustrate, the term “integrated care” resonated with physicians more than the term “medical home.” “Maybe this is vague because doctors think that the medical home is really not a new concept but the
fulfilling of their goal of good primary care. They now have the resources to help educate patients, manage chronic disease … the support structure is in place for them to feel like they can deliver good primary care. They are satisfied because they feel like they are in a system that allows them to do the kind of good primary care they want to do.” “Medical home, the way I see it, is pretty much an extension of the care we give here from our office … I think of the medical home model as extensions of ourselves as providers to help incorporate and integrate patient care a little bit better where we are able to communicate with patients outside of the office. I think it provides better integrated care, especially patients who have chronic conditions, like diabetes.” Access. Physicians commented on how patients could easily reach the chronic care nurse if needed. “She [chronic disease nurse] has a direct phone line with voicemail so my patients with chronic conditions can call in and leave a voicemail message … and they know who they’re talking to. I can’t say enough how important that is.” Care coordination. The most significant theme in the physician interviews was the team approach to managing patients with complex medical problems. Physicians defined “team” as each clinician with a support staff comprising a chronic disease nurse, department assistant, medical information nurse, and medical assistant. They described having more resources to manage medically complex patients and felt as if the burden of caring for these complex patients was distributed throughout the team rather than resting solely on their shoulders. “In internal medicine and primary care in general, we’re just overwhelmed with stuff we have to do with meds and forms and dictations, and so as much
as that can be taken away, I feel more energized.” “I feel like I’m not out there alone.” “From a physician perspective, for me it means working as a team; it means no longer having patients come in for 30-minute visits every three months. It means taking care of them all of the time and doing that in ways that aren’t necessarily just about the clinic visit. It means having some extra staff to help do things that they’re better at than I’m better at; it means communicating with patients on the phone and through electronic means rather than driving to the clinic just to have a phone conversation. I think it’s a whole new way of delivering health care.” Physicians felt that the team approach allowed them to provide more individualized care and higher quality care for patients with chronic disease. This resulted in increased satisfaction for physicians. “… I think right now … I’m giving better care. I can’t honestly say it’s making me so efficient I can see more people in a day. I think it’s that the people I see, they’re getting better care.” “I would say medical home is a model of a care team that’s working for the patient with a physician to intensify treatment and to do checks that wouldn’t otherwise happen necessarily in a busy doctor’s practice. To make sure that your diabetes or your chronic disease of any sort is going in the right track and you don’t get lost and that you have more people and more resources to help you.” Physicians repeatedly mentioned physical proximity as important to team communication and functioning. They described the importance of having the chronic disease nurse and other support staff in close proximity as a way to facilitate informal communication about patients. Close proximity enhanced trust between the physician and chronic care
nurse—in effect, encouraging them to see the nurse as an extension of their care, rather than as a referral outside their care. Physician satisfaction. Overall, physicians described higher levels of satisfaction with their practice compared to before the medical home was implemented. Some described improved efficiency; many, however, felt that while they were not shortening their work day, they were able to provide higher quality care. Many physicians described less paperwork and feeling less alone in
caring for medically complex patients. They felt able to more often work at the top of their skill level because they had additional resources for nonphysician work. “I really rely on these people. I hand things off. The reason I got excited about this project was with our former leader talking about the burnout in internal medicine and primary care, and how we have too much on the plate of the primary care doctor and the default MEDICAL HOMES to page 38
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t’s an exciting time for the field of cardiovascular medicine. Emerging technologies that include genomics, cell therapy, and new devices fuel innovation and continue to revolutionize the way we treat and prevent cardiovascular disease, both for today and in the future. Research provides a platform to launch these new discoveries and technologies toward treatment of patients with heart disease. Despite our advances, cardiovascular disease remains the No. 1 cause of death in the United States, and we spend more than $260 billion treating heart and heart-related conditions each year. In the next decade, I believe cardiology research will center on three main areas: • Improved technologies and devices • Cellular and molecular treatments • Personalized medicine
Devices will continue to be refined (i.e., miniaturized) and improved. An example of device
patients with heart failure. Pediatric heart defect patients become adults
Minnesota builds on its legacy of cardiac research By Daniel J. Garry, MD, PhD refinement is the ventricularassist devices that support patients with end-stage heart disease, which have been reduced in size compared to the first generation of pumps. In the future, I believe we will see these devices become entirely internalized without an external driveline. The internalization of these pumps will be possible with the improved battery technology. These advances in battery technology will allow the left ventricular devices to be managed more like pacemakers. Cardiovascular surgical procedures will continue to evolve, with more emphasis on developing minimally invasive techniques for procedures that once required open heart surgery. For example, at the University of Minnesota, cardiac surgeon Ken
Liao has pioneered the use of robotic surgical heart procedures. This robotic surgical technology is beneficial in older patients that have advanced disease, and results in shorter hospital stays. An increasing number of surgical procedures will utilize catheter-based strategies in valvular replacements and septal defect closures. Imaging technology
Imaging will continue to play a role in how we care for cardiovascular disease. Facilities such as the University’s Center for Magnetic Resonance Research will become even more vital in developing high-resolution images of the heart and vessels, which will guide both physicians and researchers in developing new regenerative therapies in
Congenital heart disease remains the most common birth defect in live born babies today. Due to the surgical advances pioneered by Lillehei, Varco, and others at the University of Minnesota and elsewhere in treating congenital heart defects, many of our youngest patients are now routinely living into adulthood. I believe that the future will include more clinics like our Adult Congenital Heart Disease Clinic, which provides comprehensive patient care that will include molecular analysis and whole genome sequencing for our patients. We don’t yet know whether these adult patients with congenital heart disease will face other heart-related issues as they age. Research in survivorship will become critical as we continue to care for these pioneering patients who helped us learn more about childhood heart defects. HEART to page 15
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MINNESOTA PHYSICIAN AUGUST 2011
N ED 2 RA ND ES AT ME LIN G E BI OM ID DA EC GU R AF W NO NEW
PRADAXA 150 MG TWICE DAILY—REDUCES THE RISK OF STROKE IN NON-VALVULAR ATRIAL FIBRILLATION (AF)1
For additional information, visit www.PRADAXAPRO.com
Stroke in non-valvular AF
75C, 63M, 63Y
Indications and Usage PRADAXA (dabigatran etexilate mesylate) capsules is indicated to reduce the risk of stroke and systemic embolism in patients with non-valvular atrial fibrillation.
IMPORTANT SAFETY INFORMATION ABOUT PRADAXA CONTRAINDICATIONS PRADAXA is contraindicated in patients with active pathological bleeding and patients with a known serious hypersensitivity reaction (e.g., anaphylactic reaction or anaphylactic shock) to PRADAXA.
WARNINGS AND PRECAUTIONS Risk of Bleeding PRADAXA increases the risk of bleeding and can cause significant and, sometimes, fatal bleeding. Risk factors for bleeding include: —Medications that increase the risk of bleeding in general (e.g., anti-platelet agents, heparin, fibrinolytic therapy, and chronic use of NSAIDs) —Labor and delivery Promptly evaluate any signs or symptoms of blood loss, such as a drop in hemoglobin and/or hematocrit or hypotension. Discontinue PRADAXA in patients with active pathological bleeding.
Temporary Discontinuation of PRADAXA Discontinuing PRADAXA for active bleeding, elective surgery, or invasive procedures places patients at an increased risk of stroke. Lapses in therapy should be avoided, and if PRADAXA must be temporarily discontinued for any reason, therapy should be restarted as soon as possible. Please see brief summary of full Prescribing Information on the adjacent page.
Effect of P-gp Inducers and Inhibitors on PRADAXA Exposure The concomitant use of PRADAXA with P-gp inducers (e.g., rifampin) reduces dabigatran exposure and should generally be avoided. P-gp inhibitors ketoconazole, verapamil, amiodarone, quinidine, and clarithromycin, do not require dose adjustments. These results should not be extrapolated to other P-gp inhibitors.
ADVERSE REACTIONS In the pivotal trial comparing PRADAXA to warfarin, the most frequent adverse reactions leading to discontinuation of PRADAXA were bleeding and gastrointestinal (GI) events. PRADAXA 150 mg resulted in a higher rate of major GI bleeds and any GI bleeds compared to warfarin. In patients ≥75 years of age, the risk of major bleeding may be greater with PRADAXA than with warfarin. Patients on PRADAXA 150 mg had an increased incidence of GI adverse reactions. These were commonly dyspepsia (including abdominal pain upper, abdominal pain, abdominal discomfort, and epigastric discomfort) and gastritis-like symptoms (including GERD, esophagitis, erosive gastritis, gastric hemorrhage, hemorrhagic gastritis, hemorrhagic erosive gastritis, and GI ulcer). Drug hypersensitivity reactions were reported in <0.1% of patients receiving PRADAXA.
Other Measures Evaluated The risk of myocardial infarction was numerically greater in patients who received PRADAXA 150 mg than in those who received warfarin. All images are patient portrayals. References: 1. Pradaxa [prescribing information]. Ridgefield, CT: Boehringer Ingelheim Pharmaceuticals, Inc.; March 2011. 2. Wann LS, Curtis AB, Ellenbogen KA, et al, writing on behalf of the 2006 ACC/AHA/ESC Guidelines for the Management of Patients With Atrial Fibrillation Writing Committee. 2011 ACCF/AHA/HRS focused update on the management of patients with atrial fibrillation (update on dabigatran): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2011;57:1330–1337.
PRADAXA® is a registered trademark of Boehringer Ingelheim Pharma GmbH & Co. KG and used under license. COPYRIGHT © 2011 BOEHRINGER INGELHEIM PHARMACEUTICALS, INC. ALL RIGHTS RESERVED.
PRINTED IN U.S.A.
PRADAXA® (dabigatran etexilate mesylate) capsules for oral use
(Table 2, Cont’d.)
BRIEF SUMMARY OF PRESCRIBING INFORMATION Please see package insert for full Prescribing Information. INDICATIONS AND USAGE PRADAXA is indicated to reduce the risk of stroke and systemic embolism in patients with non-valvular atrial ﬁbrillation. CONTRAINDICATIONS PRADAXA is contraindicated in patients with: s Active pathological bleeding [see Warnings and Precautions and Adverse Reactions]. s History of a serious hypersensitivity reaction to PRADAXA (e.g., anaphylactic reaction or anaphylactic shock) [see Adverse Reactions]. WARNINGS AND PRECAUTIONS Risk of Bleeding: PRADAXA increases the risk of bleeding and can cause signiﬁcant and, sometimes, fatal bleeding. Risk factors for bleeding include the use of drugs that increase the risk of bleeding in general (e.g., anti-platelet agents, heparin, ﬁbrinolytic therapy, and chronic use of NSAIDs) and labor and delivery. Promptly evaluate any signs or symptoms of blood loss (e.g., a drop in hemoglobin and/or hematocrit or hypotension). Discontinue PRADAXA in patients with active pathological bleeding. In the RE-LY (Randomized Evaluation of Long-term Anticoagulant Therapy) study, a life-threatening bleed (bleeding that met one or more of the following criteria: fatal, symptomatic intracranial, reduction in hemoglobin of at least 5 grams per deciliter, transfusion of at least 4 units of blood, associated with hypotension requiring the use of intravenous inotropic agents, or necessitating surgical intervention) occurred at an annualized rate of 1.5% and 1.8% for PRADAXA 150 mg and warfarin, respectively [see Adverse Reactions]. Temporary Discontinuation of PRADAXA: Discontinuing anticoagulants, including PRADAXA, for active bleeding, elective surgery, or invasive procedures places patients at an increased risk of stroke. Lapses in therapy should be avoided, and if anticoagulation with PRADAXA must be temporarily discontinued for any reason, therapy should be restarted as soon as possible. Effect of P-gp Inducers and Inhibitors on Dabigatran Exposure: The concomitant use of PRADAXA with P-gp inducers (e.g., rifampin) reduces exposure to dabigatran and should generally be avoided. P-gp inhibitors ketoconazole, verapamil, amiodarone, quinidine, and clarithromycin do not require dose adjustments. These results should not be extrapolated to other P-gp inhibitors. ADVERSE REACTIONS Clinical Trials Experience: The RE-LY study provided safety information on the use of two doses of PRADAXA and warfarin. The numbers of patients and their exposures are described in Table 1. Limited information is presented on the 110 mg dosing arm because this dose is not approved. Table 1 Summary of Treatment Exposure in RE-LY
Total number treated Exposure > 12 months > 24 months Mean exposure (months) Total patient-years
PRADAXA 110 mg twice daily 5983
PRADAXA 150 mg twice daily 6059
4936 2387 20.5 10,242
4939 2405 20.3 10,261
Warfarin 5998 5193 2470 21.3 10,659
Because clinical studies are conducted under widely varying conditions and over varying lengths of time, adverse reaction rates observed in the clinical studies of a drug cannot be directly compared to rates in the clinical studies of another drug and may not reﬂect the rates observed in practice. Drug Discontinuation in RE-LY: The rates of adverse reactions leading to treatment discontinuation were 21% for PRADAXA 150 mg and 16% for warfarin. The most frequent adverse reactions leading to discontinuation of PRADAXA were bleeding and gastrointestinal events (i.e., dyspepsia, nausea, upper abdominal pain, gastrointestinal hemorrhage, and diarrhea). Bleeding [see Warnings and Precautions]: Table 2 shows the number of patients experiencing serious bleeding during the treatment period in the RE-LY study, with the bleeding rate per 100 patient-years (%). Major bleeds fulﬁlled one or more of the following criteria: bleeding associated with a reduction in hemoglobin of at least 2 grams per deciliter or leading to a transfusion of at least 2 units of blood, or symptomatic bleeding in a critical area or organ (intraocular, intracranial, intraspinal or intramuscular with compartment syndrome, retroperitoneal bleeding, intra-articular bleeding or pericardial bleeding). A life-threatening bleed met one or more of the following criteria: fatal, symptomatic intracranial bleed, reduction in hemoglobin of at least 5 grams per deciliter, transfusion of at least 4 units of blood, associated with hypotension requiring the use of intravenous inotropic agents, or necessitating surgical intervention. Intracranial hemorrhage included intracerebral (hemorrhagic stroke), subarachnoid, and subdural bleeds. Table 2 Bleeding Events* (per 100 Patient-Years)
Randomized patients Patient-years Intracranial hemorrhage
PRADAXA 150 mg twice daily N (%) 6076 12,033 38 (0.3)
Warfarin N (%)
Hazard Ratio (95% CI**)
Life-threatening bleed Major bleed Any bleed
0.41 (0.28, 0.60)
Warfarin N (%)
Hazard Ratio (95% CI**)
0.80 (0.66, 0.98)
399 (3.3) 1993 (16.6)
421 (3.6) 2166 (18.4)
0.93 (0.81, 1.07) 0.91 (0.85, 0.96)
*Patients contributed multiple events and events were counted in multiple categories. **Conﬁdence interval
The risk of major bleeds was similar with PRADAXA 150 mg and warfarin across major subgroups deﬁned by baseline characteristics, with the exception of age, where there was a trend towards a higher incidence of major bleeding on PRADAXA (hazard ratio 1.2, 95% CI: 1.0 to 1.4) for patients *75 years of age. There was a higher rate of major gastrointestinal bleeds in patients receiving PRADAXA 150 mg than in patients receiving warfarin (1.6% vs. 1.1%, respectively, with a hazard ratio vs. warfarin of 1.5, 95% CI, 1.2 to 1.9), and a higher rate of any gastrointestinal bleeds (6.1% vs. 4.0%, respectively). Gastrointestinal Adverse Reactions: Patients on PRADAXA 150 mg had an increased incidence of gastrointestinal adverse reactions (35% vs. 24% on warfarin). These were commonly dyspepsia (including abdominal pain upper, abdominal pain, abdominal discomfort, and epigastric discomfort) and gastritis-like symptoms (including GERD, esophagitis, erosive gastritis, gastric hemorrhage, hemorrhagic gastritis, hemorrhagic erosive gastritis, and gastrointestinal ulcer). Hypersensitivity Reactions: In the RE-LY study, drug hypersensitivity (including urticaria, rash, and pruritus), allergic edema, anaphylactic reaction, and anaphylactic shock were reported in <0.1% of patients receiving PRADAXA. The risk of myocardial infarction was numerically greater in patients who received PRADAXA (1.5% for 150 mg dose) than in those who received warfarin (1.1%). DRUG INTERACTIONS The concomitant use of PRADAXA with P-gp inducers (e.g., rifampin) reduces exposure to dabigatran and should generally be avoided. P-gp inhibitors ketoconazole, verapamil, amiodarone, quinidine, and clarithromycin do not require dose adjustments. These results should not be extrapolated to other P-gp inhibitors. USE IN SPECIFIC POPULATIONS Pregnancy: Pregnancy Category C: There are no adequate and well-controlled studies in pregnant women. Dabigatran has been shown to decrease the number of implantations when male and female rats were treated at a dosage of 70 mg/kg (about 2.6 to 3.0 times the human exposure at maximum recommended human dose [MRHD] of 300 mg/day based on area under the curve [AUC] comparisons) prior to mating and up to implantation (gestation Day 6). Treatment of pregnant rats after implantation with dabigatran at the same dose increased the number of dead offspring and caused excess vaginal/uterine bleeding close to parturition. Although dabigatran increased the incidence of delayed or irregular ossiﬁcation of fetal skull bones and vertebrae in the rat, it did not induce major malformations in rats or rabbits. Labor and Delivery: Safety and effectiveness of PRADAXA during labor and delivery have not been studied in clinical trials. Consider the risks of bleeding and of stroke in using PRADAXA in this setting [see Warnings and Precautions]. Death of offspring and mother rats during labor in association with uterine bleeding occurred during treatment of pregnant rats from implantation (gestation Day 7) to weaning (lactation Day 21) with dabigatran at a dose of 70 mg/kg (about 2.6 times the human exposure at MRHD of 300 mg/day based on AUC comparisons). Nursing Mothers: It is not known whether dabigatran is excreted in human milk. Because many drugs are excreted in human milk, caution should be exercised when PRADAXA is administered to a nursing woman. Pediatric Use: Safety and effectiveness of PRADAXA in pediatric patients has not been established. Geriatric Use: Of the total number of patients in the RE-LY study, 82% were 65 and over, while 40% were 75 and over. The risk of stroke and bleeding increases with age, but the risk-beneﬁt proﬁle is favorable in all age groups [see Warnings and Precautions and Adverse Reactions]. Renal Impairment: No dose adjustment of PRADAXA is recommended in patients with mild or moderate renal impairment. Reduce the dose of PRADAXA in patients with severe renal impairment (CrCl 15-30 mL/min). Dosing recommendations for patients with CrCl <15 mL/min or on dialysis cannot be provided. OVERDOSAGE Accidental overdose may lead to hemorrhagic complications. There is no antidote to dabigatran etexilate or dabigatran. In the event of hemorrhagic complications, initiate appropriate clinical support, discontinue treatment with PRADAXA, and investigate the source of bleeding. Dabigatran is primarily excreted in the urine; therefore, maintain adequate diuresis. Dabigatran can be dialyzed (protein binding is low), with the removal of about 60% of drug over 2 to 3 hours; however, data supporting this approach are limited. Consider surgical hemostasis or the transfusion of fresh frozen plasma or red blood cells. There is some experimental evidence to support the role of activated prothrombin complex concentrates (e.g., FEIBA), or recombinant Factor VIIa, or concentrates of coagulation factors II, IX or X; however, their usefulness in clinical settings has not been established. Consider administration of platelet concentrates in cases where thrombocytopenia is present or long-acting antiplatelet drugs have been used. Measurement of aPTT or ECT may help guide therapy. ©Copyright 2011 Boehringer Ingelheim Pharmaceuticals, Inc. ALL RIGHTS RESERVED Revised: March 2011
6022 11,794 90 (0.8)
PRADAXA 150 mg twice daily N (%) 179 (1.5)
Heart from page 12 Cellular and molecular treatments
Stem cells will also have a seismic impact on the cardiovascular field in the coming years. While the worldâ€™s first stem-cell treatment (in the form of bone marrow transplants) occurred more than 40 years ago at the University of Minnesota, other types of stem cells, including adult and induced pluripotent stem cells, are just beginning to show their therapeutic promise. The power of induced pluripotent stem-cell technology lies in the ability to transform a patientâ€™s skin cell to form a heart cell. This technology potentially allows us to generate an unlimited number of heart cells from a patient who has heart failure. Not only would this technology allow an unlimited number of heart cells for transplantation; it also would provide us with heart cells where drugs can be tested in the laboratory setting before they are given to a patient, thus minimizing the potential adverse effects of various medications. This strategy allows us to pro-
Personalized medicine will play a huge role in prevention efforts. vide personalized treatment to each patient. The right treatment for the right patient
Cellular and molecular treatments also show potential in terms of personalizing medicine. The idea that we can grow some new heart muscle cells for a particular patient by using some of their skin cells will become a reality. In addition, molecular treatments, like the â€œmolecular Band Aidâ€? developed by the U of Mâ€™s Joe Metzger will continue to revolutionize heart failure therapies. These molecular treatments will be introduced into the body and used to unlock the heartâ€™s ability to repair itself. While these technologies are still in the laboratory, the results are promising in animal model studies. Personalized medicine will develop in terms of medications as well. Often the treatments we have for heart disease work, but
they come with a laundry list of side effects that are hard for patients to deal with. Using each patientâ€™s genetic information to find a medicine that will work the best with minimal side effects will become more commonplace, as research into what works best for various genetic profiles moves forward. Getting ahead of the problem
Prevention will be a growing area of cardiovascular disease. Instead of waiting for patients to present with symptoms, we will be working to reduce the risk factors for cardiovascular disease before these symptoms lead to costly and at times risky or invasive interventions. Personalized medicine will play a huge role in prevention efforts. Today the Rasmussen Cardiovascular Disease Prevention Program at the University of Minnesota can identify patients that have early stages of cardiovascular disease and
implement therapies before patients have an adverse event (heart attack or stroke). This intervention not only improves the quality of life for our patients and our community, but also results in both healthier citizens and the expenditure of fewer health care dollars. The Minnesota advantage
We are on the cusp of an exciting period in cardiovascular research and care. And we are lucky to be in Minnesota. Together with the next generation of cardiovascular specialists (cardiologists and cardiothoracic surgeons) who are training in our state, we will continue to build on the legacy of cardiac research and the cardiac biotechnology industry that our state has built and make a palpable impact in our patientsâ€™ lives and on our health care system. Daniel J. Garry, MD, PhD, is director of the Lillehei Heart Institute and chief of the Cardiovascular Division at the University of Minnesota.
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s of the summer of 2011, there are no effective therapies that arrest or reverse the symptoms of Alzheimerâ€™s disease (AD), nor are there any proven preventive strategies for people at risk. For the clinical diagnosis of dementia due to AD, a practitioner armed with a history, examination, routine CT or MR scan, and some simple blood work can do a reasonably good job. So, do practicing physicians need imaging or cerebrospinal fluid (CSF) biomarkers for the diagnosis of AD? At present, the answer is no. However, in the future, treatments for AD will be aimed at prevention, when at-risk individuals are still asymptomatic or at the very earliest symptomatic stages. We now believe that the pathological processes of AD have a long lead-in phase, years before dementia occurs. Therefore, physicians will need to diagnose and treat AD in people while they are asymptomatic or have, at most, subtle or minimal symptoms. Clinical diagnoses alone will be inadequate;
U P D AT E :
Diagnosing Alzheimerâ€™s disease Clinical and biomarker convergence By David S. Knopman, MD biomarkers of preclinical pathophysiology are needed. Defining AD dementia
First, letâ€™s be clear about the distinction between AD as a pathophysiology, and cognitive impairment (or dementia) as the clinical manifestations of the disease. AD refers to the biological processes that lead to the characteristic brain pathology of AD. In contrast, cognitive impairment and dementia are descriptive terms for loss of mental abilities from mild to severe. Biomarkers are for detecting the biological changes of AD, but only clinical acumen can establish whether or not a person has cognitive impairment.
The diagnosis of acquired cognitive impairment in middleaged and elderly people has undergone a major shift in the past decade, in the direction of increasing confidence in making diagnoses at milder stages of impairment. Cognitive impairment includes difficulties with thinking, memory, mental agility, and language functions. Some-times, but not always, the cognitive impairment is accompanied by substantial alterations in personality, interpersonal relationships, and behavior. The term dementia refers to cognitive or behavioral impairment that interferes with daily functioning. In contrast, the term mild cognitive impairment (MCI) is used to describe cognitive impairment that does not
substantially interfere with daily functioning. Usually, distinguishing between MCI and dementia is straightforward, but sometimes in mildly affected patients, the distinction is academic. What is not academic is the very important identification of whether or not a patient with cognitive impairment needs assistance in daily life or not. That decision has nothing to do with biomarkers. It has everything to do with taking a good history and assessing the patientâ€™s cognitive status objectively. That said, the future of AD therapeutics will undoubtedly focus on prevention of the cognitive symptoms of AD, and biomarkers will play a central role in that approach. New diagnostic criteria reflect advances in AD
The diagnostic criteria for dementia due to AD were recently revised, as the result of work by three expert workgroups spearheaded by the Alzheimerâ€™s Association and the National Institute on Aging ALZHEIMERâ€™S to page 19
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MINNESOTA PHYSICIAN AUGUST 2011
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You wouldnâ€™t give a 4-year-old a drink, so why would you give one to an unborn child? As a physician, itâ€™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.
Alzheimer’s from page 16 (NIA) of the National Institutes of Health (NIH). The updated criteria (published in Alzheimer’s and Dementia, May 2011) did not make any dramatic changes in the clinical criteria that have been used since 1984, when the first iteration appeared. Indeed, the clinical diagnosis of AD dementia has proved to be reasonably accurate compared to the pathological gold standard of the autopsied brain, but advances in the past 25 years led to the need for the update. Then and now, the core definition of AD dementia—based on information from the history and examination—is that it is a dementia in which the onset is gradual; the symptoms are steadily progressive, more or less; and difficulties with learning and short-term memory are usually the initial and most obviously debilitating problems. The new criteria acknowledge that AD dementia has a broader spectrum of cognitive difficulty than was understood in 1984, but with that broader spectrum has come the realization that identification of the AD pathophysiological process may be difficult on clinical grounds alone. For example, there are a number of patients, usually with onset of their symptoms prior to age 70 years, whose initial symptoms are aphasic (prominent word-finding difficulty), visuospatial (difficulties recognizing objects and faces or understanding geographical knowledge), or executive (what used to be called “frontal lobe” syndrome). Each of these syndromes may be caused by AD as well as non-AD diseases. The role of biomarkers in AD research, diagnosis
Biomarkers don’t add a lot of value in patients with clear-cut dementia. Even in providing increased certainty about the diagnosis of AD, positive biomarkers don’t change therapy now; nor do they clarify how fast a person will decline. When therapeutic options become available for mildly impaired patients and in those who might
be at risk for AD, biomarkers will be essential for defining the underlying disease. Therapeutic research in AD will increasingly rely on biomarkers for selecting subjects for participation. The added certainty of underlying etiology is reassuring to drug developers and federal regulators that a drug under study is targeting AD, not some non-specific target. Especially in situations where the research subjects are very mildly affected, the added diagnostic certainty provided by AD biomarkers will greatly enhance confidence in the research. And, if AD therapeutic research can actually deliver a potent intervention, biomarkers will justifiably enter clinical practice. Biomarkers can identify changes of AD biology in two ways. The first is to demonstrate abnormalities of the protein β-amyloid. The second is to prove that there is neurodegeneration in a pattern typical of AD. In the most widely accepted model of AD pathophysiology, β-amyloidosis is the first and necessary step in the AD cascade, and is entirely asymptomatic. Neurodegeneration— neuron and synapse loss— follows, with symptomatic cognitive impairment occurring thereafter. Brain imaging and cerebrospinal fluid (CSF) analysis are the two approaches to biomarkers. The amyloid story goes back to the first description of AD, more than 100 years ago, by German psychiatrist and neuropathologist Alois Alzheimer, who showed that there was an abnormal accumulation of a protein with the staining characteristics of amyloid. The unique β-amyloid protein in AD was first sequenced in 1984. By the mid-1990s, CSF assays for amyloid had been developed. Low CSF β-amyloid was shown to correlate with AD dementia. Positron emission tomography (PET) imaging of β-amyloid was first introduced in 2004. The radiotracer known as Pittsburgh compound B (PiB) used carbon-11 as its radiolabel. Unfortunately, because
carbon-11 has too short a halflife, C-11 PiB will never be available commercially. However, several companies are developing commercially practical fluorine-18 amyloid imaging compounds. One company, now owned by Lilly, has made a presentation before the FDA in order to gain regulatory approval for clinical use of amyloid PET imaging. At present, brain amyloid imaging is not available, and if the FDA approves its use, the indications for this expensive imaging test have yet to be determined.
There is a very strong inverse correlation between levels of β-amyloid in the CSF and levels measured by PiB PET. Thus, the two biomarkers are probably interchangeable. CSF β-amyloid assays are currently available for clinical use, but the test is performed infrequently. No insurance carriers cover the test. Patients’ fears of lumbar punctures may be a limiting factor in the use of CSF amyloid, but that fear is unwarranted. Lumbar puncture is a ALZHEIMER’S to page 36
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P R O F I L E S I N A D M I N I S T R AT I O N Administration from cover health care systems. All of them have contributed to their organization’s development and to improving health care delivery. Many have also participated in professional association and/or legislative and government activities. In addition to information about title/background, we asked each administrator to respond to two questions: • What current challenges is your practice addressing? • If you could change one thing about the health care delivery system, what would it be? Their responses are excerpted below. We are confident that the comments of these administrators reflect the concerns and viewpoints of their peers, in Minnesota and across the nation. We congratulate them on their achievements in the health care community, and thank them for participating in this feature.
Tri-County Health Care, Wadena
Family HealthServices Minnesota, PA
Fairview Range, Hibbing
Title: President and chief executive officer (since 2008) Background: Previously controller (1986–1988) and director of financial services (1998–2008) at Tri-County. Challenges: Successfully implementing Epic System to complete our conversion to an electronic medical record system. Provider recruitment. Access to outreach specialty care, especially in shortage areas (e.g., dermatology, rheumatology, neurology). Economic challenges (state budget, general economy, federal health reform). Continuing to develop as an integrated health system to achieve the maximum benefit for the community. Adapting to patients’ and families’ changing and expanding expectations. Change: To eliminate or simplify the unnecessary, duplicative, overwhelming administrative issues that frustrate and hinder providers’ ability to provide highquality, patient-focused care.
Title: CEO (since 2002) Background: In a senior leadership capacity with FHSM for the past 19 years. Challenges: FHSM is an independent family practice group of 12 clinics and 70 providers in the east metro area. Current challenges revolve around restructuring care delivery to effectively coordinate and deliver care with the greatest value. Worked closely with the payers to structure payment and incentives to align with the Triple Aim (low cost, high quality, and patient satisfaction). Transitioning from a volume-based to a carebased payment mechanism is extremely problematic, as we have had to invest ahead of appropriate payment structures. Change: The payment-per-code system. If at an appropriate level, global payment for population care with incentives around the Triple Aim allows us to allocate resources more efficiently.
Title: President and CEO (since 2010) Background: Twenty years of CEO experience in the health care sector. Challenges: Solving new questions and challenges under health care reform. With the unknowns of health care reform, the accelerated rate at which new procedures are available, and the availability of advanced technologies, we are paving the way for a new generation of health care delivery options. Change: To provide care in the most patient-friendly, timesensitive manner possible. Often our patients are forced to jump through hoops and make re-visits to obtain care. This system is often driven by the manner in which we get paid. One of the good things about health care reform is greater focus on providing quality health care in more innovative ways.
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MINNESOTA PHYSICIAN AUGUST 2011
P R O F I L E S I N A D M I N I S T R AT I O N
Matt C. Brandt
Multicare Associates, Fridley
Bethesda Hospital (HealthEast Care System)
Mayo Clinic Health System
Northwest Eye Clinic, Minneapolis
Title: Operations administrator (since 2010) Background: Center for Diagnostic Imaging, 1996–2006; Mayo Clinic, Rochester 2006– present. Member, American College of Healthcare Executives; president-elect, Minnesota Medical Group Management Association. Challenges: Delivering a consistent, high-quality patient experience across the Mayo Clinic Health System’s 71 locations. Integrating primary, secondary, and tertiary care across our system and delivering the right care in the appropriate setting across our various locations. Change: To change from a fee-forservice model to a system that pays for good outcomes delivered with good service in a safe environment. Care decisions should always be made with the patient’s best interest in mind.
Title: Executive director (since 2000) Background: Fellow in the American College of Medical Practice Executives. Past experiences in health care consulting, managed care, and innovative health care services development. Challenges: Preparing for changes in health care delivery that might include remote consultations, social media engagement with patients, and electronic sharing of data with other independent providers. Change: To eliminate the requirements by payers and government that add cost without value to the patients. Regulatory compliance comes at a cost that often adds expense without improving the delivery of care to patients. Providers need to focus on what is important to patients and staff; with that in mind, they will be able to deliver extraordinary services at an affordable price.
Title: Chief financial officer (since 2008) Background: Three years with Multicare Associates; held positions with HealthPartners Central Minnesota Clinics and with Brandt Medical Management. Challenges: To be paid equitably, as an independent primary care clinic. We are attempting to convince health care purchasers to invest in independent primary care groups that can deliver high quality care at a lower cost. Change: Eliminate the misuse of the terms “accountable” and “community need.” Are we really “accountable” if we continue to raise health care costs by greater than 10 percent every year? Does the community really “need” hospital lobbies with grand pianos and water fountains or another joint replacement center with an MRI machine?
Title: Operations executive (since 2010) Background: Fifteen years of experience in health care. Challenges: One opportunity is continuing education about what a long-term acute care hospital (LTACH) is and what its place is in the care continuum. Bethesda is the only nonprofit LTACH in the community. Bethesda has a case mix index that is higher than many local ICUs. We look for opportunities to educate physicians about Bethesda’s high quality outcomes. Change: Tighter coordination of care—better handoffs during transitions for patients. We hear about that from our patients at Bethesda and from the community as we work with short-term acute care hospitals, clinics, home care, and skilled nursing facilities (SNFs).
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www.mppub.com AUGUST 2011
P R O F I L E S I N A D M I N I S T R AT I O N
Bonnie A. Francisco
Dermatology Specialists, PA
Riverwood Healthcare, Aitkin
Title: Clinic administrator (since 2009) Background: Certified medical practice executive. Member, Medical Group Management Association. Principal, health care, LarsonAllen (1995â€“2009). Challenges: The current mandate for independent medical clinics to develop an electronic infrastructure in areas such as medical records, prescribing, and quality measurement puts significant stress on our financial, technological, and human resources. Managing through these operational changes without compromising the quality of patient care and interrupting the patient flow is very challenging. Change: Create open-access communication among the providers, patients, and payers. It confounds me that the key players in designing and implementing the health care system (patients, doctors, and insurance companies) rarely talk to each other!
Title: COO (since 2006) Background: Prior to 2006 worked for MeritCare Health Systems in Fargo, N.D., in administrative and management roles ranging from family medicine and psychiatry to neurology and general surgery. Challenges: All hospitals need to establish how we can leverage technology and practice redesign to support wellness and preventive medicine while simultaneously producing better quality outcomes in a more cost-effective manner. This will require fundamental changes in how we care for patients and deliver services. Change: The health care delivery system. We need to align payment with quality outcomes. With the payment system we have today, exceptional management of a patientâ€™s health could drive health care organizations out of business.
Neurosurgical Associates, Ltd., Minneapolis
Adult & Pediatric Urology (APU) and Central Minnesota Surgical Center (MSC), Sartell
Title: Administrator (since 2000) Background: In health care administration since 1982. President of Minnesota Medical Group Management Association (MMGMA) in 2000. Challenges: Preserving and promoting our independent, specialty practice in the marketplace. Providing exceptional, personal care to our patients has become increasingly challenging as we are constantly implementing state and federal policy requirements. Being cost-conscious in an environment demanding expenditures for electronic medical records, evidencebased clinical score cards, and clinical and technical advances. Change: Identify the patients with chronic conditions who generate the largest costs, and work with these patients and their families so they see the right doctor at the right time and comply with the advised plan of care.
Title: CEO/ administrator, APU; administrator, MSC (since 2003) Background: Board member, Minnesota Medical Group Management Association. Chair, Central Minnesota Clinic Managerâ€™s Association. Challenges: Private practices/ surgical centers face increased regulation, increasing consolidation in the industry, declining reimbursements, uncertainty regarding health reform, and physician angst regarding the changing nature of medical practice. Change: To establish an economically sustainable, high-quality, market-based health care delivery system where the governmentâ€™s role is limited to providing a needed safety net; patients have a high degree of personal responsibility for behavior; and providers are rewarded for managing outcomes and overall cost of care.
Congratulations to Matt Brandt for being Recognized for outstanding achievement in Health Care Administration.
Congratulations Barb Daiker xON BEING RECOGNIZED FOR OUTSTANDING ACHIEVEMENT IN HEALTH CARE ADMINISTRATION 4HE PHYSICIANS AND STAFF AT .ORTHWEST %YE CONGRATULATE AND THANK YOU FOR YOUR EXCEPTIONAL LEADERSHIP AND CONTINUED DEDICATION TO OUR PRACTICE AND OUR PATIENTS
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MINNESOTA PHYSICIAN AUGUST 2011
P R O F I L E S I N A D M I N I S T R AT I O N
Mary L. Jenkins
Partners in Pediatrics, Ltd.
ObGyn Specialists, Edina
Midwest Spine Institute
Title: Clinic administrator (since 1976) Background: Career at PIP has spanned 35 years. During that time, the practice has grown from a group of four providers and six staff members into a group of 38 providers and 150 staff members at five sites. Challenges: The transition to electronic medical records. We are exploring all aspects of the system with a number of other groups and our hospital partner. We are certain that, together, we can create a community system that will be mutually beneficial to all participants. Change: To improve access to health care for all children. As caregivers to the smallest and most vulnerable patients, this is always a concern. Most current models focus on adult medical care issues and not the unique needs of children. There is a huge need for behavioral and mental health care for children.
Title: Administrator (since 1988) Background: Twenty-three years in current position. Challenges: Trying to guide our organization in the right direction in an efficient and effective manner as the chaos continues to unfold. It is harder than ever to predict what health care will be in the next three to five years. We have always tried to stay ahead of the curve. Innovation has led us through a successful divisional merger, involvement with the Institute for Clinical Systems Improvement (ICSI)—as the only independent ob-gyn group—and other collaborative efforts with hospital systems and payers. Change: Creating a true understanding and appreciation for what our physicians do every day. I would love to see a closer link between patient and physicians without third-party involvement (which often serves to complicate and add cost to the system).
Title: Administrator (since 2009) Background: Twenty-five years’ experience in health care administration. Current president, Minnesota Medical Group Management Association. Challenges: 1) Out-of-control costs incurred in our fragmented health care system. 2) Meaningful use requirements written with primary care providers, not specialty groups, in mind. 3) E-prescribing that unnecessarily duplicates efforts and expense. 4) Accountable care organizations. 5) Peer grouping program development. Change: Federal reform that would develop a nationwide infrastructure for electronic health records for interoperability instead of providing funding to nonprofits to develop their own systems. Patients would then be able to access their medical records anywhere, anytime, for both traditional and complementary health services.
Northwest Family Physicians, Crystal
Title: Administrator (since 1990) Background: Thirty years in health care, in both hospital and clinic settings; nearly 22 years at NWFP. Challenges: Working on meaningful use certification to qualify for federal funds and on health care home certification. Building a new, $15 million medical office building, new imaging center, and administrative/business offices. Change: Improve our payment system. Our clinic is paid 25 to 35 percent less than is paid to the large systems based on fee schedule payments. Our clinic has consistently delivered what is most desired in today’s market: high quality at a low cost, according to the health plans’ quality and cost reported data. Ongoing underpayment to independent clinics will ultimately result in a loss of quality and increased costs through less competition.
Neurosurgical Associates, LTD is pleased to welcome… Christopher D. Roark, M.D. Dr. Roark will be practicing at 913 E. 26th St., Suite 305, Piper Building, Minneapolis, MN Partners with Dr. Roark are: Mahmoud Nagib, M.D. Thomas Bergman, M.D. John Mullan, M.D. Walter Galicich, M.D. Michael McCue, M.D., Sc.D. Call 612-871-7278 for appointments.
P R O F I L E S I N A D M I N I S T R AT I O N
Thomas F. Reek
Cuyuna Regional Medical Center, Crosby
Lakewood Health System, Staples
Minnesota Eye Consultants, PA, Bloomington
North Clinic, Twin Cities
Title: CEO (since 1980) Background: Joined the medical center in 1974. On the board of directors of Central MN Diagnostic, Inc. and SISU Medical Systems. Member of the American College of HealthCare Administrators, Brainerd Lakes Community Foundation, and Brainerd Lakes Chamber of Commerce. Challenges: Recruitment of physicians and other professional staff for our level III trauma hospital, as well as current economic changes. Change: Our communities want quality, compassionate, affordable health care. To better meet their expectations, I would like to streamline the whole health care system for our patients and customers by continuing to develop quality relationships with other providers and systems.
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Title: President/ CEO (since 1980) Background: Thirty-seven years in health care administration. Challenges: Reforming physician practice into value/quality emphasis. Including patients in their care. Using personnel at the top of their licenses. Developing education to enable patients to make good choices. Understanding patients’ life/health choices and keeping them aware of health delivery changes and choices. Getting the right mix of quality care and quality measurements for provider buy-in. Developing payment systems and incentives based on value. Recruiting primary care and specialists. Accessing capital for capital needs. Balancing desired practice with customer expectations. Getting enough time to educate/train physician leaders. Change: Changing reimbursement to provide the incentives to do what is best for providing evidence-based medicine to patients.
Title: President/ COO (since 1999) Background: More than 30 years of practice management experience. Past president of Minnesota Medical Group Management Association and American Society of Ophthalmic Administrators. Challenges: The unpredictability of health care reform, government mandates, and market response. Independent practices’ fears of being forced to consolidate or join an integrated delivery system. Dealing with flat or declining reimbursement levels as business expenses continue to increase. State and federal mandates that are increasing the administrative burden and cost of providing care. Change: Create a system that engages the patient to be motivated and inspired to live a healthy lifestyle, proactive about prevention, compliant with care recommendations, and a good steward when using health care resources.
Title: Executive director (since 2004) Background: Twenty-five years of experience in primary care and specialty operations. Challenges: Physician recruitment. Physicians are in short supply and often choosing to work in larger systems, due in part to financial incentives being offered to new recruits. This makes it more difficult for independent practices to compete. Change: The disparity in reimbursements! Hospitals and larger health care systems receive higher reimbursements for delivering the same services provided by smaller independent practices. As a result, many independent practices are being acquired by larger systems, at the expense of patient satisfaction. If the insurance industry would shift the focus from volume to outcomes, and reimburse services equitably, the patients would ultimately win.
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MINNESOTA PHYSICIAN AUGUST 2011
P R O F I L E S I N A D M I N I S T R AT I O N
St. Croix Orthopaedics, PA
Affiliated Community Medical Centers, PA
Integrity Health Network, LLC
St. Cloud Medical Group
Title: President and CEO (since 2005) Background: With the organization since 1997. Challenges: Our network of independent clinics faces a bias by federal, state, and commercial payers toward big corporate medicine in reimbursement. Recruitment is a challenge, as new physicians are selecting reduced hours and the security of employment by big systems over the excitement of practicing in an independent environment. Evergrowing government regulations on health care practice. Change: To allow true competition in the health care delivery system and remove regulatory and reimbursement barriers that discourage competition on an even footing. Then we would quickly see where the patient truly comes first in action and practice—not just in marketing.
Title: Administrator (since 2006) Background: Director of finance for Brainerd Medical Center 2004– 2006; controller, then administrator, for St. Cloud Orthopedics, 1992–2004. Challenges: Implementing an electronic health record as a small, physician-owned clinic. We began installing the new practice management system in July 2010 and the electronic chart in October 2010. We are continuing to improve on workflows and getting all the interfaces completed to be able to deliver services efficiently. Change: We need to 1) make some very difficult decisions about endof-life care; 2) work more closely with patients on healthy lifestyle choices, 3) emphasize nutrition education (which is a societal issue as well as a health care issue); and 4) simplify the system and/or provide guidance in navigating it.
Title: COO (since 1999) Background: In health care for more than 20 years; at St. Croix Orthopaedics for 12 years. Challenges: Negotiating the various regulatory issues while managing patient expectations and maintaining profitability. There are many large initiatives on the horizon (e.g., ICD-10, meaningful use criteria, electronic health records). Successfully navigating and implementing these items, in addition to the day-to-day operational expectations, creates a significant challenge for independent practices. Change: Reducing the complexity of the health care system and standardizing the things that make sense to support a more streamlined patient experience. Many of the proposed and ongoing health care regulations place invisible barriers between physicians and patients, which hamper the ability to focus on human interactions.
Title: Administrator (since 1998) Background: Director of operations at ACMC from 1994 to 1998. Challenges: Strategically, the primary challenge is managing transitional change from an episodic health care model to a performance-based health care system. Operationally, the challenges are balancing patient demands with physician lifestyle, managing the integration of technology into physician practices, and maintaining the overall health and vitality of our practice. Change: To develop a more coordinated approach to health care reform, versus the present uncoordinated discussion dominated by special interests. For the most part, we are seeing a situation of worrying more about whose ox is getting gored, as opposed to looking at the broader picture. This dilutes the voice of all health care providers.
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his disease was what the ancients called hydrocephalus from water which is stored in the head and gradually collects. In this case, however, the water had not collected between the skull and its outer surrounding membrane or the skin but in the cavity of the brain. This cavity and breadth of these had so increased—and the brain itself was so distended— that they contained about nine pounds of water of three Augsburg wine measures.” —Andreas Vesalius (1514–1564 AD), first accurate anatomic description of ventricular dilation and hydrocephalus
An estimated 14 percent of the United States population over age 70 will suffer from dementia. The incidence increases with age, with the most prevalent etiologies being Alzheimer’s dementia (69.9 percent) and vascular dementia (17.4 percent). The remaining 12.7 percent of cases are due to a variety of causes, including Parkinson’s dementia, frontal dementias, post-traumatic dementia, alcoholic dementia, and normal pressure hydrocephalus.
Normal pressure hydrocephalus Diagnosis and treatment of a reversible cause of dementia By Charles R. Watts MD, PhD, and Edward G. Hames III, MD, PhD Normal pressure hydrocephalus (NPH) accounts for approximately 5 percent of the population diagnosed with dementia. Although this represents a small portion of the population affected, the diagnosis is important because of the possibility of effective treatment with excellent results. This translates into improved quality of life, decreased need for supervised care, and potentially significant cost savings for the health care system. Diagnosing NPH
The diagnosis of hydrocephalus as a malady of the cerebral spinal fluid (CSF) space was initially described from an anatomic
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MINNESOTA PHYSICIAN AUGUST 2011
perspective in the mid-16th century. However, the physiology of CSF production, circulation, and absorption was not elucidated until the late 19th and early 20th centuries. Despite continued progress, the development of safe and effective treatment did not occur until the mid-20th century with the development of the ventriculo-peritoneal and ventriculo-atrial shunts. Hydrocephalus was initially considered to be a condition of CSF overproduction, underabsorption, or ventricular obstruction that resulted in elevated intracranial pressures with associated neurological decline of the patient, and, eventually, death. In 1965, the Columbian neurosurgeon Salomon Hakim identified and published a case series of patients presenting with gait disturbance, cognitive decline, and urinary incontinence with normal intracranial pressures who improved with placement of a ventriculo-peritoneal shunt, coining the term normal pressure hydrocephalus. Making the correct diagnosis of NPH can be a difficult task. The number of conditions that may present with gait instability, cognitive decline, and urinary incontinence are myriad and should be included in the differential diagnosis and evaluation. These include: neurodegenerative disorders (Alzheimer’s dementia, Parkinson’s dementia, etc.), vascular dementias, infectious diseases (Lyme disease, HIV, syphilis, etc.), urologic disorders, psychological disorders (depression), spinal disorders (cervical myelopathy and lumbar stenosis), and other hydrocephalic disorders. In order to acknowledge the differing degrees of diagnostic certainty, a classification system of probable NPH, possible NPH, and improb-
able NPH has been proposed. The diagnosis of probable NPH is based on clinical history, brain imaging (CT or MRI), neurologic examination, and physiologic data. The patient should be older than 40 years with an insidious onset of symptoms that has been progressive over the last three to six months in the absence of other neurologic, psychiatric, or general medical conditions that may explain the symptoms. Brain imaging should demonstrate ventricular enlargement not entirely attributable to cerebral atrophy or congenital ventricular enlargement. Examination of gait reveals decreased step height, length, and cadence with a widened standing base, often described as “magnetic gait.” Cognitive impairment may include psychomotor slowing, decreased fine motor speed and accuracy, difficulty maintaining attention, and impaired recall (memory). The Mini Mental Status Exam (MMSE) is often used for evaluation. Urinary symptoms should be documented as being either episodic or persistent and not attributable to other primary urologic disorders. Urgency, frequency, nocturia, and associated fecal incontinence should also be documented. A urinalysis/ urine culture (UA/UC) is often beneficial. Although formal urologic examination with bladder electromyogram and cystometrogram (EMG/CMG) is sometimes performed, this level of investigation is usually not required. A lumbar puncture with opening pressure measured in the lateral decubitus position should be obtained (5–18 mmHg is compatible with NPH) and routine CSF studies sent for evaluation (cell count with differential, protein, glucose, aerobic and anaerobic cultures, fluorescent treponemal antibody, and lyme titre). The CSF studies should be within expected normal ranges. Patients who are unlikely to have a diagnosis of NPH typically do not have any of the classical clinical triad of NPH symptoms (gait instability, cognitive decline, and urinary incontinence). Their presenting symptoms and complaints may be
explained by other, more plausible diagnoses. Imaging studies of the brain may vary based on a likely differential diagnosis. Neurologic examination that demonstrates evidence of increased intracranial pressure is also incompatible with the diagnosis of NPH. These patients will often require further neuropsychological, neurological, medical, and imaging studies to determine the etiology of their symptoms. Another population of patients will have a diagnosis of possible NPH. These are generally individuals who present with one or two symptoms of the classical clinical triad and have a brain imaging study consistent with hydrocephalus and no evidence of increased intracranial pressure on neurologic examination or lumbar puncture. Treating NPH
FIGURE 1. Diagram of an implanted ventriculo-peritoneal or ventriculo-atrial shunt system. (Illustration used with permission of Medtronic) FIGURE 2: An 84-year-old female with a six-month history of gait instability, cognitive decline, and urinary incontinence. Top image, CT of the head demonstrating significant ventricular enlargement. Bottom image, six months postplacement of ventriculo-peritoneal shunt (manufactured by Medtronic Neurologic Technologies) with good decompression of the ventricular system. The patient experienced excellent results with a near total return of normal cognitive and ambulatory function.
Once a potential diagnosis of probable or possible NPH has been made, a decision should be made for possible treatment. Traditionally, neurologists and neurosurgeons have used a vari-
ety of tests to confirm the diagnosis of NPH and determine whether the placement of either a ventriculo-peritoneal or ventriculo-atrial shunt would be of benefit. These tests have includ-
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ed radionucleotide cisternography, single large-volume LPs and serial LPs with post-LP neuropsychological and gait assessment, as well as inpatient CSF diversion with a lumbar drain.
None of these tests, with the exception of prolonged CSF drainage with a lumbar drain, have very high sensitivities or specificities. The disadvantage of the lumbar drain is that it requires a hospital admission with the associated risk of drain dislodgement, infection, and uncontrolled drainage. Because of the inadequacy of current testing methods and the requirement of hospital admission for prolonged lumbar drainage, many groups, including our own, have opted to surgically implant a shunt system as the best choice of a definitive diagnostic test and treatment of the patient. We generally implant a programmable valve set to a higher draining pressure and gradually “dial the pressure down” over several months to prevent potential overdrainageassociated complications. The shunt system (Fig. 1) consists of a proximal ventricular catheter that passes through the skull, dura, and cortex of the brain to give access to the ventricular system where CSF is NPH to page 31
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.M. is a 26-year-old male who presents with a six-month history of delusions and auditory hallucinations, in addition to erratic sleep patterns. His past medical history includes alcohol abuse in college (where he also attended AA meetings and completed a treatment program), drug use, and mild social anxiety. He does not have a psychiatrist or psychologist and has never taken neuroleptic medication. E.M. began having delusions that his upstairs neighbor— whom he had never formally met—was trying to kill him. He would hear shuffling of feet, as if many people were walking about, and gunshots emanating from the upstairs condo. He was so frightened one night that they were going to shoot into his condo, he curled himself under his coffee table the entire night and did not sleep. On another occasion, he decided to seek help at Hennepin County Medical Center at 3 a.m., but soon after checking in decided to leave. His family states that his delusions have become worse, to
First-episode psychosis The effects of early intervention on suicide risks and rates By Claudia Campo-Soria, MS
the point that he has hired professional electronic bug sweepers to come to his unit to make sure they removed all the bugs that he says his neighbor has planted to spy on him. E.M. has also confronted the neighbor about his intentions to harm E.M. and has called the police on him. E.M’s family is concerned that he will be thought of as a menace in his building and this may have negative repercussions for him. E.M. is a successful software engineer at a large firm, but recently his work performance and attendance have declined. He recently broke up with his girlfriend and states that he started drinking one scotch per day. First-episode psychosis (FEP) is defined as the first presentation of psychotic symptoms,
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which usually occur in adolescents and young adults. Like E.M., FEP patients often present as confused, scared, depressed, socially isolated, and devastated by the changes to their lives and goals. Most often patients suffer trauma related to their disturbing symptoms and increased physical and psychological risks, including suicide. Early intervention in FEP has been found to be valuable in alleviating the distress and anxiety related to psychotic symptoms, in addition to reducing suicide risk and rates. Yet treatment delays are common, either because the individual fails to seek help or because health care practitioners fail to recognize psychotic symptoms. Understanding first-episode psychosis
First-episode psychosis patients are frequently adolescents or young adults, more often male. They usually have a history of unemployment and/or dropping out of school due to symptoms and can often be socially isolated. These patients typically present to the emergency department of a hospital with many troubles, such as aggression, suicidal tendencies, and/or history of substance abuse, and often become involuntary patients. Symptoms of psychosis can range from delusions to hallucinations to erratic behaviors and disorganized thoughts. People with FEP can present with all or some of these symptoms and may appear agitated or depressed. They may or may not have insight into their behavior.
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Risk factors for first-episode suicidal behavior
The single most significant physical threat to FEP patients is suicide. It is the leading cause of death in patients with schizophrenia, and it is estimated that
two-thirds of these suicides occur within six years of the appearance of initial symptoms. Notable risk factors for suicidality (i.e., the likelihood of an individual completing suicide) in individuals with FEP have been identified as eliciting symptoms of psychosis, female gender, depression, alcohol and substance abuse, traumatic or stressful events in the first months before psychosis onset, poor social support, family history of suicide, and previous suicidal attempts. Early age of psychosis onset is associated with significantly increased rates of lifetime suicidality. These strong associations between risk factors and suicidal plans/attempts highlight the need for special crisis programs and interventions focused on suicidal ideation and behavior that are designed for individuals experiencing first-episode psychosis. Gender differences
Though the onset of psychotic symptoms can be preceded by nonspecific changes in behavior, emotional, and cognitive states, frequent signs and symptoms of the early phases of psychosis can also manifest as sleep disturbance, anxiety, anger/irritability, depressed mood, functional decline, social withdrawal, poor concentration, suspiciousness, avolition, and anergy. Males generally have an earlier onset of psychotic symptoms and a more severe form of the disease, indicated by greater cognitive and social impairment, whereas females are more likely to endure anxiety and affective symptoms. Choi et al. (J Korean Med Sci 24, 2009) demonstrated that the frequency of prodromal symptoms of FEP tends to differ between males and females. Typically, males demonstrate more frequent negative symptoms (e.g., flat affect, poverty of speech, inability to experience pleasure, lack of motivation) and attenuated positive symptoms (e.g., delusions; disordered thoughts and speech; tactile, auditory, visual, olfactory, and gustatory hallucinations) and females usually experience attenuated positive symptoms and mood symptoms (e.g.,
depression and mania). It has also been reported that the prodromal (pre-onset) period is usually longer in females than males, and the duration of untreated psychosis has been shown to be significantly longer in males than females. This suggests that the greater degree of functional impairmentâ€”both cognitive and socialâ€”seen in males may be influenced by the extended duration of exposure to negative symptoms and the relatively younger age of onset of the prodromal phase in males. Considering the manifestation of neurobiological differences between men and women in FEP, it is important for clinicians to consider the role gender plays in assessing nonspecific symptoms in the presence of attenuated positive symptoms and in determining treatment modalities for FEP patients. Prevalence and characteristics of suicide in FEP
People who suffer from psychosis during their lifetime tend to be at significant risk for suicide, with the highest peak occurring in their first episode. This period of greater risk of suicidality usually occurs before the person seeks or receives treatment. In addition, it is a time when behaviors that heighten suicide risks, such as depression and substance use, are prevalent. Compared to people with psychosis who have undergone treatment, untreated patients tend to undergo more violent suicide attempts. Robinson et al. (Aust NZ J Psychiatry 43, 2009) found that the most common method of suicide in FEP was hanging; other methods were lying or jumping in front of a train, jumping off a bridge, gunshot wound, overdose, and drowning. Studies have found that 14 percent to 28 percent of FEP patients have attempted suicide before undergoing their first treatment for psychosis and 6.5 percent to 11.3 percent of FEP patients have attempted suicide or engaged in self-injurious behavior in the time between their psychosis onset and initiation of treatment, also known as
the duration of untreated psychosis (DUP). A study by Barrett et al. (Schizophr Res 119, 2010) showed that prolonged DUP was associated with an increased risk of suicide attempts. It has been postulated that this association could be due to a longer opportunity time to attempt suicide or a prolonged exposure to psychotic symptoms, which is traumatic and distressing. Many patients with FEP encounter feelings of loss of hope and aspirations, disruption of their lives, and social isolation. In addition, it has been found that a prolonged DUP is related to a diminished quality of life. In a study by Cougnard et al. (Psychol Med 34, 2004), FEP patients who demonstrated poor premorbid functioning and atrisk behavior (e.g., substance abuse) were more apt to delay treatment. The relationship between suicide attempts and DUP is crucial. Early intervention in FEP may not only reduce and alleviate the psychosocial and physical anguish of psychosis, but may also help prevent suicidal behavior. This correlation between DUP and suicide risk was examined by Melle et al. (Am J Psychiatry 163, 2006), who developed an early detection program for FEP patients. This program formed a â€œcatch areaâ€? where FEP people came into treatment at an earlier phase of their disorder and with lower symptom levels. The results showed that areas offering the early detection program tended to have less severe suicidality reports than areas that did not incorporate an early detection program. Pathways to care: accessing early intervention
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Roger and Cortes (Am J Psychiatry 150, 1993) defined pathways to care as â€œthe sequence of contacts with individuals and organizations prompted by the distressed personâ€™s efforts and those of his or her significant others to seek help.â€? It is important to recognize the various types of pathways to care and their accessibility and effectiveness to FEP
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PSYCHOSIS to page 30 AUGUST 2011
Psychosis from page 29 patients, given the correlation between poor functional/clinical outcomes and delayed treatment. Factors that influence care pathways include social and cultural circumstances, accessibility of health services, and identification of and response to symptoms of the individual experiencing FEP. Studies have also shown that the process of seeking help and referral delays the impact of DUP, but that referral delays may be the greatest impedance to prompt treatment. Well-known pathways of care for FEP patients range from general practitioners and psychiatrists to emergency services, social services, police, school counselors, and religious organizations. However, there have been frequent reports of negative experiences with police and emergency services, which result in poor treatment adherence and/or disappointment with treatment services, causing individuals to discontinue seeking help.
Interestingly, Norman et al. (Psychol Med 34, 2004) found that patients who were already receiving mental health care from a psychiatrist and/or psychologist at the time of onset of psychotic symptoms experienced a referral delay about four times greater than the referral delay for patients who sought care after the onset of symptoms. This may be attributed to the difficulty health care providers face in either recognizing the symptoms of the early phases of psychosis or in teasing these symptoms out from other psychiatric conditions the patient may be experiencing. It may also be related to the challenge practitioners face in persuading patients to take medication for a different disease. Families of FEP patients frequently seek help either through non-physician contacts or personal contacts. Each of these resources plays an important role in linking the patient to psychiatric services and/or resources to expedite the helpseeking process.
Come to the Alexandria Lakes Area... • Dermatology • Emergency Medicine • Family Medicine • Internal Medicine • Pediatrics 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
Increasing methods and developing better systems for FEP patients to access aid can potentially improve overall outcomes of the disorder and prevent significant disability and delay in accomplishing social, educational, and career milestones. It can also reduce the psychological distress experienced by both family members and patients. Benefits of early intervention
Collectively, the data have shown that the suicide rate in the FEP population is substantially elevated, about 24 times greater than similarly-aged members of the general population. This highlights the need to create systems to reduce suicidal behavior in FEP patients. Research has shown that FEP patients who were treated by an early intervention specialist showed lower suicide rates for the length of the treatment than those who were not treated by specialized services. It would also be beneficial to implement streamlined discharge processes that involve a
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thorough risk assessment and a seamless referral process. A system of routine screening and evaluation for suicide risk, even at the point of discharge, could reduce suicidal behavior, considering the strong correlation that the data indicate between suicidal ideation and attempts, and future risk of suicidality. For patients like E.M., early intervention can help them understand their illness and develop skills that can help them live healthier and happier lives. Multidisciplinary services aimed at providing comprehensive assessment and treatment of psychotic illness as soon as possible after the development of a first episode of psychosis can relieve the burden of mental illness for both patients and their families. Claudia Campo-Soria, MS, is a fourthyear medical student at the University of Minnesota, Minneapolis.
Access Hospital, and attached Geriatric Psych Unit and LTC facility. We also provide services to the Mille Lacs Band of Ojibwe. Minimum qualifications: Must have an MD/DO in medicine from an accredited school and be licensed to practice in the state of Minnesota. • 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 seeking a Family Physician to join their rural practice on the southern tip of Lake Mille Lacs in Onamia, Minnesota. Our 7 Family Physicians, 8 PAs, and a Gen Surgeon provide a unique rural health opportunity with 4 outreach clinics, a 25-bed Critical
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 crosscountry skiing. Practice medicine where your skills and experience can be fully utilized, and where you can make a difference.
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Caring for body, mind and spirit To learn more about our practice, please visit our website at www.broadwaymedicalcenter.com
MINNESOTA PHYSICIAN AUGUST 2011
NPH from page 27 produced. This is attached to a programmable valve that allows the rate of CSF drainage to be controlled. Many modern shunt valves incorporate anti-siphon devices to prevent overdrainage of CSF while patients are in the upright position. The valve is connected to a distal catheter that is tunneled under the skin to drain into either the superior vena cava/right atrium of the heart (ventriculo-atrial shunt) or the peritoneum (ventriculo-peritoneal shunt). Under ideal circumstances (Fig. 2), the shunted patient will experience both radiographic and neurologic improvement in symptoms, with the last symptom to appear being the first to improve. Patience on the part of the family and treating physician is the key to post-shunt evaluation and management since it may take upwards of a month for the patient and family to notice a change in symptoms. This should also be kept in mind any time the shunt valve pressure is altered.
Complications of shunt placement include shunt infection, intracranial hemorrhage, subdural hematoma (overdrainage), seizures, abdominal or cardiac injury (from placement of the distal catheter), and shunt malfunction. These complications can be mitigated through appropriate preoperative planning, surgical technique, and postoperative evaluation and management. Patients taking anticoagulants for medical conditions will need to have these medications held and have normal coagulation laboratory values on the day of surgery. Antiplatelet agents such as aspirin and clopidogrel (Plavix) will need to be held for seven days prior to surgery. These agents usually can be restarted with 48 hours of surgery if the postprocedure CT of the head does not demonstrate a hemorrhage. If hemorrhage is noted, anticoagulants and antiplatelet agents may need to be withheld for a longer period of time. The risk of hemorrhage and shunt malfunction may also be reduced through the use of
image guidance systems and neuro-endoscopy to ensure accurate anatomic placement of the ventricular catheter. Appropriate preoperative prophylactic antibiotics, sterile technique and checking a UA/UC may help in preventing shunt infections. Overdrainage complications are avoided through the use of programmable valves with antisiphon devices. The overall perioperative complication rate should be under 5 percent. For those patients with a diagnosis of probable NPH or possible NPH, the overall success rate for shunt placement, as defined by symptomatic improvement, is approximately 60 percent to 75 percent. A smaller portion of the remaining patients may experience more minimal benefit, worsening of symptoms, or no benefit at all. The lack of clinical response raises the question of potential undershunting (the valve is draining at too high a pressure), shunt malfunction, incorrect diagnosis, or the presence of other significant neurologic comorbidities. In our practice,
shunted patients are generally followed with a CT of the head on a monthly basis until the optimal shunt pressure is determined, and on a yearly basis thereafter, to ensure that the shunt remains functional and that overdrainage and subdural fluid collections are not a problem. Patients who improve initially with shunting but subsequently decline should be investigated for a potential shunt malfunction or subdural hematoma. Although NPH accounts for only a small portion of the population affected by neurologic decline and dementia, the ability to provide a treatment paradigm with good results and maintain patient independence and functionality should prompt physicians to consider it in their differential diagnosis. Charles R. Watts MD, PhD, and Edward G. Hames III, MD, PhD, practice with the Spine and Brain Clinic at Fairview Southdale Hospital and are employed by University of Minnesota Physicians through the Department of Neurosurgery at the University of Minnesota.
Family Medicine St. Cloud/Sartell, MN We are actively recruiting exceptional part-time or full-time BC/BE family medicine physicians to join our primary care team in Sartell, MN. This is an out-patient only opportunity and does not include labor and delivery or hospital call and rounding. Our current primary care team includes family medicine, adult medicine, OB/GYN and pediatrics. Previous electronic medical record experience is preferred but not required. We use the Epic electronic medical record system at all of our clinics and admitting hospitals. Our HealthPartners Central Minnesota Clinics – Sartell moved into a new primary care clinic in the summer 2010. We offer a competitive salary, an excellent benefit package, a rewarding practice and a commitment to providing exceptional patient-centered care. St Cloud/Sartell, MN is located just one hour north of the Twin Cities and offers a dynamic lifestyle in a growing community with a traditional appeal. For more information, please contact diane.m.collins@ healthpartners.com or call Diane at 800-472-4695 x3. EOE
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 • Emergency Department Physician • Psychiatrist
To be a part of our proud tradition, contact:
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www.siouxfalls.va.gov AUGUST 2011
Blood transfusion practices
wo recent studies published in the Oct. 13, 2010, issue of the Journal of the American Medical Association compared intraoperative and postoperative transfusion practices in patients undergoing coronary artery bypass graft (CABG) surgery. The studies addressed the use of replacement blood transfusions in two patient groups. The “liberal” group received transfusions when the hemoglobin dropped below 10 gm/dl (hematocrit 30 percent); the “restrictive” group was transfused when the hemoglobin dropped below 8 gm/dl (hematocrit 24 percent). The 30-day outcome between the two groups revealed no difference in mortality or complications. The sole difference was that the “liberal” group received three times as many blood transfusions. The above reports, representing a subject of intense interest to me, left me incredulous, as both studies appeared to be a reinvention of the wheel. We at North Memorial had addressed the subject of surgical blood replacement more than
Re-inventing the wheel? By Seymour Handler, MD three decades ago. Through a series of CME conferences and transfusion peer review, we were able to reduce the number of blood transfusions to a level unmatched in the Twin Cities or, to the best of our knowledge, anywhere else. Developing a new approach
The recent studies constituted repetition of attempts to place numbers on measured surgical blood loss or the level of postoperative anemia as indications for blood replacement. Using these numbers appeared to provide simple (though arbitrary) indications to gauge the need for blood replacement. The results of this unthinking approach, used in hospitals nationwide throughout the mid-20th cen-
tury, was the reason for excessive blood replacement with its inherent adverse effects and increased costs. Beginning in the early 1970s, the approach we followed at North Memorial was to study the impressive compensatory mechanisms occurring in patients with active surgical blood loss or postoperative anemia and then replace blood physiologically. The compensation occurs in a stepwise fashion, as shown in the abundant experimental data available from Vietnam battle experience and in surgery on Seventh Day Adventists (a group unwilling to be transfused). Generous utilization of balanced electrolyte infusions serves to maintain adequate tissue perfusion despite
heavy surgical blood loss or severe postoperative anemia. The initial compensation consists of active and passive contraction of the vascular bed. That reduction preserves adequate venous return to the heart, thereby maintaining cardiac output. The next 24 to 36 hours involve restoring the preoperative blood volume by extracellular fluid, a process readily supplemented by generous infusions of electrolyte solutions. After 24 to 36 hours, erythrocyte concentration of organophosphates, notably 2,3 DPG (the substance in the red blood cells that enhances the movement of oxygen from red blood cells to body tissues), is increased, further enhancing oxygen release from red cells to tissues. The above compensatory mechanisms are very significant, far greater than most clinicians appreciate, as they enable maintenance of adequate tissue perfusion despite major surgical blood loss or profound postoperative anemia. The adequacy of compensation can be ascerTRANSFUSIONS to page 34
St. Cloud VA Health Care System is accepting applications for the following full or part-time positions:
• Internal Medicine
(Alexandria, Brainerd, St. Cloud—Nursing Home)
• Family Practice (Alexandria, Brainerd, St. Cloud)
• Psychiatrist (Brainerd, St. Cloud)
• ENT (St. Cloud) • Geriatrician
• Neurology (St. Cloud) • Dermatology (St. Cloud) • Disability Examiner (IM or FP) (St. Cloud) • Weekend Medical Officer of the Day (IM or FP) (St. Cloud)
(Nursing Home—St. Cloud)
URGENT CARE Mankato Clinic is looking for BC/BE physicians for our Urgent Care Department. Urgent Care is three rotations of 3–12-hour shifts in a week, and one rotation of 2–12-hour weekday shifts plus a Saturday 8 a.m. — 5 p.m. and Sunday 11 a.m. — 5 p.m. There are no Call or hospital privileges required for Urgent Care. Service lines that support our group include our own lab, sleep center, nuclear medicine, Medicare Certified endoscopic center and radiology department with a 128 slice CT and co-ownership in an ambulatory surgery center. Opportunity highlights: • Market competitive compensation guarantee to start, followed by RVU based production income thereafter • Fully integrated Allscripts electronic medical record
US Citizenship required or candidates must have proper authorization to work in the US. J-1 candidates are now being accepted for the Hematology/Oncology positions. 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.
• 35 PTO / CME Days + paid holidays; generous CME allowance • Practice connects to a regional, 270 bed, not-for-profit Mayo-affiliated hospital, Level 3 Trauma Center • State university with 14k students; 150 undergraduate / 100 graduate / 4 PhD programs; 1800 Faculty / Staff • Named one of America’s Promise “100 of the Best Places for Youth”
Excellent benefit package including: Favorable lifestyle 26 days vacation
CME days Competitive salary
13 days sick leave Liability insurance
• Essential retail in the community; Target, Best Buy, Lowe’s, Sears, Old Navy • Affordable housing: 4-bed, 4.5 bath, 3,572 Sq/Ft. home - $264,900 • 50 miles of local, paved trails / hundreds of acres of community parks
Interested applicants can mail or email your CV to VAHCS 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
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
MINNESOTA PHYSICIAN AUGUST 2011
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. Olmsted Medical Center provides an excellent opportunity to practice quality medicine in a family oriented atmosphere. The Rochester community provides numerous cultural, educational, and recreational opportunities.
Family Medicine Rochester Northwest Clinic Rochester Southeast Clinic St.Charles Clinic Internal Medicine Southeast Clinic Occupational Medicine Southeast Clinic Dermatology Southeast Clinic
Send CV to: Olmsted Medical Center Administration/Clinician Recruitment 1650 4th Street SE Rochester, MN 55904
Olmsted Medical Center offers a competitive salary and comprehensive benefit package.
email: email@example.com Phone: 507.529.6610 Fax: 507.529.6622
University of Wisconsin Stout is recruiting for Physician to join our team of professional medical staff. Clinic provides ambulatory medical care to a campus of over 9300 students. This is a 9 month position, no weekends, holiday, or on call duty.
Send Application to: Janice Lawrence Ramaeker 103 1st Avenue West, Menomonie WI 54751 Send Electronic Transmission of Application to: firstname.lastname@example.org Please call 715-232-2114 or visit http://www.uwstout.edu/geninfo/empop.html for more information. UW-Stout is an EO/AA Employer. Employment contingent upon passing a criminal background check.
Minneapolis VA Medical Center 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, possible recruitment incentive, and benefits with performance pay. Interested candidates should contact Don Rainwater, 413-584-4040, ext. 2907, or email@example.com.
Orthopaedic Surgery Opportunity Live in Beautiful Minnesota Resort Community
Two BC/BE Orthopaedic Surgeons wanted to join four orthopaedic surgeons at Sanford Bemidji Orthopaedics Clinic in Bemidji, Minnesota. Part of an 85-physician, multi-specialty group practice and 118 bed acute care hospital. 1:6 call anticipated. Competitive compensation/benefits package, paid malpractice, relocation assistance and more. Sanford Health of Northern Minnesota has 1,450+employees and is part of Sanford Health system based in Fargo, ND and Sioux Falls, SD. Bemidji, Minnesota, located in northwestern Minnesota, is a beautiful resort community offering exceptional schools, a state university, and yearround cultural activity as well as great access to the outdoors for year-round recreation activity. To learn more about this excellent practice opportunity contact: Kathie Lee, Director Physician Placement Phone: 701-280-4887 Fax: 701-280-4136 Email: Kathie.Lee@sanfordhealth.org AA/EOE
Equal Opportunity Employer
Transfusions from page 32 tained by simple clinical observations—pulse and blood pressure, urine output, warmth of skin, and mental state. Arbitrary assays of measured surgical blood loss or level of anemia are inferior to the readily observed clinical parameters. Our efforts at North Memorial to improve transfusion practices in surgical care were not initially accepted enthusiastically by surgeons and anesthesiologists. Not surprising! As a nonclinician pathologist, far removed from the surgical environment, I had no direct patient care responsibility. What I was proposing was to alter physician behavior. Besides, surgeons did not see a problem; they simply ordered replacement transfusions with scant consideration, just as they were trained to do. And their patients did just fine. Blood bank logistics and cost containment were not their problem. I was fortunate to gain the attention of some key and influential physicians who worked solely at North Memorial. They
were willing to modify their behavior in transfusion philosophy. As soon as they overtly limited their transfusion usage and noted that their patients did well, they were convinced. Results of a peer review study
Over the years, during which I was invited to present our transfusion program at several Twin Cities and outstate hospitals, it became apparent to me that we were accomplishing something different; our transfusion practices were clearly superior. This impression was reinforced by several physicians at North who also worked at other hospitals, where emphasis on reducing transfusions was rare. All of the above observations were based only on impressions or hearsay. What I desired was to collect hard data and publish our results. Unfortunately, my time was occupied by an active pathology practice and a growing responsibility for education of medical students at the University. Purely by coincidence, I was handed a copy of a report on the quality of surgical
practices in Minnesota by a local peer review organization, the Foundation for Health Care Evaluation (in 1997, the organization merged with the Health Outcomes Institute to become the quality improvement organization Stratis Health). This required Medicare study included data on blood transfusions. The study involved five large community hospitals, four in the Twin Cities and one outstate. The case content of the study were five commonly performed operations, all of which frequently involve transfusions. More than 500 cases were studied, the majority derived from North Memorial. The data assembled were numbers of transfusions, surgical blood loss, and blood hemoglobin preoperatively and on the day of discharge. Results confirmed that North administered much less blood for the five procedures than did the other four institutions. North transfused only 7 percent of cases; the other four ranged from 40 to 80 percent. Despite using much less blood
replacement, the patient outcomes at North were comparable to the others. The sole difference was the number of blood transfusions administered. Advantages of improved transfusion practices
Several advantages can be realized from the improved transfusion practices. Better patient care can be achieved because blood transfusions may create well-described adverse effects. Although we did not know about hepatitis C virus and its ability to cause chronic hepatitis at the time, we now know that we may have prevented hundreds of cases. In addition, using less blood could improve the logistics of the blood supply. Finally, fewer transfusions could save a lot of health care dollars. Currently a single blood transfusion costs approximately $500. Our program both saved money and enhanced patient care. The knowledge is available. Let’s use it. Seymour Handler, MD, is a retired pathologist who lives in Edina.
Family Medicine w/ OB Opportunities in 2 Wonderful Rural Locations Altru Health System is seeking Family Practitioners to join our existing and thriving practices in Crookston, MN and Roseau, MN. Crookston, MN, a strong community of 8,000, is located along the Red Lake River in the heart of the fertile Red River Valley. Altru Clinic—Crookston is a well-established, collegial medical group with 3 Family Practice Physicians, 3 Internists and 4 Mid-Level Providers. We have an ongoing partnership with RiverView Hospital in Crookston that is a 25-bed, critical-access hospital connected to our clinic. Call is 1:10.
Altru is a physician-led, not-for-profit integrated health system that serves a referral population of more than 225,000. More than 180 physicians representing 44 specialties serve this population base. Altru Health System provides competitive compensation, reviewed annually with specialty-specific industry data, along with an extensive benefits package including generous pension and profit-sharing plans.
Roseau, MN, which is just 20 minutes from beautiful Lake of the Woods, is a Family Practice clinic consisting of 6 Family Practice Physicians and 3 Mid-Level Providers. The town of Roseau has over 2,500 residents. LifeCare Medical Center is a 25-bed, criticalaccess hospital just adjacent to our clinic. Our friendly community is safe and welcoming. Call is 1:7.
Contact: Kerri Hjelmstad, Physician Recruiter Altru Health System PO Box 6003 Grand Forks, ND 58201-6003 1-800-437-5373 Fax: 701-780-6641 firstname.lastname@example.org www.altru.org
MINNESOTA PHYSICIAN AUGUST 2011
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tĞ tĞ ŽīĞƌ ŽīĞƌ ĂŶ ĂŶ ĂƩƌĂĐƟǀĞ ĂƩƌĂĐƟǀĞ ĐŽŵƉĞŶƐĂƟŽŶ ĐŽŵƉĞŶƐĂƟŽŶ ƉĂĐŬĂŐĞ ƉĂĐŬĂŐĞ ŝŶĐůƵĚŝŶŐ͗ ŝŶĐůƵĚŝŶŐ͗ ͻ ' 'ƵĂƌĂŶƚĞĞĚ ƵĂƌĂŶƚĞĞĚ ƐƐĂůĂƌǇ ĂůĂƌǇ ǁ ǁŝƚŚ ŝƚŚ ƉƌŽĚƵĐƟŽŶ ƉƌŽĚƵĐƟŽŶ ŝŶĐĞŶƟǀĞƐ ŝŶĐĞŶƟǀĞƐ ͻ SSigning igning b bonus onus We have part-time and on-call positions available at a variety of Twin Cities’ metro area HealthPartners Clinics. Evening and weekend shifts are currently available. We are seeking BC/BE full-range family medicine and internal medicine-pediatric (Med-Peds) physicians. We offer a competitive salary and paid malpractice. For consideration, apply online at healthpartners.jobs and follow the Search Physician Careers link to view our Urgent Care opportunities. For more information, please contact email@example.com or call Diane at: 952-883-5453; toll-free: 1-800-472-4695 x3. EOE
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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
Visit our website at www.NWFPC.com
An A n eequal qual opportunity opportunity employer employer and and provider provider
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 firstname.lastname@example.org.
safe procedure, and it is minimally painful. Imaging or CSF biomarkers also provide evidence of neurodegeneration due to AD. Hippocampal atrophy is a common feature at autopsy in people with AD. With the availability of the coronal imaging capability of MR, hippocampal atrophy was indeed found in patients with AD dementia. Unfortunately, there is considerable overlap of simple measurements of hippocampal atrophy between AD dementia patients and others (either cognitively normal or with other dementias). There are visual rating scales for hippocampal atrophy, as well as quantitative software applications that might be more accurate. In addition, there has been increased interest in quantitative measurements of other brain regions that characteristically undergo atrophy in AD. These might prove to be more discriminating. For now, logistical and computational limitations will keep quantitative
cortical volumetric measurement techniques in the research laboratory. PET scanning with the tracer fluorine-18 (F-18) fluorodeoxyglucose (FDG), called FDG-PET, measures brain metabolism. In AD dementia patients, FDG-PET shows an apparently unique pattern of hypometabolism in the lateral parietal, lateral temporal, and posterior cingulate cortices. Although approved by Medicare for the differential diagnosis of AD versus frontotemporal degenerations, it does not offer much additional value in diagnosis. Carefully done studies in individuals with MCI revealed that those MCI patients who had the “AD pattern” of hypometabolism had a greatly increased risk for subsequently
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: Jean Keller Physician Recruiter Phone: (701) 280-4853 Jean.Keller@sanfordhealth.org
both β-amyloid and tau measurements.
Biomarkers hold promise for improved, earlier, and more definitive diagnosis of Alzheimer’s disease, especially in asymptomatic individuals.
Alzheimer’s from page 19
Cardiology Dermatology ENT Emergency Medicine Family Medicine Gastroenterology Hospitalists Internal Medicine Neurology Occupational Medicine Oncology Orthopedic Surgery Pediatric Specialties Psychiatry Pulmonology (Sleep) Rheumatology Urology
From research to clinic?
developing dementia. But, like hippocampal atrophy, absence of the “AD pattern” on FDGPET does not rule out the possibility that the cognitive disorder is due to AD. In addition to structural MR and FDG-PET imaging, there is a CSF biomarker of neuronal injury: the microtubule-associated protein tau. Although tau protein is an integral component of the histological hallmark of AD pathology (i.e., the neurofibrillary tangle), elevations in CSF tau occur with any brain disease that causes death of neurons. In the setting of abnormally low levels of CSF β-amyloid, elevated CSF tau is a sensitive biomarker for AD pathophysiology. In practice, the commercial assay for CSF AD biomarkers includes
The revised guidelines for Alzheimer’s state that “presently, the use of biomarkers to enhance certainty of AD pathophysiological process may be useful in three circumstances: investigational studies, clinical trials, and as optional clinical tools for use where available and when deemed appropriate by the clinician.” Though additional research needs to be done to validate the application of biomarkers, they hold promise for improved, earlier, and more definitive diagnosis of Alzheimer’s disease, especially in asymptomatic individuals. Introduction of therapies for preventing or delaying the appearance of cognitive deficits from AD pathophysiology will require biomarkers to identify those at risk. David S. Knopman MD, is a professor in the Department of Neurology, Mayo Clinic, Rochester, and is an investigator in Mayo Clinic Alzheimer Research Center.
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 state’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 Region’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: • Internal Medicine • Internal Medicine • Pediatrics • Pediatrics
• Family Medicine • Urology • Family Medicine • General Surgery • Psychiatrist • General Surgery
For more information contact
Barb Miller, Physician Recruiter email@example.com • (218) 736-8227
712 Cascade St. S. Fergus Falls, MN 736-8000 | (800) 439-6424
Lake Region Healthcare is an Equal Opportunity Employer. EOE
MINNESOTA PHYSICIAN AUGUST 2011
We invite you to explore our opportunities in: In the heart of the Cuyuna Lakes region of Minnesota, the medical campus in Crosby includes Central Lakes Medical Clinic, a 30-physician multispecialty group and Cuyuna Regional Medical Center, a critical access hospital offering superb new facilities with the latest medical technologies. Outdoor activities abound, and with the Twin Cities metropolitan area just a short drive away, you can experience the perfect balance of recreational and cultural activities. Enhance your professional life in an environment that provides exciting practice opportunities in a beautiful Northwood’s setting. The Cuyuna Lakes region welcomes you.
• Family Medicine • Internal Medicine • Emergency Room Medical Director
CENTRAL LAKES MEDICAL CLINIC P.A.
Contact: Todd Bymark, firstname.lastname@example.org (866) 270-0043 / (218) 546-4322 | www.cuyunamed.org
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
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: • Family Medicine • General Surgery • Geriatrician/ Outpatient Internal Medicine • Hospitalist • Infectious Disease
• Internal Medicine • Oncology • Orthopedic Surgery • Pain Management • Psychiatry
• Pediatrics • Pulmonary/ Critical Care • Radiation Oncology • Rheumatology
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
Medical homes from page 11 is ‘send it to the doctor’ and we need people to work up to the top of their license.”
Discussion We found that physicians reported increased satisfaction with their practice after implementation of the medical home. Using qualitative data, we were able to understand key factors that contributed to their satisfaction, such as the team approach to patient care and the addition of chronic disease nurses to assist with medically complex patients. Physicians described being able to provide higher quality care for patients and more often work at the top of their skill level for medical decision-making. Studies of physician satisfaction suggest that conditions such as pace, work control, and organizational factors are highly associated with physician satisfaction. One study found that 26.5 percent of primary care physicians reported burnout, and this burnout was
associated with high stress, decreased satisfaction, and intent to leave the practice. With fewer physicians entering general internal medicine, increasing satisfaction for practicing internists is important in preventing burnout and attracting more physicians to primary care. This study adds to the body of work seeking to understand physician perceptions of practice redesign and, in particular, the medical home model of care and key components helpful to physicians. Our most meaningful finding was that doctors embraced the small, dedicated team approach to chronic disease management. They felt it improved care for patients by providing resources for education, access, and care coordination not previously provided. They enjoyed the enhanced relationships with staff that a team approach offered, yet did not describe losing the close relationship with the patient that is so important in primary care. A critical component of the team approach was clearly
defined roles for team members, enabling all members to work at the top of their skill level. In the current environment where many primary care physicians feel overwhelmed with their workload, it is not surprising that physicians welcomed a role-defined, teambased approach to the most medically complex patients. Physical proximity of staff was repeatedly mentioned as key to team functioning. The medical home model facilitated frequent, informal, face-to-face communication among team members about patient care. Physicians who were part of teams in close proximity felt more connected with their teams than those in teams more geographically divided. Limitations. Our findings are based on comments from 14 physicians at a single site, which limits the ability to generalize. Because the medical home intervention was phased in over years, the potential for recall bias exists.
A critical component Physician perceptions of the medical home in their department were universally favorable. Key elements were the added resource of chronic disease nurses and a team approach to caring for medically complex patients, allowing physicians to more often work at the top of their skill level. During a time when primary care is struggling, improving the satisfaction of practicing physicians is important for retention in and recruitment to the field. It may in fact be a critical component in improving the U.S. health system. Mary Sue Beran, MD, MPH; Elizabeth A. Kind, MS, RN; and Cheryl E. Craft, RN, are investigators with the Park Nicollet Institute in St. Louis Park. Jinnet B. Fowles, PhD, was senior vice president for research at the Park Nicollet Institute and is currently in the U.S. Peace Corps in the South Pacific island of Tonga. This study was funded by a grant from the Park Nicollet Foundation. The authors acknowledge the skilled help of Jennifer O’Connell, BS, senior research assistant, in transcribing each of the taped interviews.
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MINNESOTA PHYSICIAN AUGUST 2011
In tune with pediatric care Medicine is more than just our gig at Sanford Childrenâ€™s. Backstage, we have the right teams whose expertise, courage and skill delivers the best outcomes, making your patient feel center stage. Our crew focuses on over 70 services and specialties, research to cure rare pediatric diseases and advocacy programs to bring health and wellness to the community. Helping your patients do what they do best: shine like the rock stars they are. Thatâ€™s the art and science of health care. Only at Sanford Childrenâ€™s.
100-11395-1898 Rev. 8/11
Published on Aug 12, 2011
Published on Aug 12, 2011
Health care infomation for Minnesota doctors Cover: Medical homes by Mary Sue Beran, MD, MPH Healthcare administration by MPP staff Profess...