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PHYSICIAN SPOTLIGHT PAGE 3

Julio A. Leey, MD, MS

ON ROUNDS

Commercial Market Update Medical space appears healthy, as physician practices merge with health systems Earlier this year, SSM Health Care opened a renovated urgent care center, its third urgent care center in 2013. Total Access Urgent Care unveiled its fifth location, while Sonny Saggar, MD, opened locations in Creve Coeur and north St. Louis, bringing his total to four urgent care centers ... 4

Two-Night Minimum

Zevacor unveils nation’s first 70 MeV commercial cyclotron dedicated to radiopharmaceuticals for medical use By LyNNE JETER

St. Louis will be home of the nation’s first private non-government entity with the only 70 MeV commercial cyclotron strictly dedicated to making radiopharmaceuticals for medical use. Zevacor, an independently owned healthcare firm based in Indianapolis, Ind., and established in 2012 to manufacture and distribute PET and SPECT radiopharmaceuticals, recently acquired Pioneer Pharmacy, a radiopharmacy in St. Louis that will soon be renamed Zevacor, and opened a facility in nearby Springfield, Ill. Both facilities operate in tandem to support Zevacor’s facility in Decatur, Ill. “It’s an option for physicians to bring the best technology to their patients, and an opportunity for hospital administrators to save money on the overall diagnosis and treatment,” said John Zehner, executive vice president of Zevacor. (CONTINUED ON PAGE 8)

Observation, Inpatient & the Two-Midnight Rule If being quite specific while leaving plenty of room for interpretation was an art form, the Centers for Medicare and Medicaid Services surely would have achieved ‘master class’ status by now. The two-midnight rule, the recent compliance mandate that went into effect on Oct. 1, is an example of this dichotomy ... 6

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A Coup for St. Louis

A cyclotron at the world’s only installed and operational 70 MeV system, located in Nantes, France.

Union Movement Des Peres RNs post first collective bargaining pact at Tenet hospital By LyNNE JETER

Since its founding in 2009, the National Nurses United (NNU) has organized 15,000 RNs at 40 hospitals in 13 states. The largest union and professional association of registered nurses in the United States – the result of a merger of three strong nurse unions – represents nearly 190,000 RNs. That rising number includes RNs at Des Peres Hospital in St. Louis, who won their first collective bargaining pact Oct. 18. The action occurred 16 months after

Now Available!

Des Peres RNs voted to join the NNU, simultaneously with Saint Louis University Hospital (SLUH). Both hospitals are Tenet Healthcare properties acquired during the late 1990s. During the organizational campaign, both hospitals had relatively new CEOs – John Grah at the 143-bed SLUH, and Phillip Sowa at the 356-bed Des Peres Hospital. SLUH nurses finalized their first contract in June, which union organizers say set the table for the Des Peres pact. The SLUH three(CONTINUED ON PAGE 10)

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1 IN 3 AMERICANS WILL DEVELOP DIABETES IN THEIR LIFETIME? That’s why Fifth Third Bank is proud to support the American Diabetes Association and its mission to fund research to prevent, cure and manage diabetes. Please join us in our support by referring people living with diabetes to the ADA for objective and credible information. For more information please contact Robyn Pilliod, Executive Director, Greater St. Louis American Diabetes Association at 314-822-5490 extension 6827, or rpilliod@diabetes,org.

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PhysicianSpotlight

Julio A. Leey, MD, MS By LUCY SCHULTZE

While the average weight of Americans continues to rise with each passing decade, Julio A. Leey, MD, MS, finds reason to look ahead. “Some positive changes are already being seen in kids,” said Leey, an endocrinologist with BJC Medical Group in Alton, Ill. “The prevalence of obesity is no longer going up among kids,” he said. “I think there is more awareness, especially among teenagers, about the importance of eating more healthfully.” The trend is an encouraging one for Leey, who devotes some three quarters of his practice to patients with diabetes. Positive signs in recent years include such measures as California’s ban on junk food in schools, he said. “There are many things being done at the same time whose impact is hard to measure,” he said. “But I think several of these changes are in the right direction. “It is easier to change the behavior of kids than it is for people to start making better choices 20 years later.” It’s such convictions that have drawn Leey into taking part in educational and fundraising efforts in the field of diabetes since launching his practice in 2010. “I encourage people who have diabetes or have relatives with diabetes to become members of the diabetes community, through the American Diabetes Association or Juvenile Diabetes Research Foundation,” he said. “There are organizations that are really helping the community to raise awareness and change people’s lifestyles.” Serving as a board member for the local chapter of ADA and taking part in the organization’s special events is one way Leey has connected with the greater St. Louis area. A native of Peru, Leey is the son of a family physician and decided to pursue his own career in medicine. He was attracted to medical research during medical school through the influence of valued mentors in Peru. His interest in diabetes was sparked after his grandmother was diagnosed with the disease while he was in high school. Leey received his medical degree from the Universidad Peruana Cayetano Heredia in Lima and came to the United States to continue his training. He completed a residency in internal medicine at the University of Louisville in Kentucky, where he also earned a master of science degree in clinical investigation. “It is well-known that the U.S. has the best medical training, so that’s why I decided to apply and get all the requirements, take the tests and apply for interviews,” he said. “There is a big difference, in that the well-organized academic environment here is conducive to a good learning experience in all aspects. The people are stlouismedicalnews

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very respectful, also. I really enjoyed my training here and wanted to continue my work in the U.S.” Leey completed a fellowship in geriatric medicine at the University of Louisville and came to Washington University for a fellowship in endocrinology. He worked with the late M. Alan Permutt, MD, a wellknown researcher in the field of beta cell. Leey liked the St. Louis area and was glad for the chance to stay connected to the Wash U system through its close collaboration with BJC HealthCare. “I stay in touch with the same system where I was trained,” he said. “The community has a great need for endocri-

nologists, and I was looking for a good job position that would be a good match. I decided to stay.” Today, Leey is based across the river from St. Louis, where he heads Diabetes and Endocrine Care of Alton. His practice recently won a top 10 national honor for excellent outpatient clinic responses based on overall quality of care, as determined by Professional Research Consultants Inc. Leey received a Five-Star Excellence Award. Leey serves as medical director of the diabetes program at Alton Memorial Hospital. He is also an adjunct clinical assistant professor of medicine at Southern Illinois University at Springfield, where he also serves as medical advisor of the Department of Kinesiology and Health Education. In his clinical practice, Lee offers a strong emphasis on patient education. “That’s the big difference,” he said. “For someone who has pneumonia or an upper-respiratory infection, you are given treatment for a few days, and that’s it. “With diabetes, you stay with that disease, so the patient really needs to understand the importance of a healthy diet and counting carbs, and how important it is to check their blood sugar and recognize when their blood sugar is low.” The process of walking patients through everything they need to know to manage their diabetes day-to-day is something Leey approaches over a series of visits.

“Normally, in the first appointment, I get to know the patient,” he said. “It’s very difficult to give all the information in the first appointment, because too much is overwhelming. It can frustrate the patient, because they’re not able to understand the whole thing.” Instead, Leey focuses on a couple of key points, such as medication compliance and blood-sugar monitoring. “In between appointments, I ask them to see a nutritionist and take part in diabetes education to get another view of the disease,” he said. While practicing medicine in the United States offers its own challenges — particularly in a time of transition for the national healthcare system — Leey brings the perspective of his experience in Peruvian healthcare. “We always complain here in the U.S. that the system is fragmented, but our system is much more connected than in Peru,” he said. “Over there, for example, we don’t have electronic medical records. If someone in the same system orders a lab, I don’t have access to that lab. “It’s also easy here to order something and get it done. Over there, in the past, patients have been mostly cash payers. You would order a lab or an x-ray — then have to wait until the patient had the money to pay for those.” Outside of work, Leey enjoys spending time with his family, which includes wife Jessica and son Joaquin, 2.

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Commercial Market Update

Medical space appears healthy, as physician practices merge with health systems By LYNNE JETER

Earlier this year, SSM Health Care opened a renovated urgent care center, its third urgent care center in 2013. Total Access Urgent Care unveiled its fifth location, while Sonny Saggar, MD, opened locations in Creve Coeur and north St. Louis, bringing his total to four urgent care centers. The geographic expansion of urgent care clinics, emergence of onsite healthcare clinics on corporate and college campuses, and blending of physician practices with hospitals and health systems impacted the St. Louis metro area’s commercial market activity for the third quarter of 2013. According to CRBE Global Research and Consulting’s 3Q13 Local Medical Market View, the average direct asking rate for medical/office space in the St. Louis metro area is $21.32 per square foot and pure medical space averages $22.52 per square foot. Full service gross represents a slight de­crease over the prior quarter and remains lower than the rate of $23.49 in 2006. Two notable trends: merging practices moved into office suites 4,000 square feet and larger, and practices geographically expanding via satellite offices leased office suites less than 1,000 square feet. Overall, the report reflected a commercial market vacancy rate of 16.2 percent, lower than the first two quarters of 2013. For the third quarter, overall commercial rates averaged $21.44 per square

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foot. Specifically, third quarter activity reflected a decreased vacancy rate for the medical market and posi­tive net absorption. The CRBE market report covers buildings 10,000 square feet and larger, 80 buildings with roughly 4 million square feet of rentable space. The local overall vacancy rate includes sublease space on the market, which comprises a scant percent­ age of the overall market. Suburban commercial market space remains a good value. For example, Tony Kennedy, senior vice president of commercial leasing firm Colliers International, reported in late October that 90,000 of 112,000 square feet of a commercial component of the new 1.2 million-square-foot CityPlace in Creve Coeur had been recently leased; remaining space is being marketed at $23.50 per square foot, according to reports. “It’s a tenant market, but conditions are swinging back to equilibrium for Class A space in the suburbs,” Jim Mosby, senior managing director and principal with commercial real estate firm Cassidy Turley, recently told the St. Louis Business Journal. “Demand will continue to increase, and supply will continue to decrease.” CRBE Report Medical Market Highlights: Mercy opened a 199,000-square-foot orthopedic hospital in Springfield at a reported cost of $578 per square foot. Sonny Saggar, MD, expanded his fourth Urgent Care Center to North St.

Louis; three existing ones are located in downtown St. Louis, Creve Coeur and Eureka. Memorial Hospital plans to raise $157 million to fund its new Memorial Hospital East, planned for 2016. St. Luke unveiled its new urgent care at Ladue Crossings, its seventh in St. Louis. St. Luke’s Hospital plans to raise $40 million to expand physician of­fices and

outpatient services. Lutheran Senior Services is designing a 700,000-square-foot senior care community in Lake St. Louis at $714.28 per square foot. The Jefferson Barracks VA intends to complete a $105.8 million expansion, consisting of an 86,000-square-foot medical office building and an 112,900-squarefoot clinic.

Cardiovascular Workup and Weight Loss SI Medical Weight Loss partners with Health Diagnostic Laboratory on advanced blood work testing for cardiovascular disease SI Medical Weight Loss has advanced blood work testing for cardiovascular disease available at its Marion, Mt. Vernon and Belleville clinics. The weight loss clinic teamed up with Health Diagnostic Laboratory Inc. to offer advanced medical testing to identify early risk factors. Based on results of the deep blood panels, SI Medical then implements dietary strategies and engages in exercise programs with patients.  “By using the blood tests offered by Health Diagnostic Laboratory, SI Medi-

cal Weight Loss clinics have the ability to easily follow our patients’ biomarkers and hidden risk factors of cardiovascular and related diseases,” said Donald Griffin, MD, who leads the SI Medical Weight Loss group. “Our patients are better able to reach optimal cardiovascular and metabolic health.” Health Diagnostic Laboratory, a national firm based in the Virginia Biotechnology Research Park in Richmond, Va., runs more than 200,000 tests daily. It’s adopted a model that partners with physicians to provide highly advanced practices for the diagnosis and treatment of cardiovascular and related chronic diseases, and offers a comprehensive panel of tests to help physicians personalize treatment based on more complete patient profiling. As a result, SI Medical Weight Loss detects risk factors pre-disposing patients to disease earlier and engages patients in more advanced evidence-based treatments with fewer progressing to overt disease, said Griffin. “Health Diagnostic Laboratory has provided us an objective view of people’s health,” said Warren Willey, DO, a founding diplomat of the American Board of Holistic Medicine, and the author of popular mainstream books, including What Does Your Doctor Look Like Naked? “It’s dynamic, and allows both the physician and patient to see the effects of lifestyle and medication on chronic disease and cardiovascular risks.” HDL CEO Tonya Mallory pointed out that stories of people surprised by sudden heart attacks are becoming more common. “It’s perplexing that so many patients aren’t identified as at risk for heart disease at a much earlier stage,” said Mallory. “Today’s extremely limited cholesterol tests are failing to identify the majority of people who are at risk for heart attacks. There’s hope, however. When practices use diagnostics effectively, lives are saved.” stlouismedicalnews

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Understanding the Fiduciary Role for Retirement Plans Provided by CHARLES GRBCICH

Serving as a trustee of an Employee Retirement Income Security Act (ERISA)sponsored retirement plan or as part of an investment committee that acts as a fiduciary is an important responsibility. You agree to preserve the assets entrusted to you on behalf of the plan participants and beneficiaries you represent. The legal requirements expected of most fiduciaries are, in many ways, the same as those of prudent investment professionals. In other words, fiduciaries are expected to make fund-management decisions with the same professionalism as a prudent expert.

Who can be a fiduciary?

A fiduciary is a person, company or association that acts in a capacity of trust and is therefore held to higher standards with respect to plan-related actions. A fiduciary can be an entity that holds in trust such assets as qualified retirement plans, endowments and other institutional investments. An investment fiduciary is responsible for investing the money wisely for the beneficiary’s benefit. It’s quite common to have trustees of retirement plans and board members of foundations in the fiduciary roles. However, business

owners, company presidents, principal shareholders, corporate officers and corporate trustees of institutional funds may also have fiduciary status.

What is the role of a fiduciary?

Generally, you are a fiduciary if you control plan assets or provide investment advice for a fee. Some fiduciaries are fiduciaries only for certain actions, such as selecting investment managers for the plan. Under ERISA guidelines, there are five general standards of fiduciary conduct. As a fiduciary, you are responsible for ensuring that: • Employee benefit plans exist solely to serve the interests of the participants and beneficiaries. • The funds inside employee benefit plans are used only to provide benefits to participants and their beneficiaries and to defray reasonable plan-administration expenses. • Employee benefit plans are discharged in accordance with written instruments and documents that should include written investment objectives. You have

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the right to rely on professionals to help you through this process. • Investment duties are fulfilled with the care, skill, prudence and diligence of an expert familiar with such matters. You must consider all the facts and circumstances that are relevant to the plan’s investment objectives. • Investments are diversified to minimize the risk of large losses unless it is clearly prudent not to do so under the circumstances.

As a fiduciary, if I allow participant-directed accounts, does this eliminate my fiduciary responsibilities?

You and the plan sponsor will always have fiduciary responsibilities. However, section404(c) of ERISA states that if a

participant exercises control over assets in his or her account, a participant is not considered a fiduciary by reason of that control, and no other fiduciary can be held responsible for losses resulting from that control. In order to rely on section 404(c), note that certain disclosure and other requirements must be met and that the plan sponsor and other fiduciary will still be responsible for the investment options made available in a plan.

What is a corporate trustee, and when should I consider one?

A corporate trustee is a financial institution that performs the duties and fulfills the responsibilities described in the plan document and trust agreement. Through its banking and trust affiliates, Wells Fargo Advisors offers different levels of corporate trust services. This article was written by Wells Fargo Advisors and provided courtesy of Charles Grbcich, First Vice President – Investment Officer in Chesterfield, MO at charles.grbcich@wfadvisors.com . Wells Fargo Advisors does not provide legal or tax advice. Be sure to consult with your tax and legal advisors before taking any action that could have tax consequences NOT FDIC-INSURED/NOT BANK-GUARANTEED/MAY LOSE VALUE. Wells Fargo Advisors, LLC, Member SIPC, is a registered broker-dealer and a separate non-bank affiliate of Wells Fargo & Company.

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Two-Night Minimum

Observation, Inpatient & the Two-Midnight Rule day rule is universally hated. Hospitals and advocacy groups want time in observation to count if a patient ultimately is admitted.” While CMS did not opt for that route, the two-midnight rule could be seen as a step toward ensuring a more timely determination of whether or not a patient should be admitted.

By CINDY SANDERS

If being quite specific while leaving plenty of room for interpretation was an art form, the Centers for Medicare and Medicaid Services surely would have achieved ‘master class’ status by now. The two-midnight rule, the recent compliance mandate that went into effect on Oct. 1, is an example of this dichotomy and has left physicians and hospital administrators scrambling to understand what it means for patients … and the bottom line. Boiled down, the new rule sets “two midnights” as a benchmark for inpatient admission, but there are exceptions. Meant to clarify the difference between appropriate observation status and inpatient admission, the IPPS final rule caused enough confusion that CMS offered a three-month amnesty period, which is set to expire at the end of 2013. During this last quarter of the year, hospitals will not face financial penalties even if deemed out of compliance with the rule. Instead, the federal agency has used this time period for a “probe and educate” program where Medicare Audit Contractors (MACs) have focused reviews on claims that are for stays of less than “two midnights” after admission and have offered feedback and education to providers about compliance and missteps. During this period, the Recovery Audit Contractors (RACs) have not conducted medical necessity reviews. At year’s end, CMS has said it will assess the findings to see if additional guidance is needed. Brian Contos, executive director overseeing the clinical research and insights programs at The Advisory Board Company, recently spoke with Medical News to shed a little light on the confusing and controversial rule.

The Backstory

“There are probably two storylines behind why they have implemented the twomidnight rule,” Contos said of CMS. “On the one hand, they’re instituting this policy to address concerns surrounding extended observation stays.” He continued, “I think the Brian Contos other reason is the simple fact that there are a tremendous number of very short stay inpatient admissions.” Looking to the first motivating factor, Contos said, “Between 2006 and 2011, there was a dramatic increase in observation stays … a 65 percent increase.” In addition, he continued, there was a 176 percent increase for those kept in observation for an extended period — 48 hours or longer. As for the second issue, Contos said, “Of the roughly 15 million Medicare admissions in 2012, about 2 million of those were admitted with a one-day stay.” Since the cost to Medicare is far greater under Part A than under Part B 6

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The Problem for Hospitals

(outpatient or observation status), the federal payer has a vested interest in how patients are classified, but CMS made it clear the goal is neither to keep patients in observation limbo when inpatient admission is warranted nor to pay Part A rates when services could be rendered in a more cost effective manner. Contos said, “From CMS’ perspective, there’s a yin and yang here … we don’t want a really long observation period nor do we want to pay for these really short inpatient stays.” He said it’s all about finding equilibrium. Going forward, one-night inpatient stays will probably serve as a red flag for auditors to dig deeper to ascertain whether Part A reimbursement was appropriate. While two midnights is the benchmark for inpatient status, there certainly are exceptions. First and foremost, any procedure that appears on the inpatient-only list is exempt from the rule. Second, there are other conceivable situations where a patient could have reasonably been expected to meet the benchmark but only stayed one night, including self-discharge against medical advice, death, or transfer. However, Cantos stressed the documentation must clearly show that the physician admitted the individual to inpatient status with an anticipation that the patient’s condition warranted a stay of at least two midnights. In addition to the marked increase in observation cases, Cantos said the issue of post-acute care was another catalyst for the rule. For Medicare to pick up the tab for a stay in a skilled nursing facility or rehab unit, a patient has to stay in the acute care facility for three days, and observation days don’t count. Pressure has been mounting on CMS … both by patient advocacy groups and through legal challenges … to ‘do something.’ A report based on Medicare data from 2012 and released this July by the Office of Inspector General found there were more than 600,000 hospital stays last year that lasted at least three nights but didn’t qualify for inpatient payment … which means those stays would not have satisfied the three-day rule if needed. Contos noted, “I would say the three-

“It’s a judgment call at the end of the day,” Contos said of whether or not a physician admits a patient. Therein lies part of the problem for hospitals … the two-midnight rule is specific in that it is a judgment call and simultaneously very loose because, by its very nature, a judgment has many shades of gray, which could leave the soundness of the decision open to interpretation … perhaps by an auditor. Although CMS actually expects about 400,000 observation cases to become inpatient and 360,000 inpatient cases to move out, many hospitals don’t believe the rule will help the bottom line. First, the inpatient payment rate is being adjusted down slightly to achieve budget neutrality. The other concern is that for some hospitals, the number of inpatients gained from extended observation will be considerably less than the number lost from shorter stays, which will negatively impact margins that are already extremely tight. “I don’t think we can assume what happens in one hospital will happen in all. It will be institution by institution. Every hospital is going to look differently,” Cantos said. Certain service lines will probably be disproportionately impacted. For example, about one-third of hypertension cases and approximately 40 percent of Medicare chest pain cases result in a one-day admission. Presumably, those patients will wind up as observation patients in the future. Cantos encouraged hospital administrators to work closely with their analytics team to get a better sense of the anticipated effect of the rule on their specific hospital. Exacerbating the financial concern is the increased out-of-pocket burden on patients. Moving from Part A inpatient to Part B observation status typically means the patient will shoulder more of the costs, adding strain to the collection process and potentially increasing the hospital’s bad debt ratio. So what is to keep a hospital from skewing the numbers in their favor … keeping short stays longer and admitting more observation patients? Cantos said some hospitals certainly might opt to roll the dice, but there are inherent risks in this plan. First, demanding a patient be admitted contrary to a doctor’s medical opinion is never optimal. “Physician judgment should really be held almost sacred,” Cantos said. “There is nothing more disruptive to hospital/physician relationships than for

a hospital administrator to tell a physician how to assess or judge a particular patient’s care.” Cantos continued, “This is something that starts with a physician’s medical judgment, and I don’t think most hospitals want to dictatorially stipulate how physicians must practice.” The second risk is that a hospital could ultimately wind up taking an even bigger hit to the bottom line. Although CMS offers a rebilling process to move claims incorrectly filed as Part A to Part B, hospitals only have one year to do so. By the time an auditor comes in to review inpatient claims, there is a good chance many would be past the one-year mark. In those cases, a claim deemed inappropriate by the auditor wouldn’t be eligible for rebilling. Instead, the hospital would be liable to CMS for the full amount of those claims plus any fines.

Prepping for Post-Amnesty

With the grace period granted by CMS rapidly coming to an end, Cantos offered four observations about steps hospital administrators could take to optimize compliance. First, there should be an emphasis on physician education. “You don’t want to dictate, but you do want to make sure everyone understands the rule and documentation requirements,” Cantos said. In the eyes of CMS, he added, ‘admit’ and ‘admit to inpatient care’ are different. No one wants to lose out on reimbursement because of incorrect terminology. Hospitals also don’t want to present RAC auditors with widely divergent case documentation. “As a hospital, you do want to try to establish some norms here so it’s not a total crapshoot if audited,” Cantos said. “If you’re all over the map, it becomes really difficult to right-size your program.” The second recommendation is for hospitals to look at the processes in place to assess and reassess observation cases. “There’s a timing element,” Cantos pointed out. While it’s critically important to document how, when and why a decision was made to admit to inpatient status, it’s also important to expedite that process. “It’s something every hospital is going to have to push on — timely decision-making,” he said. Cantos said hospitals also should review their internal auditing process. “Likewise, you want to develop a self-review process to identify cases that were inappropriately admitted so you can rebill under Part B within the one-year filing window,” he noted. The fourth item is to make sure that in addition to educating staff about the twomidnight rule, hospitals also remember to explain it to patients. “It’s very important the patients understand that just being in a bed in a hospital doesn’t mean you are admitted. Patients pay more out-of-pocket for Part B so they must understand the nuances about payment for inpatient and observation,” Cantos stated.

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A Coup for St. Louis, continued from page 1 With the advent of the 70 MeV cyclotron, Zevacor is changing the way hospitals secure isotopes for diagnostic imaging. That’s very good news in light of the looming international isotope shortage, and represents part of a larger strategy to provide hospitals nationwide with a reliable and steady stream of radiopharmaceuticals critical to patient care. “Medical isotopes are critical to early and accurate diagnosis of cancer, heart disease and a number of other life-threatening diseases,” said Zehner. “In the past, the supply of medical isotopes hasn’t been continuous, making it difficult to offer these diagnostics and therapeutics. This investment will allow us to provide year- Cardiac PET CT images courtesy of GE Medical Systems. round production of medically necessary isotopes for patients.” and a few other places. However, on the Zevacor’s 70 MeV cyclotron is expected North American continent, the demand to be operational by the end of 2016, for this isotope puts pressure on the sysaround the time North America’s only tem. We have very short expiration drugs, reactor will cease operations. The Canaso shipping them long distance isn’t condian reactor, built in the 1950s, produces ducive to a viable supply line. The (U.S. technedium 99, an isotope needed for Department of Energy) is making efforts diagnostic imaging and therapies within to correct that by investing money in oncology, neurology and cardiology. The grants to spur activity. Our project indiCanadian government plans to take the rectly addresses the problem by offering a reactor offline in 2016. better option.” “That one is nearest the U.S.,” exZehner pointed out the large-scale plained Zehner. “There are reactors in machines producing these isotopes domesPoland, Belgium, South Africa, Australia,

tically aren’t dedicated to medical use; the “part-time” supply won’t keep pace with long-term demand. “No single cyclotron operates year-round to produce these generators,” he said. “We’ll be the first group to provide a very stable supply of these isotopes to image patients. If you have PET scanner, you’ll be able to count on the fact it’ll be available.” Zehner also noted that other companies with cyclotrons producing medical isotopes don’t have the capacity – limited in horsepower by 30 MeV, for example – to make certain ones. “The long-term Zevacor business plan is to change the way hospitals do business by giving them an opportunity to create a profit stream for their hospitals through investment in a smaller-scale cyclotron that will allow them to produce necessary isotopes onsite and supply both short- and long- life nuclear medicines to hospitals within a three-hour radius,” said Zehner. Zevacor is part of a purchasing group, UPPI (United Pharmacy Partners Inc.), a chain of independent pharmacies that’s in talks with various healthcare facilities to establish local markets. “In today’s healthcare environment,

everyone’s striving to provide the same or better outcomes with lower overall cost,” said Zehner. “Even though PET is more expensive upfront, it eliminates multiple unnecessary tests compared to the information it provides.”

Zevacor Molecular’s EVP John Zehner has experience as a nuclear pharmacist, radiation safety officer and cyclotron operator for drug manufacturing, and extensive regulatory affairs knowledge collaborating with the Nuclear Regulatory Commission (NRC), Food and Drug Administration (FDA), Department of Transportation (DOT) and various state pharmacy boards. In 1995, the Purdue alum led the effort to acquire Eastern Isotopes from three nuclear pharmacies in Washington, DC. The emerging company became one of the world’s largest producers of Positron-emitting radioisotopes, IBA Molecular. Also, Zehner has a patent involving the automation of nuclear medicine products.

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Medical Imaging Utilization The trend might surprise you By CiNdy SANdERS

Whether in the context of discussing defensive medicine or the latest diagnostic technology, there seems to be a pervasive belief that increasing overutilization of medical imaging is a key driver of healthcare spending. Yet, those within the field point to recent studies that find a flaw in that line of thinking … within the Medicare population, utilization rates are actually in decline. A study conducted by the Harvey L. Neiman Health Policy Institute and published this summer in the Journal of the American College of Radiology found the number of physician visits by patients age 65 or older that resulted in an imaging exam has consistently trended downward over the past decade from Richard 12.8 percent in 2003 to Dr. Duszak, Jr. 10.6 percent in 2011. Using Medical Expenditure Panel Survey (MEPS) data in addition to Medicare claims data, the researchers also said that annual spending on imaging for the senior population grew from $294 per enrollee in 2003 to $418 per enrollee by 2006 but had declined to $390 per enrollee by 2011. Richard Duszak, Jr., MD, FACR, chief medical officer and senior research fellow at the Neiman Health Policy Institute, which is part of the research arm of the American College of Radiology, noted a major concern for those in the profession is that outdated information could be used to inform healthcare policy with a direct impact on patients and providers. “We’re in an interesting time where there is immense scrutiny on our health delivery system,” he said. “We really need good, credible information driving policy decisions.” Duszak, a board-certified radiologist, noted that at some point the mantra that imaging utilization was continually spiraling upward “didn’t match what we in the trenches saw.” He added imaging studies were rapidly growing until 2006, “Then it plateaued and has, in fact, declined.” Duszak added he isn’t suggesting imaging utilization shouldn’t continue to be monitored but that similar scrutiny should accrue to other Medicare service lines that are now growing at a faster rate. “Like any tool … like any technology … like any discipline, how good imaging is — how useful it is — really depends upon how it is utilized. I think there are some appropriate areas where we can reduce injudicious use of imaging, but,” he stressed, “we should not be throwing the baby out with the bathwater in the process.” The medical discipline has already

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taken a number of financial hits. The Deficit Reduction Act of 2005 significantly decreased financial reimbursement for diagnostic imaging. Sequestration, bundled payments and other changes to reimbursement models and formulas also threaten to further erode the financial viability of the field. In this most recent research, the study’s authors wrote, “A failure to understand changes in utilization that may accompany these potential payment reductions could ultimately produce adverse effects on patient care regardless of whether the intended cost containment goals are realized.” Duszak pointed out the field of radiology has seen incredible technological and diagnostic advancements that have helped physicians accurately pinpoint health issues and improve outcomes. He said the downstream effect must also be considered when determining appropriate imaging utilization levels. He said looking solely at the front-end savings is a bit like only watching the first part of a movie without regard to how the story ends. “The hero did great. He saved money … but what happens in the next scene? Did that money really get saved, or are there other unforeseen costs as a result of the hero’s actions in scene one?” Duszak questioned. It’s a topic Duszak explored in a brief he authored for the Neiman Health Policy Institute last fall. “Lawmakers, regulators and medical professionals are making medical imaging policy decisions without fully understanding or examining their downstream effects, which may include an increase in hospital stays, associated costs and other adverse events,” he wrote. “We need to examine imaging, as it relates to a patient’s overall continuum of care, to ensure that decision-makers don’t create imaging cost reduction policies which paradoxically raise overall costs, create barriers to care and ultimately harm patients.” Getting a better handle on the bearing imaging has on the overall cost of care is an area where Duszak said more research is critically needed. What impact does imaging play in catching cancers early when treatment is most effective? Did skipping a diagnostic study result in a patient staying extra days in the hospital while providers tried to determine the source of illness? “We need more research in this space to answer these questions definitively,” he said. Ultimately, Duszak said, everyone’s goals should align — find out where imaging is most beneficial and push for more of it … determine where it isn’t as helpful and push for less. “We need to continue a sophisticated analysis to determine appropriate usage,” he concluded.

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Union Movement, continued from page 1 year contract includes raises across the board of 8.5 percent to 9.5 percent. It also bans mandatory overtime and prevents the hospital from implementing technology that could “undermine the professional judgment of the nurses,” according to the St. Louis Post-Dispatch. Carmen Moorehead, a SLUH RN for four decades, said the primary issue involved increasing the nurse staff. “The main problem is that we would like to see more nurses, or have more nurses available, so we can improve the quality of our patients’ care,” Moorehead told the St. Louis Business Journal in early 2012. According to a statement from SLUH, Tenet hospital executives voiced displeasure with the results: “It’s best for employees and management to work together without involvement from a third party. It’s always been our position that the hospital offers competitive wages and benefits,

and management promotes a positive work environment. Although disappointed in the election results, we won’t let this distract us from our focus of providing high-quality to our patients.” RNs at Des Peres reported important improvements in patient care protections and secured their employer-paid health coverage, according to the National Nurses Organizing Committee-Missouri (NNOCMissouri). The agreement also includes strong RN job security protections and economic gains. “Both these agreements show it’s possible for nurses through collective unity and a strong union to advocate and secure significant improvements for their patients and their own livelihood and economic standards,” said NNU executive director Rose Ann DeMoro, a St. Louis native. Terrie Chilton, an endoscopy RN at Des Peres Hospital, noted that NNOC

nurses are “holding the line on healthcare costs at a time when other St. Louis hospitals are raising premiums, raising co-pays, and eliminating coverage for some nurses.” Eileen Wallhermfechtel, an orthopedic RN at Des Peres Hospital, pointed out the new contract “gives us the tools we need to better advocate for our patients, while securing a future for our jobs and our families. This agreement ensures that if the hospital is sold, nurses will keep their jobs, salaries, and all the other improvements secured in the contract.” Concerning patient care, the Des Peres RN pact bars mandatory overtime and limits the number of consecutive RN shifts to reduce RN fatigue and therefore minimal medical errors; limits the assignment of nurses to areas in which they lack clinical expertise and orientation; and establishes a committee of direct care RNs elected by their colleagues to meet with

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management to address how to improve patient care. The agreement also stipulates that new technology implemented at the hospital won’t be used “to override RN clinical judgment to protect the right of nurses to act on behalf of individual patient needs,” according to the NNUC-Missouri. The pact also states the hospital will maintain existing healthcare plans without increasing the share of nurse-paid premiums. The agreement, which runs through August 31, 2016, provides for wage increases of up to 7.75 percent with negotiations for a new agreement to begin in April 2016. Earlier this year, Des Peres RNs received a 2.5 percent raise.  More nurse unionization activity may be occurring in St. Louis. A former nurse at BJC HealthCare filed a proposed class action lawsuit in October, alleging the non-profit health system improperly calculated employees’ overtime hours and meal breaks. A jury trial could determine whether BJC’s wage and hour practices contradict Missouri law and if the health system’s practice of rounding down overtime hours to the nearest quarter of an hour is legitimate. Annette Speraneo, RN, filed the lawsuit, which ascertains that BJC was “unjustly enriched” by those payroll practices. “In the computer age, there’s no longer a necessity for rounding up or down. All these records are computerized,” James R. Dowd, a Clayton lawyer and former judge who filed the proposed class action on behalf of Speraneo and other similarly affected BJC employees, told the Post-Dispatch. NNU spokesperson Chuck Idelson weighed in, calling the situation in the lawsuit “clearly a scam designed to deprive employees for the time they worked.” “We know ... one thing that’s happening in a lot of places is they put pressure on nurses to work past the end point of their shifts to finish up paperwork on patients and not pay overtime for it,” he said. BJC HealthCare operates 13 acute care hospitals in Missouri and Illinois, with roughly 25,000 employees in St. Louis.

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Case Study: ICD-10 Conversion ChartWise comprehensive CADCDI software program significantly enhances documentation efficiency while also optimizing reimbursements for busy Atlanta-area health system By LyNNE JETER

LAWRENCEVILLE, GA. — When leaders at Gwinnett Hospital System were tasked with implementing a program for ICD-10, they were concerned about tightened Medicare reimbursement standards and projected losses in productivity associated with conversion from ICD-9. The Lawrenceville, Ga.-based market leader, with 38 percent market share in Gwinnett and Barrow counties, had been using the same software tool since 2004. Even though Gwinnett Hospital System had developed a clinical documentation improvement (CDI) program that ranked in the top 5 percent nationally for clinical quality, the software could no longer support the needs of its 553 beds, 800 affiliated physicians and 4,100 employees. “Our system required a tool that would streamline workflow by automating manual processes,” said Maria Mann, RN, BSN, clinical documentation integrity manager and for Gwinnett Hospital System, who was tasked with researching and selecting a new Computer-Assisted CDI (CACDI) provider. “We also needed a platform Maria Mann capable of providing advance metrics and more efficient reporting. We were looking for a state-of-the-art software solution designed to handle present and future documentation challenges associated with reimbursement, (CMS’s) RAC (Recovery Audit Contractors) audits and the ICD-9 to ICD-10 conversion.” The most salient attribute the health system required from their CACDI software to move the program forward was a user-friendly interface and an overall easy-to-use platform. An impactful, comprehensive CACDI program could significantly enhance a coder’s documentation efficiency while ultimately impacting the organizations’ bottom line through optimized reimbursements. Also, coders needed to be able to query physicians electronically for speed, efficiency and accurate recordkeeping, noted Mann. “We didn’t have the time or resources

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to execute extensive training with physicians, and needed to make certain any advanced features contained within the software would improve efficiency for the hospital systems’ CDI and IT staff,” she explained. Mann invited the top vendors in the field to make a presentation demonstrating the value and functionality of their software to integrate into their CDI program. “Once we reached the point of working through each software solution’s user

functionality and integrative capabilities, it became readily apparent that there are no other tools on the market today offering what ChartWise:CDI does,” said Mann. “We were searching for the most userfriendly solution and that’s what drew us in, but ChartWise’s advanced reporting capabilities were extraordinary. We also found that the ChartWise software would help facilitate our transition from ICD-9 to ICD-10 and that their solution would streamline our workflow while increasing productivity.”

Hyperbaric Oxygen Therapy

In the first five months of implementing ChartWise’s CDI application, Gwinnett Hopsital System, reported significant results. In January, the month preceding implementation of ChartWise’s software solution, the CDI staff engaged in a total of 774 initial chart reviews searching for further documentation that could alter the severity of illness/risk of mortality or DRG (diagnosis related group) codes, along with 439 follow-up reviews to see if the physician had answered their clarification query. In March, the first full month after assimilating the new CDI program, the same team was able to complete 1,445 initial reviews and 1,850 follow ups, an increase of 87 percent and 321 percent, respectively. Gwinnett Hospital System also reported a substantial increase in physician response rate after integrating ChartWise:CDI software. Last year, the average response rate was 75 percent. From February to May, with ChartWise:CDI implemented, the average physician response rate rose to 86.8 percent. Mann attributes the increase to the quality and content of the queries, along with the ability to easily respond to a query. “The entire process has been an overwhelming success,” said Mann. “From the easy-to-use interface, to the reporting capabilities, to the electronic query functionality, the transition has been seamless.”

Barnes-Jewish Hospital and Washington University Physicians

Now accepting your referrals for: • Diabetic foot wounds • Chronic wounds that threaten patients with non-healing or amputation as part of our Limb Preservation Program • Enhancement of healing in selected problem wounds or infections • Post radiation wounds, cystitis, proctitis, or osteoradionecrosis • Chronic refractory osteomyelitis • Poorly healing skin grafts or flaps John Kirby, MD, and a technician prepare a patient for hyperbaric oxygen therapy.

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GrandRounds Architect of Curriculum Reform at SLU Medical School Captures a Top National Teaching Award Stuart Slavin, M.D., M.Ed., a pioneer in reforming medical school education and associate dean for curriculum at Saint Louis University School of Medicine, received one of the Association of American Medical College’s highest teaching awards for 2013. Dr. Stuart Slavin The association represents all accredited medical schools in North America, and presented the award at its annual meeting in November. Slavin is one of four educators who received the Alpha Omega Alpha Robert J. Glaser Distinguished Teaching Award for significant contributions to medical education made by gifted teachers. A professor of pediatrics, Slavin has demonstrated a passion for medical education and curricular design throughout his 26 years in academic medicine. He most recently spearheaded a plan to restructure SLU’s four-year medical school curriculum so that students have more time to explore which specialty they intend to pursue during residencies. In a nutshell, SLU shortened its preclinical curriculum allowing for earlier entry in to the third and fourth years and substantially more time for students to take electives to decide on their specialty choice. At the same time, they made a number of significant changes to the curriculum -- realigning and combining some preclinical courses, expanding the focus on clinical issues in basic science courses, and better integrating material across courses. Slavin noted the change is part of SLU’s initiative to help students reduce the stress of medical school, innovations that have led to marked decreases in rates of depression and anxiety that research has shown many medical students experience. Before coming to SLU, Slavin served in numerous capacities at the David Geffen School of Medicine at the University of California, Los Angeles (UCLA). He was co-founder of the Doctoring curriculum and spearheaded other changes in the medical school curriculum. Slavin has received numerous teaching awards at SLU and UCLA. His teaching receives consistently high reviews from his students, making him “one of the highest rated teachers in the medical school,” says Philip Alderson, M.D., dean of SLU’s medical school. Slavin received his B.S. degree from Haverford College, his M.D. degree from Saint Louis University School of Medicine, and his M.Ed. degree from

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the University of Southern California. Established in 1836, Saint Louis University School of Medicine has the distinction of awarding the first medical degree west of the Mississippi River.

Stone Carlie to Host HIPAA Compliance BootCamp™ Stone Carlie & Company, L.L.C., certified public accountants, business consultants and wealth advisors, is pleased to bring its partner, Clearwater Compliance, and a faculty of leading national HIPAA experts, to St. Louis for a one day HIPAA Compliance BootCamp™ on Wednesday, December 11 at the Ritz Carlton. The BootCamp will provide an intensive educational experience focused on HIPAA-HITECH regulations. This nationally renowned curriculum is geared toward professionals who are responsible for ensuring their healthcare organizations become and remain compliant with the HIPAA Privacy, Security and HITECH Breach Notification regulations. The BootCamp uses a highly interactive classroom setting to tackle HIPAA-HITECH fundamentals, while offering practical tools and support for organizations to apply their learning. It is designed to help organizations understand the regulations, recognize high priority gaps and formulate a step-by-step implementation strategy and key progress metrics for enhancing compliance efforts. Specifically, HIPAA BootCamp attendees will receive: – Interaction with nationally recognized, fully credentialed HIPAA-HITECH experts in a small classroom setting. – Comprehensive instruction on HIPAA Privacy, Security and Breach Notification Rule Requirements, as amended by the Omnibus Final Rule. – A curriculum designed to equip teams with practical, actionable activities to enable them to recognize high priority gaps and develop prioritized remediation plans. – Complimentary toolkit and resources to develop or strengthen participating organizations’ compliance programs. The cost for the BootCamp is $595 per attendee and includes course materials, hot breakfast and lunch and a post event networking reception. Space is limited. Interested organizations can learn more and reserve their spot for the St. Louis In-Person BootCamp at http://clearwatercompliance.com/ products-and-services/education-andworkshops/clearwater-hipaa-compliance-bootcamp/ Guests can receive $100 off by entering “STONECARLIE100” when registering.

Mercy Clinic Welcomes New Physicians and Announces New Practices Mercy Clinic, the multi-specialty physician group affiliated with Mercy Hospital, recently added new doctors and established new practices. Leah Glass, DO, OB/GYN, joined Mercy Clinic Women’s Health. She will see patients in O’Fallon, Mo., and in Ballwin. She earned her doctorate of osteopathy degree from Kansas City University of Medicine and Bioscience in Kansas City, Mo., and completed her OB/GYN residency at Mercy Hospital St. Louis. Randi H. Becker, MD, family medicine physician, joined Mercy Urgent Care and will care for patients at all four Mercy Urgent Care locations in the St. Louis and St. Charles area. She earned her medical degree from the American University of Antigua College of Medicine in St. Johns, Antigua in West Indies, and completed a family medicine residency at Mercy Hospital St. Louis. Andrea Pepin, MD, pediatrician, joined Mercy Clinic Children’s Hospitalists providing care for patients when they are hospitalized at Mercy Children’s Hospital. She earned her medical degree from Texas A&M Health Science Center College of Medicine in Temple, Tex., and completed a pediatric residency at Children’s Mercy Hospital in Kansas City, Mo. Jad A. Khoury, MD, infectious disease physician, has merged his practice with Mercy Clinic Infectious Disease. He’s been on staff at Mercy Hospital St. Louis since 2006 and will continue to see patients at his current office location. Kimberly Molik, MD, pediatric surgeon, joined Mercy Clinic Children’s Surgery. She earned her medical degree from Northwestern University School of Medicine in Chicago, Ill., and completed a general surgery residency and pediatric surgery fellowship at Indiana University Medical Center in Indianapolis, Ind. Melissa Strike, DO, physiatrist, has opened Mercy Clinic Physical Medicine and Rehabilitation in Chesterfield. She earned her doctorate of osteopathy from the New York College of Osteopathic Medicine in Old Westbury, N.Y., and completed a physiatry residency at the Rehabilitation Institute of Chicago in Chicago, Ill. Muhammad Ali Javed, MD, critical care and sleep medicine physician, joined Mercy Clinic Adult Critical Care and will care for patients in the ICU at Mercy Hospital St. Louis and through Mercy SafeWatch, eICU. He earned his medical degree from Dow Medical College in Karachi, Pakistan, completed an internal medicine residency at UMPC Shadyside Hospital in Pittsburgh, Penn., and a critical care and sleep medicine

fellowship at Saint Louis University Hospital in St. Louis, Mo.

Study confirms benefit of back braces in treating scoliosis For years, adolescents instructed to wear back braces to correct scoliosis have protested having to wear the rigid plastic devices. Considering the lack of evidence in support of bracing, some may have felt they were justified in their complaints. While bracing has been recommended for decades to treat curvature of the spine, studies of its effectiveness have produced conflicting results. But now, new results from a multicenter clinical trial provide the strongest evidence yet that back braces work in a significant percentage of cases. Further, the more hours per day they’re worn, the more effective they are. Bracing is something that has been used for years but without any true evidence that it’s effective, so it’s been hard to convince patients that it’s the right treatment, especially because they don’t enjoy wearing braces according to Matthew B. Dobbs, MD, professor of orthopaedic surgery at Washington University School of Medicine in St. Louis and one of the study’s principal investigators. The braces were so effective at slowing the progression of scoliosis and helping patients avoid spine surgery that the clinical trial was ended early. The randomized study involved 242 patients, ages 10 to 15, at 25 sites in the United States and Canada. Each patient had a spinal curvature of 20 to 40 degrees. The researchers randomly assigned 116 of the children to observation or to wear a back brace for at least 18 hours each day. A second group of 126 patients had the option to choose between observation and bracing. Among patients who wore braces, curvature of the spine was corrected successfully in 72 percent. This compared with a 48 percent success rate among those under observation who did not wear braces. Further, the more hours per day a patient wore a brace, the more likely that child’s treatment was a success. Helping to measure how long the braces were worn by each participant were temperature-sensitive sensors in the braces.

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GrandRounds Study looks at safety, effectiveness of generics for treating depression Researchers at Washington University School of Medicine in St. Louis are studying the quality, effectiveness and safety of generic drugs used to treat depression. The research is supported by the U.S. Food and Drug Administration (FDA) and is the only study of its kind funded by the agency. The study will determine whether Dr. Even D. Kharasch brand-name 300 mg bupropion hydrochloride (HCl) extendedrelease (ER) tablets — sold commercially as Wellbutrin XL — and the various generic versions of bupropion HCl ER tablets work the same in the body and deliver the same therapeutic benefits. The principal investigator is Evan D. Kharasch, MD, PhD, the Russell D. and Mary B. Shelden Professor of Anesthesiology and an expert in clinical pharmacology, drug metabolism, drug interactions, mechanisms of drug toxicity and pharmacogenetics, a clinical pursuit that focuses on understanding the ways that individuals can respond to the same drug differently. Since generic versions of extended-release bupropion HCl were introduced, there have been some reports that they may not be as effective as the brand-name drug and may be associated with adverse events, according to Kharasch. The first time a 300 mg generic version of this drug was tested, there were significant differences in drug concentrations in the blood compared with what was seen with the brand-name drug, Wellbutrin XL, and that generic formulation eventually was taken off the market. They are going to study several generics to evaluate their blood concentrations in patients, how effective they are, and whether they are associated with side effects or with relapse. This study will go beyond the tests that have been conducted previously. Kharasch, an anesthesiologist at

Barnes-Jewish Hospital and also vice chancellor for research at Washington University, is collaborating with Eric Lenze, MD, professor of psychiatry. They will study blood samples from patients with depression to learn how much of the generic and brand-name drugs get into the bloodstream and how long the medications remain in the system. Kharasch believes the three-year, $2.8 million dollar grant will help determine whether this particular generic drug works as well as the brand-name version. It also should contribute to the understanding of how an individual’s DNA can influence whether a particular medication is effective.

SSM Health Care – St. Louis hospitals recognized as ‘Top Performers’ for providing high quality care The Joint Commission, the leading accreditor of health care organizations in the United States, has named SSM Health Care – St. Louis hospitals as being among the nation’s top performers in clinical quality measures. The SSM hospitals were recognized for using evidence-based clinical care processes that are closely linked to positive patient outcomes. To be recognized with this honor, hospitals must attain and sustain nearly perfect quality indicator scores – in the 95th percentile or above – across all reported key quality measures throughout 2012. A 95 percent score means a hospital performed nearly perfect by using an evidence-based practice 95 times out of 100 opportunities. Each key quality measure represents a best practice process shown to improve care for certain conditions, including heart attack, pneumonia, surgery, children’s asthma, stroke, venous thromboembolism and inpatient psychiatric services. The SSM Health Care – St. Louis hospitals recognized as Top Performers include: SSM DePaul Health Center, Bridgeton SSM St. Clare Health Center, Fenton

SSM St. Joseph Health Center, St. Charles SSM St. Joseph Hospital West, Lake Saint Louis SSM St. Mary’s Health Center, Richmond Heights / SSM Cardinal Glennon Children’s Medical Center, St. Louis (recognized jointly) This is the third year in a row that SSM St. Joseph Hospital West is being recognized as a Top Performer and the second year in a row for SSM St. Mary’s Health Center and SSM Cardinal Glennon Children’s Medical Center to receive the honor. Other SSM Health Care hospitals receiving this recognition from The Joint Commission include: St. Mary’s Health Center, Jefferson City, Mo.; St. Mary’s Hospital, Centralia, Ill.; and St. Clare Hospital, Baraboo, Wis.

Scientists identify clue to regrowing nerve cells Researchers at Washington University School of Medicine in St. Louis have identified a chain reaction that triggers the regrowth of some damaged nerve cell branches, a discovery that one day may help improve treatments for nerve injuries that can cause loss of sensation or paralysis. The scientists also showed that nerve cells in the brain and spinal cord are missing a link in this chain reaction. The link, a protein called HDAC5, may help explain why these cells are unlikely to regrow lost branches on their own. The new research suggests that activating HDAC5 in the central nervous system may turn on regeneration of nerve cell branches in this region, where injuries often cause lasting paralysis. The research appears Nov. 7 in the journal Cell. Axons are the branches of nerve cells that send messages. They typically are much longer and more vulnerable to injury than dendrites, the branches that receive messages. In the peripheral nervous system — the network of nerve cells outside the brain and spinal column — cells some-

times naturally regenerate damaged axons. But in the central nervous system, comprised of the brain and spinal cord, injured nerve cells typically do not replace lost axons. Working with peripheral nervous system cells grown in the laboratory, Yongcheol Cho, PhD, a postdoctoral research associate in Cavalli’s laboratory, severed the cells’ axons. He and his colleagues learned that this causes a surge of calcium to travel backward along the axon to the body of the cell. The surge is the first step in a series of reactions that activate axon repair mechanisms. In peripheral nerve cells, one of the most important steps in this chain reaction is the release of a protein, HDAC5, from the cell nucleus, the central compartment where DNA is kept. The researchers learned that after leaving the nucleus, HDAC5 turns on a number of genes involved in the regrowth process. HDAC5 also travels to the site of the injury to assist in the creation of microtubules, rigid tubes that act as support structures for the cell and help establish the structure of the replacement axon. When the researchers genetically modified the HDAC5 gene to keep its protein trapped in the nuclei of peripheral nerve cells, axons did not regenerate in cell cultures. The scientists also showed they could encourage axon regrowth in cell cultures and in animals by dosing the cells with drugs that made it easier for HDAC5 to leave the nucleus. When the scientists looked for the same chain reaction in central nervous system cells, they found that HDAC5 never left the nuclei of the cells and did not travel to the site of the injury. They believe that failure to get this essential player out of the nucleus may be one of the most important reasons why central nervous system cells do not regenerate axons.

Medical News is pleased to provide space for press releases by providers in our Grand Rounds section. Content and accuracy of the releases is the sole responsibility of the issuer.

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Nurturing healthcare practices to reach peak Nurturingand healthcare to reach peak for performance to createpractices exceptional experiences performance and to create exceptional experiences for patients, employees, physicians and the professionals patients, employees, physicians and the professionals who manage them. who manage them. «««««««««« «««««««««« For more information visit mgmastl.org For more information visit mgmastl.org

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GrandRounds Saint Louis University Hospital Earns ‘Top Performer on Key Quality Measures™’ Recognition Saint Louis University Hospital is one of the nation’s Top Performers on Key Quality Measures in a new report from The Joint Commission, the leading accreditor of health care organizations in America. SLU Hospital was recognized by The Joint Commission for exemplary performance in using evidence-based clinical processes that are shown to improve care for certain conditions. SLU Hospital is one of only 1,099 hospitals in the U.S. – the top 33 percent of all Joint Commission-accredited hospitals reporting data – in earning the distinction of Top Performer on Key Quality Measures for attaining and sustaining excellence in accountability measure in the following measure sets: heart attack; heart failure; pneumonia; surgical care. The ratings are based on an aggregation of accountability measure data reported to The Joint Commission during the 2012 calendar year. Each of the hospitals that were named as a Top Performer on Key Quality Measures must: 1) achieve cumulative performance of 95 percent or above across all reported accountability measures; 2) achieve performance of 95 percent or above on each and every reported accountability measure where there are at least 30 denominator cases; and 3) have at least one core measure set that has a composite rate of 95 percent or above, and within that measure set all applicable individual accountability measures have a performance rate of 95 percent or above. A 95 percent score means a hospital provided an evidencebased practice 95 times out of 100 opportunities to provide the practice. Each accountability measure represents an evidence-based practice – for example, giving aspirin at arrival for heart attack patients or giving antibiotics one hour before surgery.

University funds three Scholars of Pediatrics Washington University School of

Medicine in St. Louis and its Department of Pediatrics have established funding for three pediatric scholars named in honor of a trio of highly regarded former pediatricians at the university. The School of Medicine is funding the Scholars in Pediatrics with $3 million to be divided among three faculty members, in support of their time and efforts devoted to scholarship and teaching. Each inaugural scholar is being appointed for three years. The new Scholars in Pediatrics, each of whom practices at St. Louis Children’s Hospital, are well-known in their fields. They are Paul Hruz, MD, PhD, Shalini Shenoy, MD, and Andrew White, MD. Paul Hruz, MD, will serve as the inaugural Julio V. Santiago, MD, Scholar in Pediatrics. Hruz is an associate professor of pediatrics and of cell biology Dr. Paul Hruz and physiology, as well as director of the Department of Pediatrics’ and Children’s Hospital’s Division of Endocrinology and Diabetes. He is an internationally renowned researcher in childhood diabetes and the molecular mechanisms of glucose biology. Santiago served as co-director of the Division of Endocrinology and Diabetes from 1984 to 1997 and, like Hruz, was recognized globally for his research in childhood diabetes. He was a leader in the development and testing of miniaturized portable insulin infusion pumps, as well as other contributions in diabetes care. At the time of his death in 1997, Santiago was involved in the Diabetes Prevention Program, at that point the largest national diabetes study to evaluate whether medication or lifestyle changes could prevent or delay adultonset diabetes. Shalini Shenoy, MD, will serve as the inaugural Teresa J. Vietti, MD, Scholar in Pediatrics. Shenoy is a professor of pediatrics Dr. Shalini and director of the PediShenoy atric Bone Marrow Transplant Program at Washington University, Children’s Hospital and Siteman Cancer Center. She is recognized as a superior

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clinician, teacher and renowned leader in pediatric stem cell transplantation. Vietti, a pediatric oncologist who earned the nickname “the mother of pediatric cancer therapy,” was director of the School of Medicine’s Division of Hematology/Oncology from 1970 to 1986. A leading clinical and translational investigator, she conceived the concept of multi-institution pediatric cooperative groups and founded the Pediatric Oncology Group (POG), now known as the Children’s Oncology Group (COG). Under her leadership, POG grew to more than 100 institutions and 1,500 investigators. Vietti, a professor emeritus of pediatrics and of radiology, died in 2010. Andrew White, MD, will serve as the inauguDr. Andrew ral Philip R. Dodge, MD, White Scholar in Pediatrics. White, an associate professor of pediatrics, is the Pediatric Residency Program director at Children’s Hospital and director of the Division of Rheumatology at Washington University and Children’s Hospital. He is a consummate clinician and teacher and is beloved by trainees. Dodge, one of the founders of pediatric neurology, served as chair of the Department of Pediatrics from 1967 to 1986. A professor emeritus of pediatrics and of neurology at the School of Medicine, Dodge is credited with bringing the Department of Pediatrics and Children’s Hospital to international prominence for clinical care, teaching and research. Known for his vision, wisdom and compassion, he was a respected clinician and revered teacher and mentor. He died in 2009.

Saint Louis University Hospital and Des Peres Hospital Launch ‘Path to Health’ Campaign Saint Louis University Hospital and Des Peres Hospital have launched “Path to Health,” a community education and outreach initiative to raise awareness and understanding of the Affordable Care Act (ACA). “Path to Health” is designed to inform and educate the region’s uninsured population and others within the community on how the changes implemented in the healthcare law will impact them and what they need to do in order to secure affordable healthcare coverage. The “Path to Health” campaign will work with community partners and offer educational materials and resources around navigating the insurance exchanges and the ACA. The comprehensive campaign will break down barriers by helping to interpret this complicated law, and provide user-friendly guidance and tips on what community members need to know in order to make sure they are prepared to choose the best coverage for themselves and their families. For more information, visit www. pathtohealth.com

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Saint Louis Medical News December 2013