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Western New York

buffalo and the great lakes

PHYSICIAN the local voice of practice management and the business of medicine

VOLUME 3 / 2017

Advances in Breast Reconstruction Mean Less Pain, More Natural Appearance

No End in Sight

New Changes to Statue of Limitations Require Proactive Risk Management

A Cervical Cancer Wake-Up Call

Preventing and Treating Colorectal Cancer

Local Colorectal Surgeons Lead Screening and Early Detection Efforts


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Contents WESTERN NEW YORK PHYSICIAN I VOLUME 3 I 2017

buffalo and the great lakes

10 23

Practice Profile

The Cosmetic Vein & Laser Center Celebrating 20 Years of Cosmetic Dermatology and Vein Care in Western New York

Professional Liability No End in Sight New Changes to Statue of Limitations Require Proactive Risk Management

COVER STORY

05 Advances in Breast Reconstruction Mean Less Pain, More Natural Appearance Innovations in breast surgery and reconstruction help minimize perfusion complications during surgery and improve the reconstruction treatment process. Regional experts Drs. Wong Moon, Roswell Park Cancer Institute, and Andrew Smith, Plastic Surgery Group of Rochester, discuss some of the biggest strides for patients.

14

Medical Research Research Supports Use of Enhanced Recovery Approaches in More Abdominal Surgeries

15 Sedentary Lifestyle Appears to Increase Risk for Both Kidney and

Bladder Cancer

Practice Management 20 Local Firm Supporting CMS and

Clinical Features 19 A Cervical Cancer Wake-Up Call

03 When people ask about my job

NY State Programs to Transform

Care in Western NY

26

What’s New in Area Healthcare

04

Editorial Outlook

at a cocktail party, I become

16 Preventing and Treating Colorectal Cancer: Local Colorectal Surgeons

instantly popular: “A sleep doctor? Really?”

Lead Screening and Early Detection Efforts

Cover Photo: Dr. Wong Moon, Roswell Park Cancer Institute. Photo courtesy of Roswell Park Cancer Institute.

14 16

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WNYPHYSICIAN.COM VOLUME 3 I 2017 I 1


from the publisher

Western New York

Visit us Online www.WNYPhysician.com

Welcome to the latest issue of Western New York Physician – Buffalo and the Great Lakes where you will find informative stories and articles about and for physicians in western NY. Welcome Readers— Current Breast Cancer Statistics About 1 in 8 U.S. women — about 12% — will develop invasive breast cancer over the course of her lifetime. In 2017, an estimated 252,710 new cases of invasive breast cancer are expected to be diagnosed in women in the U.S., along with 63,410 new cases of non-invasive (in situ) breast cancer. According to the Breastcancer.org

PHYSICIAN the local voice of

practice management and the business of medicine

publisher

Andrea Sperry creative director

Lisa Mauro writer

Randi Minetor medical advisory board

Michael Silber, MD Chuck Lannon contributors

Randi Minetor

Our cover story meets with regional plastic surgeons to learn about some of the latest surgical approaches to breast reconstruction and innovative imaging technology now being used during surgery which reduces perfusion complications for patients. With anticipated completion of the John R. Oishei Children’s Hospital in November it is perfect timing that the focus of the next issue is the pediatric patient. If you are a Buffalo provider working with this special patient demographic and want to take part in the issue – please email me at wnyphysician.com. Join the Conversation Sharing your expertise is a valuable way to communicate with your medical colleagues. We invite your feedback and article suggestions. Please drop me an email or call to discuss being part of an upcoming story or to submit an article. In the meantime, please enjoy the numerous other articles within the issue. As always, we thank each of our supporting advertisers — your continued partnership ensures that all physicians in the region benefit from this collaborative sharing of information and provides the WNYP editorial staff with a deep pool of expert resources for future interviews and articles.

Sandra Block, MD Kunle Odunsi, MD, PhD Colleen Mattrey Joni Steinman Roswell Press Julie Nusbaum contact us

For information on being highlighted in a cover story or special feature, article submission, or advertising in Western New York Physician WNYPhysician@gmail.com Phone: 585.721.5238 reprints

Reproduction in whole or part without written permission is prohibited. To

Best –

order reprints of articles appearing in the magazine, please contact the Publisher. Although every precaution is taken to ensure the accuracy of

Andrea WNYPhysician@gmail.com (585)721-5238

published materials, Western New York Physician cannot be held responsible for opinions expressed or facts supplied by its authors. Western New York Physician is published monthly by Insight Media Partners.

2 I VOLUME 3 I 2017 WNYPHYSICIAN.COM


clinical

When people ask about my job at a cocktail party, I become instantly popular.

“A sleep doctor? Really?”

Usually, it's women sidling up to me for a chat. Sometimes, they just want to complain about their husbands snoring. But more often than not, they are desperate for help with their own sleep. It's not surprising. Women are twice as likely as men to experience insomnia with a risk of about 73% by age sixtyfive. And to make matters worse, this loss of sleep appears to affect women more than men as well, associated with higher incidences of weight gain, depression, and even heart disease. So, why do women have so much trouble with their sleep? One obvious answer is hormones. Hot flashes can certainly wreak havoc on sleep. But other psychosocial issues, mood disorders, and sleep disorders like sleep apnea can also play a role. In fact, women with sleep apnea may present with insomnia and fatigue instead of the typical loud snoring. The risk for sleep apnea increases with age, and is twice as likely in postmenopausal women. This is because as progesterone decreases, the upper airway muscles become more collapsible, which can cause sleep apnea. Another sleep disorder which is common in women is restless legs syndrome (RLS). The prevalence is especially high during pregnancy (which incidentally also worsens sleep apnea.) In RLS, patients describe an uncomfortable “creepycrawly” feeling in their legs at bedtime, which may then cause insomnia. RLS often runs in families, and can also be due to iron deficiency. So, now we know why women can't sleep, but what can we do about it?

Sandra Block, MD

If the issue is purely insomnia, the most effective treatment is not medication, but a therapy called cognitive-behavioraltherapy. This entails changing both patient thinking and behaviors regarding their sleep and insomnia. The process can take weeks to employ, but here is a simple cheat sheet.

The Eleven Commandments of Insomnia 1. Go to bed when you are sleepy (not when you think you should be.) 2. Go to bed and wake up at the same time every day. (Don't sleep in after a bad night.) 3. Do not nap. (This steals from your night-time sleep.) 4. Stop caffeine after noon at the latest. (It's a stimulant, dummy.) 5. Turn around your clock so you can't see it. (The light wakes up your brain). 6. Use your bed for sleep only. (Don't hang out and watch TV all day in bed.) 7. Don't drink alcohol before bed. (It disrupts your sleep.) 8. Leave the bed if you can't sleep. (Tossing and turning only aggravates your brain) 9. Avoid bright light activities before bed (This isn't time for Facebook!) 10. Exercise every day (This tires out your body). 11. Do not worry about your sleep. (Huh??) That's right. Don't worry about your sleep. People with insomnia understandably ruminate about their poor sleep. But, though it seems counterintuitive, the more you worry about

WNYPHYSICIAN.COM VOLUME 3 I 2017 I 3


sleep, the harder it is to sleep. Anti-anxiety techniques such as meditation and progressive muscle relaxation can be extremely helpful for this. And if cognitive behavior therapy does not work, we can try always medications, such as zolpidem (ambien), zaleplon (lunesta) or doxepin. For RLS, we also start with non-pharmaceutical approaches, such as avoiding caffeine, alcohol and chocolate. We may check an iron and ferritin level as well. However, if symptoms remain, effective medications are out there, including ropinarole (requip) or pramipexole (mirapex) as well as gabapentin (neurontin) and pregabalin (lyrica.) Sometimes, especially for sleep apnea, we need to obtain a sleep study. You may be saying, “I can't sleep at home, how am I going to sleep in a lab with all those wires?” I have some good news for you - we now have home studies available! Often, we can get our answer right in the comfort of your own home. For sleep apnea, the most effective treatment is

CPAP, a machine which blows air to open the airway. And have no fear: the masks are more comfortable than they used to be. Some are quite small, just going inside or under the nose. Other treatment options for sleep apnea include a dental appliance or nasal valve therapy. So ladies, next time you're at a cocktail party, I'd love to chat about all of your sleep problems. But just in case you miss me... here’s a number to call for more help.

Koo BB, Dostal J, Ioachimescu O, Budur, K. The effects of gender and age on REM-related sleepdisordered breathing. Sleep Breath. 2008 Aug 12 (3): 259-64. Manber R, Armitage R. Sex, steroids, and sleep: a review. Sleep. 1999 Aug 1. 22 (5): 540-55. Owens JF, Matthews KA. Sleep disturbance in healthy middle-aged women. Maruritas. 1998. Sep 20. 30 (1): 41-50. Manconi M, Ulfberg J. Berger K et al. When gender matters: Restless legs syndrome. Report of the "RLS and woman" workshop. Sleep Med Rev. 2011 Nov 8. Ameratunga D, Goldin J, Hickey M. Sleep disturbance in menopause. Intern Med J. 2012 Jan 31.

connect with your referring colleagues through

Western New York Physician

Share Your Expertise

Join the discussion. Stand apart from your colleagues when you offer your medical perspective through an interview on a specialty topic or by contributing an article to an upcoming issue. Contact the Publisher, Andrea Sperry, at the following: Email: WNYPhysician@gmail.com or Call: (585) 721-5238

Practice Profile

Designed specifically for medical practices and providers to introduce your practice and highlight scope of services. Profiles create a unique communications opportunity with the referring physician readership. To learn more or arrange a meeting, please call Andrea Sperry (585) 721-5238 or email http://wnyphysician@gmail.com.

Volume IV The Pediatric Patient

Volume V Oncology Update

Volume VI Geriatrics & Aging

Close Date: Aug. 17, 2017

Close Date: Oct. 5, 2017

Close Date: Nov. 30, 2017

www.WNYPhysician.com 4 I VOLUME 3 I 2017 WNYPHYSICIAN.COM


cover story

Advances in Breast Reconstruction Mean Less Pain, More Natural Appearance

Photo credit: Elizabeth Soufleris

Randi Minetor

Andrew Smith, MD

F

or patients with breast cancer, a total mastectomy may be the best option for recovery from the disease and for a lifetime of continued good health. Losing a breast can have significant emotional consequences, however, and many women choose reconstruction to restore a natural appearance. Traditional methods for breast reconstruction have

not always produced the results patients wanted, however. For decades, the method involved insertion of a tissue expander, a breast implant meant to expand the space under the chest muscle. The expander stretches the skin and the chest muscle over time. This can be painful for some patients, and for a limited number the pain may become chronic.

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Photo credit Lynne Tseng

Andrew Smith, MD, FACS, a board-certified plastic surgeon with Plastic Surgery Group of Rochester In some cases, the procedure involves cutting the muscle. There was another drawback to the traditional method: With the implant under the chest muscle, there are sometimes difficulties stretching the muscle enough to match the other breast. The result may leave the patient with breasts of two different sizes. All of this has changed in the last few years. Innovations in breast reconstruction not only create a natural-looking breast, but they also reduce the pain associated with older procedures. “Probably the biggest recent innovation is the pre-pectoral tissue expander,” said Andrew Smith, MD, FACS, a boardcertified plastic surgeon with Plastic Surgery Group of Rochester. Smith completed a fellowship in microsurgery and oncologic reconstruction at Memorial Sloan Kettering Cancer Center in New York, and he specializes in cancer reconstruction. A tissue expander is a balloon-like inflatable breast implant, which stretches the skin gently over time to create space for a permanent implant. Using the tissue expander, Smith and fellow surgeon Mark Davenport, MD, place the expander in front of the chest muscle instead of behind it. They first insert a layer of Alloderm®, a tissue matrix often used in 6 I VOLUME 3 I 2017 WNYPHYSICIAN.COM

reconstructive surgery, around the tissue expander to reduce the development of capsular contracture—scar tissue that can form around a breast implant and change its shape. “The pre-pectoral expander gives the patient a breast mound a little more easily and quickly,” said Smith. “We’re putting the implant in the same anatomic position as the breast tissue that was removed. We can put more volume into the implant right away because the overlying pectoral’s muscle does not need to be stretched, so they have a significant mound right away.” The tissue expander has a port built into the wall of the implant, allowing the surgeon to fill the implant after surgery. “The implant can be filled either with air or fluid,” said Smith. “Then there’s a second surgery down the road, when we exchange the expander for a permanent implant filled with either silicone gel or saline.” Some patients ask that the implant be placed during their mastectomy, to minimize the change in their appearance and to minimize the number of surgeries. Patients who will be treated with radiation or chemotherapy must wait until these therapies are completed before proceeding with an implant. Even when no further therapies are required, however, immediately placing a traditional implant can, in some cases, jeopardize healing. “If there’s a problem with blood flow to the skin after the mastectomy, it can be exacerbated by the weight and pressure of a full-size implant,” Smith said. “The tissue expander allows us to fill it with air initially, and then swap out the air for saline three weeks later. There is less stress and pressure on the skin.” A second procedure may be preferable in many cases, Smith explained. “When you have a tissue expander, you can adjust the volume after surgery, so we can get closer to what a patient wants,” he said. “So after the surgery, if the patient would like the breast to be a little larger, we can add more fluid or air to the tissue expander, and continue to add to the breast mound.” If the implant looks too prominent or if some shaping is required, Plastic Surgery of Rochester can modify the appearance using liposuctioned fat from another part of the patient’s body. “We process the fat in a specialized way, and inject it into the soft tissue on top of the implant,” said Smith. “It can add volume and help correct contour issues. We’ve been doing this for five to ten years to help camouflage the implant, especially in patients with thinner skin.”

Reconstruction through tissue transplant

At Roswell Park Cancer Institute in Buffalo, plastic surgeon Wong Moon, MD, takes a different approach to breast reconstruction. Instead of using implants, Moon uses


Photo courtesy of Roswell Park Cancer Institute

Wong Moon, MD, FACS is an Associate Professor of Oncology in the Department of Head and Neck Surgery/Plastic and Reconstructive Surgery at Roswell Park Cancer Institute. a microsurgical technique known as flap reconstruction, a procedure pioneered by the Buncke Clinic in San Francisco. “You can take tissue from any region of a patient’s body and transplant it to another region,” said Moon. “The main thing that we’ve done for the last three and a half years is tissue transplants.” Several kinds of flap procedures are in use by specially trained surgeons across the country who, like Moon, have training in microsurgery as well as plastics. In a DIEP flap procedure, Moon makes a tummy-tuck-like incision in the patient’s lower abdomen, an area that often has a large volume of tissue. Moon removes blood vessels known as deep inferior epigastric perforators (DIEP), as well as the skin and fat connected to them. The skin, blood vessels and fat form the “flap,” and the surgeon transplants this flap to the patient’s chest using microsurgery to connect the blood vessels, shaping the flap carefully to achieve a natural look. In some cases, the surgeon will take a SIEA flap, a section of blood vessels, skin and fat from a different part of the

abdomen. A TUG flap, from the upper inner thigh, may be used if the lower abdomen does not have enough excess tissue and fat to be useful—but this involves severing a muscle called the gracilis, leaving this muscle inoperative. Flaps can also be taken from the buttocks and back. For some patients, repeated surgeries may be required to further shape the breast or to reach the patient’s desired size. “You can harvest fat from any other area in the body, and you can increase the breast size by another cup size,” Moon said. Minimal to no muscle tissue in the chest or abdomen is severed, so the patient does not lose any function—making recovery relatively quick in most cases. “The healing process is slightly longer than for implants,” said Moon. “The whole process may take about two or three months, but after that they typically are fully healed.” Moon reports positive feedback from patients who’ve received this procedure regarding their ability to return to their normal activities after their surgeries. “Whether they are working outside the home, taking care of their kids or doing something else day-to-day, they seem to be very pleased both with their ability to get back to their usual activities and with their appearance after the healing process is completed.” Moon says a key element is determining for which patients the flap procedure is appropriate. “We are selective in who we pick,” he said. “There are a lot of issues to consider from a medical standpoint. First and foremost, you want to be sure they are cured from their cancer. Treating the cancer has to come first. Then after the treatment is complete, we can look at our options for reconstruction and cosmetic repair.” The decision to present the patient with options for breast reconstruction is a team effort, he said. “We have to consider the patients’ needs, priorities, their quality of life, and the amount of time they want to dedicate to this process,” he explained. “They may not be able to take the time off from work or other obligations. But often we can schedule their procedures for a time that’s more convenient, such as when they have additional vacation or their children will be in school. At Roswell Park, we implement a team approach to breast reconstruction. Plastic surgeons, breast surgeons, medical oncologists, the radiation oncologists, nursing specialists—we all discuss the optimal options for the patient and help guide the patient through them.” It’s important to distinguish between breast reconstruction and breast augmentation, he noted. “They are totally different processes. Breast reconstruction involves medical as well as cosmetic focuses. In some cases, we can put an implant in directly as part of the breast reconstruction. It’s all about what the patient prefers and what’s safe in terms of her cancer treatment.”

WNYPHYSICIAN.COM VOLUME 3 I 2017 I 7


SPY Technology Visualizes Blood Flow During Microsurgery During a mastectomy or a flap breast reconstruction surgical procedure, the surgeon divides numerous blood vessels going to the breast skin in order to remove the breast and cancer. This compromises the normal blood supply to the skin and requires the surgeon to make critical decisions about the health of the tissue and whether normal blood flow is present. To aid in this process, Wong Moon, MD, at Roswell Park Cancer Institute makes use of indocyanine green-based (ICG) fluorescent angiography—specifically the SPY Elite fluorescence imaging system from Novadaq—that provides images of the blood flow in the tissue in real time during surgery. ICG technology has been in use for ophthalmic surgery for many years, but its application in breast reconstruction surgery is fairly recent. “Removal of breast tissue during surgery may damage the blood supply of the breast skin,” Moon explained. “The SPY imager is a device that images the perfusion, or flow of fluids, of tissue. Immediately after a mastectomy is performed, this device can be used to assess blood supply to the skin. If the skin has no blood supply, then this area is excised. These steps can help prevent future problems such as skin necrosis and infection, and may prevent additional surgery.” The use of SPY imaging during mastectomy and flap reconstruction surgery has been shown to reduce complications that may occur during these procedures. A study published in the journal Gland Surgery in 2016 concluded, “In prosthesis-based breast reconstruction, intraoperative assessment of the mastectomy skin flap to guide excision of hypoperfused areas translates to improved clinical outcomes.” “Complications related to poor perfusion can be physically disfiguring and emotionally devastating, but most importantly, can delay the start of further treatments, such as chemotherapy and radiation,” the Novadaq website notes. “SPY images have been shown to supplement clinical judgment in assessing the quality of perfusion in tissue by allowing the surgeon to visually identify areas of poor perfusion that can potentially compromise the newly created breast.” Having the ability to assess perfusion rates during the surgery provides financial benefits as well. A study conducted at the Cleveland Clinic showed significant reductions in costs per patient when SPY technology was used to visualize blood flow. With no need for a second surgery to remove additional tissue, the cost of a flap reconstruction was reduced by as much as $22,659. Other reports suggest that by avoiding a second surgery, the cost savings could be as much as $35,000.

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PRACTICE PROFILE

The Cosmetic Vein & Laser Center Celebrating 20 Years of Cosmetic Dermatology and Vein Care in Western New York It all started in 1997 in a small, medical office in Snyder, NY. Three employees and three brand new cosmetic dermatology lasers. Dr. Daniel Buscaglia dreamed of combining his keen desire to help patients with their skin care concerns and his passion for advanced, high-tech medical lasers. Now in his 20th year of successful private practice, this is the story of how The Cosmetic Vein & Laser Center began with Dr. Buscaglia at the helm. He and his team have brought innumerable advancements in cosmetic dermatology to Western New York for the first time. Dr. Buscaglia was extremely fortunate to have been chosen to complete an experimental dermatology laser fellowship in

Photodynamic Therapy from 1993 to 1994 at Roswell Park Cancer Institute, using lasers to treat skin cancer. “At that time, there were only a handful of dermatologists in the whole country performing skin laser treatments,” according to Dr. Buscaglia. “What an amazing opportunity it was for me to jumpstart my career in this ever-expanding field.” Dr. Buscaglia attended his first American Society for Laser Medicine and Surgery Conference in 1996. He has attended or presented at the conference every year since then. This is the premier venue for discovery of new cosmetic laser treatments and advancements that are unveiled to the world.

Bethany S. Lema, M.D., Daniel A. Buscaglia, D.O., P.C., Lisa Esler-Brauer, M.D. 10 I VOLUME 2 I 2017 WNYPHYSICIAN.COM


Interview with Dr. Buscaglia, Dr. Esler-Brauer and Dr. Lema How did you initially start this amazing practice in Lasers, Vein Care and Cosmetic Dermatology? Dr. Buscaglia: Just prior to completing dermatology residency in 1997, I returned home to Buffalo to interview with local dermatologists. After three potential job offers where I was told: ‘there aren’t enough interested patients in the Buffalo area to solely practice Cosmetic Laser Dermatology and Vein Treatments,’ I realized that I had to take the risk and begin on my own. I am so glad that they were wrong! What are some of the biggest challenges you’ve faced in practice? Dr. Buscaglia: Growth. It’s a fine line between acquiring medical laser technology and predicting the number of patients that will come in for these services. I am very thorough in evaluating and purchasing devices that make tangible changes to improve our patients’ skin condition. However, there are plenty of devices that make false claims about their effectiveness. It’s our job as specialists to avoid these pitfalls and provide legitimate treatments with durable and favorable outcomes for our patients.

“The staff at CVLC is always very helpful and polite. They go out of their way to make you feel comfortable. The physicians and assistants are the best. I would highly recommend this Center.”

How do you account for your success? Dr. Buscaglia: Hard work and the right team. It’s an ongoing task to assemble the right team. Every patient’s happiness and satisfaction with us is what has provided our 20 years of success. My team and I make it ALL count.

“The staff and doctors are great here. While the procedure I had proved to be more challenging than was originally thought, they honored their quote and did an amazing job. I couldn't be happier with the results!” What is the most rewarding part of your job or practice? Dr. Esler-Brauer: The absolute most satisfying part of my job is establishing long-term relationships with our patients. Hearing patient concerns, and then helping them feel good about the way they look, with gradual, minimally-invasive treatments is fulfilling for us and the patient! I do think that patients become more confident and empowered as they choose to be proactive with their skin care and the aging process. I also have a special interest in non-invasive body contouring, and helping patients feel good about their body.

WNYPHYSICIAN.COM VOLUME 3 I 2017 I 11


How has your chosen field changed in the last 20 years? Dr Lema: The application of lasers for the treatment of many cosmetic, dermatological, and vein concerns has revolutionized therapy. We are now able to safely and effectively treat common cosmetic and medical concerns with very little or no downtime for the patient. This is an exciting time, filled with advancements in laser technology, and we continue to stay at the forefront of laser medicine. With these changes comes greater responsibility as well. Continuing our education to provide safe, effective outcomes and patient safety have always been and will continue to be our goal. I feel privileged to be able to help our patients feel their best, especially during a time where so many advancements are being made in our field.

“I have been going to CVLC since 1998. Dr. Buscaglia and his staff are personable and caring, and I might add that he is always on the cutting edge of every new technology. I have had just about every procedure this practice offers with no negative side effects.” What were some of the best practice decisions you have made over the last 20 years? Dr. Buscaglia: Staying true to the course of providing the best treatments for our patients, regardless of the influence of economic and marketing bias. Adding amazing associate dermatologists, like Dr. Esler-Brauer and Dr. Lema, and support

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staff to continue to provide superior results and achieve happy patients.

“I won't go anywhere else for my cosmetic and vein needs. They are the most trusted professionals I have ever met. I enjoy the non-invasive treatments, which have minimal downtime - if at all - and allows me to return to the gym and/ or work immediately.” What advice would you give a new dermatology graduate about starting his or her own practice? Dr. Buscaglia: Stay true to your goals. Creating something you believe in is truly one of the most rewarding accomplishments you can achieve professionally. Work hard and you will succeed. Where do you see you and your practice over the next 20 years? Dr. Buscaglia: I am excited about our field and the potential. Surgical skin treatments will become a thing of the past. Look at how far we’ve come: unwanted hair can be permanently removed, underarm sweating and body odor can be permanently eliminated, reversing 10 years of skin age and sun damage with one treatment is standard, permanently and non-surgically reducing fat and contouring someone’s body shape. This is what we do. The future is utilizing and combining all of these technologies to achieve results that emulate a surgical face lift, but without surgery. Stay tuned!


becomes the information engineer,” says Dr. Valvo. In the next decade, medical patient information systems will revolutionize minimally invasive surgery for over 65 years. the information available to surgeons. “Efficiencies will follow THROUGH INNOVATIVE TREATMENT YEARS and become FOR second20 nature to everyone involved.” Other physiKARL STORZ has been dedicated to the education cians will be able to chime in their iPads, The Cosmetic Vein & Laser Center began its long list of “firsts” via by starting its helping to advise and evolution of surgical procedural approaches, practice with three staff members in a modest office space on Harlem Road while eliminating the need for more people on-site in the OR. and hasFirst leveraged competency to develop in WNY this to offer: With large, multi-purpose screens, surgeons can benefit from Laser hair removalfor Alexandrite In-office Varicose VeinorMicro-Phlebectomy technology solutions the ORLaser, thatMicrodermabrasion support the skin tele-consulting tele-proctoring with doctors in another part rejuvenation and Intense Pulsed Light Photorejuvenation treatments of the hospital or even another city—a process which is somesurgical workflow. The clinical goals of efficiency, times mandatory. patient centric, ergonomic, safety are a foundation The practice continued its growth with seven staff members KARL STORZ has been an industry leader in

PROVIDING CONFIDENCE

1997-2000

2000-2008

and expanded office space on Main Street in Snyder to the engineering of any solution KARL STORZ Introducing The

First in WNY to offer: manufactures. Non-ablative skin resurfacing, Cool Touch Laser KARL STORZ with with RGH Laser Hairpartnered Removal in patients darkto skininstall types key (Altus Medical, Long Pulsed Nd:YAG laser) systems as a means “integrate” their new roboticDevice Non-invasive skintotightening with Thermage Radiofrequency In-office Endovenous Therapy of Saphenous room. Essential NEO andLaser StreamConnect are the Vein Insufficiency with the Cool Touch Endovenous Laser

Future OR #16

“We began looking at this model three years ago and it already Fraxel Laser skin resurfacing and within two years became the needs to evolve based on how quickly technology has changed 2nd busiest practice in the USA utilizing this device since then, says Cosmetic Dr. Pennino. Injectable Restylane Dermal “We Filler must constantly think for the Pulsed dye combined with lasertoday.” for improved future as laser we re-create ourNd:YAG OR of Vascular Lesion treatments Specifically, the state grant will support a STORZ System of minimally invasive endoscopic and robotic technologies for KARL STORZ state-of-the art integration systems Added new treatments: complete integration. Streaming Altus Medical OR Long Pulsed Nd:YAG Laser (Coolglide video XEO) will provide realDualthe mode Q-switched LonginPulsed that mange video and and audio the Ruby OR-Laser from time “dashboard” technology including surgical for Laser Hair removal, vascular lesions and skin rejuvenation video, a picture for Tattoo and Hair Removal creation to archiving. Radiesse (calcium cosmetic dermal (PACS) filler Juvederm Injectable Cosmetic Filler archiving and hyroxylapettite) communication system and lab reports Dr. Buscaglia was chosen to participate Welcomed Dr. Lisa Dr. Buscaglia selected HD screens allEsler-Brauer, displayed side by side on large, was wall-mounted

in Vascular Birthmark and Hemangioma Clinic at Children’s Hospital of Buffalo all computerunder physician enDr. Lindaorder Brodsky and Dr. Mark Nagy

2nd Board Certified Dermatologist (Dr. Buscaglia was booked out for appointments nine months in advance)

to become Procedural Dermatology Director for the SUNY at Buffalo Dermatology Residency Program

try, medical records, scheduling software, and practice manageAfter more than a decade of innovation, the practice and its 22 staff members ment applications—enabling the moved to its largest and most technologically advanced location in Williamsville doctors to access and consider the Dr. Buscaglia became first in WNY to achieve Diplomate Status of the American College of patient’s active medical problems, Venous and Lymphatic Medicine (there are still only four physicians in WNY with this status) current medications, and drug Added new treatments: First in WNY to offer: allergies when Fraxel making care dePerlane (now Restlane Lyft) Cosmetic Dermal Filler CO2 any microablative laser resurfacing for Malar Cheek enhancement Sciton Broad Band Light Photorejuvenation cision. Sculptra Aesthetic Injectable for liquid facial lifting Sciton Microablative Erbium Yag Profractional Laser This new OR is in reality a beta Xeomin botulinum Toxin treatment of facial wrinkles for skin rejuvenation test site for future design. For MiraDry Microwave laser technology for permanent underarm Sciton OR Pro Lipo Laser LipoSculpture perspiration, hair reduction and body odor elimination Sciton 1319 in office with EndoVenous Laser Therapy of example, recent advances Dermapen Micro-needling system Saphenous Vein Insufficiency HD cameras and 3D digital imagSecond Sciton Broad Band Light device for Photorejuvenation Coolsculpting, non-invasive body contouring (cryolipolysis) ing technologies will continue to Added HydraFacial MD® for advanced skin rejuvenation Dysport botulinum Toxin treatment of facial wrinkles require increased in-wall orfractionated laser for Fraxeluse Dualof Thullium 1927 pigmented systems skin rejuvenation Office staff trip to New York City for overnight hanging monitoring and Micro-Fractional percutaneous microneedle celebration of 15 successful years in practice intercommunications, so the OR radiofrequency for skin tightening Welcomed Dr. Bethany Lema, 3rd Board will be designed for Silk easy integraRestylane cosmetic dermal filler for lip wrinkles Certified Dermatologist and lipand enhancement tion of new data communicaCurrent staff includes: three Board Certified Dermatologists, Cellfina Permanent Cellulite dimpling removal system tions interfaces. two Physician Assistants, one Registered Vascular PiQo4 Pico/Nanosecond Nd:YAG Laser for advanced tattoo “In this new OR,pigmented the surgeon Technologist, and 16 front and back office staff removal, lesions and fractionated skin rejuvenation

Photo: Jeff Blackman

2008-2017

2018

Next year, the practice will establish CVLC Beyond Borders, a mission program that will the Robotic impoverished town of SanMaquet Pedro, Belize, America, to Redesign of OR in over 60 years Widespread Use of Minimally Invasivesend Surgeryteam members Firstto Remote Surgery Designs Vari-op Central Modular Surgical Room First perform skin cancer screenings, leg ulcer and vein care to the population New York – Strasbourg Spartenburg, SC

1990

2001

2009

8 i VOLUME 2 i 2014 WNYPHYSICIAN.COM

WNYPHYSICIAN.COM VOLUME 3 I 2017 I 13


medical research

Research Supports Use of Enhanced Recovery Approaches in More Abdominal Surgeries Roswell Park team’s analysis shows clear benefit from ERAS through improved clinical outcomes, cost control

Steven Nurkin, MD, MS, FACS of Roswell Park Cancer Institute with a patient. In a new study, Roswell Park Cancer Institute researchers have demonstrated that an approach shown to improve outcomes for patients receiving colorectal surgery is just as effective in patients requiring many other abdominal and pelvic operations. Their findings, published online ahead of print in the journal Annals of Surgery, support the conclusion that Enhanced Recovery After Surgery (ERAS) programs are safe and beneficial for a broad range of patients with surgically treatable diseases while also decreasing both length of stay and cost of care. The ERAS approach was developed in the late 1990s as a way to maximize clinical outcomes for patients undergoing surgery. These pathways, or systems of reproducible best practices and clinical interventions, were first applied and studied in patients receiving surgery to remove cancerous colorectal tumors, and involve steps taken before, during and after surgery. ERAS elements employed at many medical centers worldwide include patient counseling, carbohydrate loading, antimicrobial pro14 I VOLUME 3 I 2017 WNYPHYSICIAN.COM

phylaxis, use of short-acting anesthetics, minimal use of drains and nasogastric tubes, control of body temperature, early catheter removal, minimizing use of opioid analgesics and stimulation of the gut to encourage return of normal bowel function. Working with colleagues from the Roswell Park departments of Surgical Oncology and Biostatistics and Bioinformatics, Steven Nurkin, MD, MS, FACS, and Anthony Visioni, MD, performed a meta-analysis of 39 studies involving more than 6,500 patients. They reviewed the impact of “enhanced recovery after surgery” or “fast track” approaches in major abdominal and pelvic surgeries, including procedures to remove, in part or in whole, the liver, pancreas, stomach, esophagus, genitourinary and reproductive organs. The team found that ERAS protocols decreased patients’ length of stay by 2.5 days, on average, and significantly reduced costs of care by decreasing incidence of surgical complications and postsurgical readmissions. “ERAS showcases the benefits of a comprehensive and multidisciplinary approach to both planning and evaluating major surgical procedures,” says Dr. Nurkin, Assistant Professor of Oncology in the Department of Surgical Oncology at Roswell Park and senior author on this research. “ERAS pathways require buy-in from multiple specialties and from facility administration, but the upfront time and costs of implementing these pathways are quickly repaid with reduced costs and improved surgical outcomes.” “One of the more surprising findings is that ERAS pathways are applicable to all studied abdominal procedures. There was not a single procedure we looked at where we weren’t able to find a benefit to ERAS,” adds first author Dr. Visioni, a Clinical Fellow in the Department of Surgical Oncology at Roswell Park. “And it’s important to note one of the most critical parts of any ERAS program — getting patients engaged in their recovery, even before their surgery.” The team expects to pursue further research in this area as ERAS pathways are implemented and tracked across various surgical specialties at Roswell Park and other centers.


Sedentary Lifestyle Appears to Increase Risk for Both Kidney and Bladder Cancer Inactivity shown to increase kidney cancer risk by 77% and bladder cancer risk by 73%, independent of obesity A new study led by researchers at Roswell Park Cancer Institute establishes a connection between a sedentary lifestyle and risk of developing kidney or bladder cancer. The findings extend a line of inquiry that has already revealed a connection between chronic inactivity and heightened risk for both

recreational physical inactivity and cancer — 77% increased risk of developing renal cancer and 73% increased risk of developing bladder cancer. They found similar risk exposure among both obese and non-obese study participants, suggesting that the connection between inactivity and these cancers is not driven by obesity. The data add to the growing body of evidence that physical inactivity may be an important and independent risk factor for cancer, the authors write, noting that larger studies are needed to substantiate the current findings and support conclusive determinations about these connections. “We hope that findings like ours will motivate inactive people to engage in some form of physical activity,” says Dr. Moysich, senior author on the study and Distinguished Professor of Oncology in the Departments of Cancer Prevention and Control and Immunology at Roswell Park. “ You don’t have to run marathons to reduce your cancer risk, but you have to do something — even small adjustments like taking the stairs instead of the elevator, walking around the block a couple of times on your lunch hour or parking the car far away from the store when you go to the supermarket.”

Kirsten Moysich, PhD, MS

ovarian and cervical cancer, and also highlight the possibility of reducing risk for some cancers by increasing physical activity. The new research, published online ahead of print in the journal Cancer Epidemiology, details the findings of a hospital-based case-control study involving 160 patients with renal (kidney) cancer, 208 with bladder cancer and a control group of 766 people of the same ages who did not have cancer. A team led by Kirsten Moysich, PhD, MS, and Rikki Cannioto, PhD, EdD, MS, surveyed the participants in order to determine whether lifetime recreational physical inactivity was associated with risk of developing renal or bladder cancer. Using multivariable logistic regression analysis, the team observed significant positive associations between lifetime

“Our findings underscore how important it is to maintain a healthy lifestyle, including getting and staying active,” adds Dr. Cannioto, Assistant Professor of Oncology in the Department of Cancer Prevention and Control at Roswell Park and first author on the new study. “The Department of Health and Human Services recommends 150 minutes each week of moderate physical activity or 75 minutes each week of vigorous physical activity as a way to generate significant, lasting health benefits.” The study, “The association of lifetime physical inactivity with bladder and renal cancer risk: A hospital-based case-control analysis,” is available at sciencedirect.com. This work was supported by grants from the New York State Department of Health, Roswell Park Alliance Foundation and National Cancer Institute (project no. T32CA108456).

WNYPHYSICIAN.COM VOLUME 3 I 2017 I 15


clinical feature

Preventing and Treating Colorectal Cancer Local Colorectal Surgeons Lead Screening and Early Detection Efforts A widely publicized study in the February 28, 2017 issue of the Journal of the National Cancer Institute, reported findings that both colon and rectal cancers are on the rise in younger populations. “A person born in 1990 has double the risk of colon cancer and four times the risk of rectal cancer than one born in 1950,” explains Dr. Bryan Butler, a Board-certified colorectal surgeon who chairs the Buffalo Medical Group and heads the University of Buffalo colorectal residency program. “Results in my practice in Buffalo bear this out. We are seeing colon and rectal cancers more commonly in younger patients.” Dr. Claudia Hriesik, a Board-certified colorectal surgeon who is also trained in surgical oncology, has seen multiple patients younger than 50, without a family history of cancer, in her Rochester practice with Rochester Colon and Rectal Surgeons, P.C. Both of these western New York colorectal surgeons stress the importance of investigating why this cancer is occurring in a younger population, and what can be done to reverse this concerning trend. These recent findings are even more worrisome given that colorectal cancer rates overall have been steadily declining since the mid-1980’s. “Because of early screening, the incidence of colorectal cancer in the population, and mortality due to colorectal cancer, has decreased significantly over the years,” says Dr. Butler. “A lot of the credit for this, especially in the last 10 years, is attributed to the colonoscopy, which can diagnose cancer at an early stage, when the cancer is more treatable, and thus contribute to a better prognosis,” Dr. Butler continues. Colorectal cancer is a cancer that originates in the colon or the rectum. Most colorectal cancers start as a polyp, or growth on the inner lining of the colon or rectum. While not all polyps turn into cancer, adenomas are considered precancerous and can sometimes evolve into cancer. The number of polyps found, their size, whether they have invaded the colon or rectal wall, and whether or not there are abnormal looking cells, or dysplasia, all help determine a person’s risk from colorectal cancer. “There are different kinds

Bryan Butler, MD of polyps, but a polyp found in a colonoscopy can save a person’s life,” states Dr. Hriesik. “Colorectal cancer can be a lethal cancer. It is the third most diagnosed cancer in the U.S., and second leading cause of cancer-related death. Yet it is potentially preventable if patients are screened at the recommended times,” stresses Dr. Butler. The numbers are staggering. “We expect 950,000 new cases of colon cancer and 40,000 new cases of rectal cancer in 2017,” reports Dr. Butler. While colon cancer is slightly more common in men, who have a 4.7 per cent lifetime risk, versus a 4.4 percent lifetime risk for female patients, “colon cancer is an equal opportunity killer,” warns Dr. Hriesik. “Colorectal cancer does not spare one gender or the other,” she adds. Screening and early detection are critical to preventing colorectal cancer. The American Cancer Society, the U.S. Multi-Society Task Force on Colorectal Cancer and the American College of Radiology, among others, have issued guidelines recommending routine screening for colorectal cancer beginning at the age of 50 for individuals with no

“There are different kinds

of polyps, but a polyp found in a colonoscopy can

save a person’s life.”

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symptoms or risk factors. Further, colonoscopy screening at an earlier age and at more frequent intervals is recommended if there is a family or personal history of rectal or colon cancer, or a personal history of chronic inflammatory bowel disease. In addition, colorectal cancer occurs more frequently, at a younger age, and with a higher risk of mortality, in the African American population. Screenings for African Americans are recommended to start five years earlier, at the age of 45. The Journal of the National Cancer Institute’s findings do raise the question of whether general screening should start at an even younger age. Dr. Butler responds, “While we don’t have an answer for that yet, it will surely stimulate further debate for the appropriate time to start screening.” While there are many colorectal cancer screening options available for average risk individuals, according to Dr. Butler, “the colonoscopy is the gold standard. It is the only screening test that can detect a precancerous polyp, remove it, and prevent a person from developing cancer.” A colonoscopy enables a physician to image and examine the colon and rectum with a colonoscope, a flexible tube with a light and camera at the end. The camera sends video images of the intestinal lining to a monitor, and the images help to identify polyps, which can then be removed during the same procedure. In addition to polyps and colon cancer, a colonoscopy can help evaluate ulcers, swollen tissue, diverticulosis, and inflammatory bowel disease, among other conditions. Other tests that do detect polyps and colon and rectal cancer often require a colonoscopy to confirm the results and diagnosis. For example, a flexible sigmoidoscopy, in which a flexible tube with a small video camera attached is inserted into the rectum to evaluate the lower part of the colon, can extract tissue samples. But this test does not reveal the entire colon, and could miss polyps located farther into the colon. Additional screening tests available include the double contrast barium enema, computed tomographic (CT) colography, fecal occult blood test, and stool DNA study or Cologuard, which can look for blood and DNA in the stool. While Dr. Butler emphasizes that “any screening is better than no screening,” there are limitations on screening alternatives. Some of these tests can

Claudia Hriesik, MD miss polyps as well as 8 % of colorectal cancers. Doctors do not know exactly why colon cancer is on the rise in the younger population. But certain lifestyle factors, including obesity, lack of physical activity, smoking, increased alcohol consumption, and diets high in red meats, processed meats and meats cooked at high temperatures, are all associated with a higher risk of colorectal cancer. “Patients with diabetes are also at a higher risk, and the prevalence of obesity in our community affects the colorectal cancer rate,” says Dr. Butler. But, “If a person is active, not overweight, eats a fiber-rich diet with vegetables, fruit and whole grains, and avoids smoking, alcohol and red and processed meats, the overall risk of colorectal cancer should decrease.” There are several key warning signs for colorectal cancer, most commonly, changes in bowel habits, rectal bleeding, weakness and fatigue, cramping or abdominal pain, dark or bloody stools, or unintended weight loss. Dr. Hriesik explains,

“While there are many

colorectal cancer screening options available for

average risk individuals, the colonoscopy is the gold standard.”

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“It is important to be aware of what your body tells you. If you experience any symptoms, or hear personal alarm bells, you need to be proactive, and bring it up to a doctor or colorectal surgeon to address your concerns.” She cautions that the changes may be subtle, but if something seems abnormal, “find out if it is a problem that needs further investigation.” Yet some patients are reticent to seek treatment. Dr. Hriesik knows that colorectal cancer “is not exactly dinner conversation. But, she says, “often, an individual experiences rectal bleeding, assumes that it is hemorrhoids and fails to seek immediate help. Sadly, by the time of testing, cancer can be more advanced.” Treatment of colorectal cancer varies based on the type and staging of the cancer. “There are many nuances in the treatment of colorectal cancer. It is not the case that there is a specific protocol. We treat the patient, and tailor the treatment to the patient and specific disease,” remarks Dr. Hriesik. But in the past ten to twenty years, surgical and drug treatments have advanced significantly, leading to improved options and outcomes for patients. Both Dr. Hriesik and Dr. Butler agree that minimally invasive surgery has had the biggest impact. Whether laparoscopic or robotic, minimally invasive surgery yields “smaller incisions, less pain, less time in the hospital and a faster recovery,” offers Dr. Hriesik. Dr. Hriesik’s practice, Rochester Colon and Rectal Surgeons, has been performing colorectal robotic surgery since 2008. “The da Vinci robotic laparoscopic is the most cutting edge treatment that we have right now,” she says. “It is the most precise tool in the right hands.” The da Vinci robotic assisted surgical device provides surgeons a three-dimensional view of the inside of the body and uses tiny instruments that rotate and bend, making it “a more ergonomic way to operate,” according to Dr. Butler. “The robotic surgery offers greater control and precision, and has a lower conversion rate to open surgery,” he says. In addition to greater adoption of laparoscopic and robotic procedures, and many variations of minimally invasive surgery, there have been great strides made in non-surgical treatments as well. “Locally advanced chemotherapy and radiation therapy can be delivered more precisely now,” states Dr. Hriesik. With genetic testing and testing of specimens for certain genetic mutations, patients “can see if they carry the pathway gene that makes them more susceptible to colorectal cancers,” she expounds. “If they are diagnosed with the genetic trait, hereditary nonpolyposis cancer syndrome, or HNPCC, they can also be prone to other cancers.” Also promising, offers Dr. Butler, is a new trend of “testing cells in tumors to get a better sense of a patient’s prognosis, 18 I VOLUME 3 I 2017 WNYPHYSICIAN.COM

Screening guidelines for average risk patients from 50 to 75 years of age:

Colonoscopy every 10 years Flexible sigmoidoscopy every 5 years Fecal occult blood test every year Stool DNA test every 3 years Air contrast barium enema every 5 years CT colonography or virtual colonoscopy every 5 years and targeting specific therapies for those patients.” He adds that continuing research of targeted therapy and chemotherapy has yielded new drugs approved for colorectal cancer, and in particular, two new drugs for advanced colorectal cancer that could prolong a patient’s survival. “There are over a million survivors of colorectal cancer in the population at this time,” asserts Dr. Butler. “Colorectal cancer is a curable disease. It is always best to prevent it, or detect it at its earliest stages.”


clinical

A Cervical Cancer Wake-Up Call Earlier this year, a new study sounded the alarm about the mortality of cervical cancer in the United States, finding death rates to be higher than previously believed—and significantly higher in women of color. According to the study, published in the journal Cancer, the death toll among African-American women in the United States is similar to that of women living in poor, developing countries. The study recalculated the annual U.S. cervical cancer mortality rates after correcting for the prevalence of hysterectomy. Previous figures included women who had a hysterectomy in the at-risk population denominator, despite the fact they are not at risk for cervical cancer due to the removal of their cervix. This led to an underestimation of cervical cancer’s impact. After eliminating women with hysterectomy from the equation, the study determined the corrected mortality rate for white women was 4.7 per 100,000 (compared to the uncorrected rate of 3.2). For black women the corrected mortality rate was 10.1 per 100,000 (compared to the uncorrected rate of 5.7). While we knew that racial disparities in cervical cancer existed, without the correction for hysterectomy, the disparity in mortality between races was underestimated by 44%. In addition, the highest rates were seen in the oldest black women, age 85 and older. These findings are a wake-up call to us as physicians, and I hope a call to action. Cervical cancer is one of the few cancers that can be prevented, and when diagnosed early, is highly treatable. With the availability of HPV vaccination, combined with regular pap and HPV testing, cancer of the cervix and dying from the disease should be largely preventable. Specific efforts are needed to address the disparities found in this study. All physicians, and primary care physicians in particular, are the key to educating their patients and pushing for the prevention and early detection measures that we already know reduce mortality. Starting with prevention, we must increase HPV vaccination rates among girls and boys ages 9 to 26, with concerted effort aimed at vaccinating before patients become sexually active. Unfortunately, too many adolescents and young adults are missing

Kunle Odunsi, MD, PhD, FRCOG, FACOG

out on this life-saving step. Beyond cervical cancer, the vaccine prevents HPV strains associated with other oral, head and neck, and genital cancers. Screening guidelines now recommend women receive the Pap test every three years, beginning at age 21. At age 30, women should have both a Pap test and HPV test every five years. Women over age 65 no longer need to be screened unless they have been diagnosed with precancerous cells of the cervix. When it comes to a diagnosis of cervical cancer, it is important for patients to be treated by a gynecologic oncologist. The treatment usually involves a combination of surgery, radiation, and/or chemotherapy. While many patients respond well to these treatments, some patients develop recurrent or metastatic disease. At Roswell Park, we have initiated a clinical trial in patients with recurrent or metastatic disease, whereby we obtain killer immune cells (T cells) from the metastatic tumor, expand these cells to large numbers and infuse them back into patients. This treatment approach is unique and highly promising, and for the first time offers hope to patients with recurrent or metastatic cancer of the cervix. Community outreach and education is a key facet of Roswell Park’s mission. Through a culturally sensitive program called the Witness Project of Buffalo and Niagara, we work toward greater awareness, access to services and compliance with screening guidelines among populations that this study confirms need it most. Roswell Park also has a robust cancer prevention and screening program that promotes access for all people, regardless of economic status. Kunle Odunsi, MD, PhD, FRCOG, FACOG is Deputy Director, Chair of the Department of Gynecologic Oncology, the M. Steven Piver Professor of Gynecologic Oncology, Executive Director of the Center for Immunotherapy, and Co-Leader of the Tumor Immunology and Immunotherapy research program at Roswell Park Cancer Institute. Dr. Odunsi monitors all research-related initiatives, steering the development of programs and policies to transfer scientific discoveries to the clinical setting. His personal research focuses on the molecular characterization of tumor antigens in ovarian cancer and their application to the development of vaccine therapies for the disease.

WNYPHYSICIAN.COM VOLUME 3 I 2017 I 19


practice management

Local Firm Supporting CMS and NY State Programs to Transform Care in Western NY September 30th Deadline Approaches for FREE Practice Transformation Assistance Value-based payment (VBP) is here. Well, almost. VBP arrangements are emerging rapidly to take the place of feefor-service reimbursement, refocusing physicians’ and other providers’ attention to a new era of rewarding quality and outcomes over volume of services performed. Medicare and Medicaid reforms and demonstrations of VBP are accelerating, influencing an increasing cohort of the reimbursement policies of public and private payers here in New York State. To prepare, physicians in western New York should research and evaluate changes required to transform their practices to reconfigure how they offer care and manage their patients’ health and medical needs. In other words, practice transformation should be on every physician’s front burner. Luckily, CMS, NYS DOH, and the New York eHealth Collaborative (NYeC), have programs in place offering services to help providers prepare for and successfully embrace these changes. If you regularly hear about “MACRA,” “MIPS” and “QPP,” or if you are asked to participate in an ACO then you know

that the world of paying for care is changing, ‘big time.’ And, with that change, comes one of the most substantive overhauls of the way in which physicians and other health practitioners deliver care to their patients since the introduction of Medicare and Medicaid in the mid-60s. Congress passed the Medicare Access & CHIP Reauthorization Act of 2015, aka MACRA, which got the ball rolling with due speed toward VBP, in which Medicare payments were based on quality measurements rather than volume.

As the American College of Physicians has noted: “The MACRA law eliminated the sustainable growth rate (SGR) formula that had previously been used to calculate Medicare payments to physicians and had resulted in repeated threats of severe payment cuts. The law provides a more predictable Medicare payment schedule for physicians and other clinicians, while moving the payment system away from a volume-based system toward a system that rewards value. This new payment system is called the Quality Payment Program (QPP).” MACRA launched the Merit-based Incentive Payment Sys-

Source: “Value-based Reimbursement vs. Volume-based Care, by McKesson Corporation 2016

20 I VOLUME 3 I 2017 WNYPHYSICIAN.


tem (MIPS) and the Alternative Payment Models (APMs) in 2017. This transition year requires eligible practices to prepare and begin the process of measuring quality improvement and a new approach of quality based payments for the reimbursement year of 2019. The MIPS model as depicted below, will rate care provided to each patient according to a formula that assigns value to quality (60% in 2017, decreasing to 30% over time), resource use or cost (0% in 2019, increasing to 30% over time), clinical practice improvement activities (15%) and ad-

ors and health plans are pursuing ACOs and other risk-sharing models. So, the question is, clearly: How do I get ready for VBP? Am I on my own in this pursuit? Thankfully, no. Strategic Interests, a Rochester-based healthcare strategy and IT consulting firm has been engaged in Upstate and Western, NY to offer services, many of them at no cost to the practice, to help different types of providers. A growing number of western NY outpatient practitioners,

18% difference by 2022

Sources: American College of Physicians (top) and NY eHealth Collaborative (bottom)

vancing care information (formerly “meaningful use”; 25%). And though MACRA/MIPS targets Medicare beneficiaries and those physicians who serve them, all indications are that Medicaid is moving similarly in the VBP direction, with significant momentum towards managed care. Commercial pay-

both primary care physicians and specialists, have already sought out the free “practice transformation” services being provided by Strategic Interests. SI has been selected by the state’s Practice Transformation Network (PTN), NYeC, to assist outpatient primary care and specialist physician practices

WNYPHYSICIAN.COM VOLUME 3 I 2017 I 21


as part of the CMS Transforming Clinical Practice Initiative (TCPI). This initiative is designed to help over 140,000 clinicians within larger practices nationally to adopt and develop quality improvement strategies. SI is also funded by NYeC to offer other services:

• BHIT: SI helps agencies providing home and community based services to patients on Medicaid to select and implement EMR systems as part of the NYS DOH Behavioral Health Information Technology (BHIT) Program. • EP2: SI helps specialists serving the Medicaid population (Eligible Providers) with administrative processes to attain MU. • APC: SI will help primary care providers in small practices throughout Western NY to prepare for payment reform with transformation and ongoing education and support as part of Advanced Primary Care. For PTN, SI is utilizing a specialized methodology, based on the successful experiences of other firms in the PTN program, to help doctors and other providers gain the strategic, business, operational and technology capabilities to be prepared to participate and succeed in the rapidly evolving VBP environment. You may ask “Why should we put time and resources in quality improvement now?” “Reimbursement changes are eminent, even if the specifics of the payment criteria have not been clearly defined, and even though they will probably change. Proactive practices”, says Bill Lavoie, SI’s Project Manager, “are utilizing this program to determine their shortfalls and making operational changes to be prepared, regardless of how the specifics end up shaking out. They recognize the need to consistently improve outcomes for their patients while measuring and increasing patient satisfaction. Eventually, this will have a direct impact on MIPS or APM reported results, and a practice’s ability to perform well in an ACO. These successful practices will realize improved reimbursement resulting from focusing on quality and reducing healthcare costs.” The Practice Transformation Network Team at Strategic Interests guides enrolled practices through a comprehensive selfassessment of current capabilities and goals for development. A work plan is then drafted to direct improvement activities going forward from which action plans are initiated to a) Use data to drive care b) Guide you as you progress through a series of program milestones, including care coordination, population health, evidence based care, quality improvement strategy, workplace satisfaction, performance measuring and reporting, strategic use of practice revenue and operational efficiency c) Learn how to achieve and sustain benchmarks d) Seek out and prepare to enter into contractual relationships with payers and plans using value-based payment principles. 22 I VOLUME 3 I 2017 WNYPHYSICIAN.COM

And throughout the practice transformation process, normally encompassing about a year, clinicians can be earning MOCs and CMEs, again with no charge. A recent survey1 showed only 23% of physicians felt they were “well prepared” to meet MACRA/MIPS requirements today. So, if you and your practice have not yet decided to pursue those transformation activities that will position you for quality based payment programs, the time is now to take this first critical step and be positioned to “jump in” when the time is right. The deadline for enrolling new providers and practices in the Practice Transformation Network program and the free consulting support is September 30, 2017. AMA/KPMG Survey June 2017

1

For more information or to enroll your practice, please send an email to Strategic Interests at nysptn@strategicinterests.com. You may also visit their website at www.strategicinterests.com.

Strategic Interests (SI), is a boutique healthcare consulting firm formed in 2010 in Rochester, NY, that offers advisory and implementation services to providers, payers, collaboratives, and vendors, with the transformation required to improve the quality and lower the cost of healthcare. Serving clients throughout New York State, other regions of the country, and several foreign nations, SI has grown to over 20 professionals who address the business, clinical, and technical aspects of innovation that are required for successful introduction into healthcare. SI supports providers in Upstate and Western, NY as a Transformation Agent of NYeC for several different programs.


professional liability

No End in Sight

New Changes to Statue of Limitations Require Proactive Risk Management

Colleen K. Mattrey, Esq.

Colleen K. Mattrey, Esq., Smith Sovik Kendrick & Sugnet, PC Medical practitioners in New York State have many odds stacked against them when it comes to litigation. As the state with the highest number of claims and the highest claim settlement amounts in the nation, New York physicians are plagued with high malpractice premiums and spend more time than they have to spare engaging in defensive medicine and/or participating in their defense of existing claims brought by patients and their families. With no tort reform in sight and the number of lawyers out there telling patients that every poor outcome must be the result of negligence, many New York physicians are finding it almost impossible to devote their attention to the cause that matters—patient care. Sadly, the state of affairs for physicians in New York has not improved over the past two (2) years, and in fact, for many practitioners, is about to get a lot worse. There have been many recent attempts by the legislature and the Courts to make practicing medicine that much more arduous. Specifically, there has been a push in the legislature and the Courts to extend the statute of limitations for medical negligence claims generally. Presently, New York law requires an adult patient to bring a malpractice claim within 2 ½ years from the date of the alleged malpractice; a wrongful death claim within 2 years; and an infant claim within 10 years. The intent of a statutory time period in which to bring a claim is theoretically supposed to limit the number of claims, prevent claims from becoming outdated, and to provide piece of mind to practitioners that claims will not linger into infamy. Traditionally, the statutory period could be extended in the event of continuous treatment of the patient by the same practitioner for the same condition. If continuous treatment applies, which is a determination that must be made by the Court, the statute of limitations will begin to run from the date of the last treatment for the condition at issue, by

the practitioner against whom the claim is being pursued. However, that rule, once relatively black and white, is quickly becoming gray. In 2015, a Bill was being considered in the New York Legislature to extend the statute of limitations in a medical malpractice claim. Lavern’s Law, named after NYC native Lavern Wilkinson, sought to have the statute of limitations for a medical malpractice claim extended to run from the first date a patient becomes aware that their physician or hospital was negligent. Lavern Wilkinson died in 2013 from a treatable form of lung cancer. Three (3) years prior to her death, the cancer was detected by radiological studies but the patient was not informed nor was treatment initiated by her physician. Unfortunately, Ms. Wilkinson was not aware of the mistake until the cancer had already progressed to terminal status. Despite wide spread bipartisan support in the Senate and support from the Governor, Senate majority leader John Flanigan halted the bill by not allowing it to be voted on. Well folks, portions of Lavern’s Law are about to become a reality. On June 18, 2017, the New York State Senate passed a bill amending the statute of limitations to extend the limitations period in cases involving diagnosis of cancer and/or malignant tumors to seven (7) years from the last date that one “should have known or reasonably should have known of the negligent failure to diagnose cancer and/or a malignant tumor, or, from the last date of treatment where there is continuous treatment for the same condition or injury that will give rise to the malpractice action”. In other words, if a patient is treating with their primary for a cough, and it can be even loosely shown that there would have been any medical justification to get a chest scan to diagnose malignancy (i.e. patient is a smoker, persistent cough absent viral or bacterial infection, etc.), the seven (7) year statute of

WNYPHYSICIAN.COM VOLUME 3 I 2017 I 23


limitations either from last date of treatment or discovery of the malignancy would apply. With the Governor’s support of prior Bills to extend the statute, it is fully expected that this Bill will be signed into law forthwith. While this new law will be limited to cancer cases, the effort to extend the limitations period generally continues through the Court system. In Devadas v. Niksalri, 120 A.D.3d 1000 (1st Dept. 2014), the Court allowed a patient to file a claim that would otherwise have been time barred on the theory of continuous treatment. In Devadas, the patient had bilateral LASIK surgery. Following the surgery, he returned to Dr. Niksalri for all regularly scheduled post-operative visits. During those visits, he complained of some blurred vision (a very common complaint in LASIK patients), but otherwise his result was excellent. Three (3) years later, the patient returned with complaints of blurred vision, which plaintiff argued was the result of keratoconus, a condition he alleged was caused by the LASIK surgery. The Court held that because the blurred vision was a condition the patient had treated with this practitioner for, that the patient believed further treatment was necessary and sought treatment from the same practitioner for the condition, and, that the original surgery may have caused the condition, the lapse in time, in this case almost three (3) years, was irrelevant. Likewise, in the recent Fourth Department case of Lohnas

American HIFU

D VVEER R T I TS IE S R SE R S AA D

v. Luzi, MD, et al, 140 A.D.3d 1717 (4th Dept. 2016), the Court upheld the Trial Court’s decision, allowing claims that would otherwise be beyond the statute and outside of the traditional rule about continuous treatment. In Lohnas, the plaintiff originally saw the defendant physician in 2002 on one occasion and was only to return on an “as needed” basis. The plaintiff returned again in 2003 after being shoved into a wall and experiencing pain in her shoulder. The defendant recommended home exercises and NSAIDs for pain relief, but no other intervention or treatment was deemed necessary. Again, the patient was told she could return on an “as needed” basis. The patient did not return until 2006—more than 2 ½ years later. The Court held that because this patient “contemplated” future treatment and was told she could return if needed, an issue of fact remained and the defendant’s motion for summary judgment, dismissing the malpractice claim, was denied. Both Devadas and Lohnas did not involve cancer or malignant tumors, yet both allowed the physician to be sued after the statutory period. Long story short—the effort to extend the time that a patient may bring a claim against a physician in New York is strong and ongoing. Practitioners and their groups should be proactive in risk management measures now, or be prepared to be defending claims well into retirement.

The Value of Advertising in WNY Physician Magazine

ECMC - 28 The Cosmetic Vein & Laser Center - 10 Roswell Park Cancer Institute - 25 Catholic Hospital – back cover Great Lakes Medical Imaging – 27 Manning & Napier Advisors – inside back cover Medical Liability Mutual Insurance Co. – inside front cover Vascular & Endovascular Center of Western New York - 19

24 I VOLUME 3 I 2017 WNYPHYSICIAN.COM

If maintaining and building referrals is important to your practice, advertising in WNY Physician serves as a touchpoint with your current and future referring colleagues. With a current readership of over 3,500, your name will be at the top of the medical community's mind. For more information or to explore a customized advertising program, contact Andrea Sperry at 585.721.5238 or wnyphysician@gmail.com


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Download our free mobile app — exclusively for physicians and physician offices — for direct access to a complete, up-to-date directory of Roswell Park physicians wherever you go. Email or call to refer a patient or ask a question with a click of a button.


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WHAT’S NEW in

Area Healthcare

KENMORE MERCY HOSPITAL Kenmore Mercy Hospital Awarded 2017 Magnet Recognition

Excitement was in the air this April, when associates at Kenmore Mercy heard the news that they had received Magnet Recognition for nursing excellence from the American Nurses Credentialing Center’s (ANCC). The culmination of a several year journey, Kenmore Mercy joins a select Magnet community – only 454 hospitals worldwide have received the recognition. The north town hospital is the only Magnet-recognized hospital in Western New York. “This recognition reflects the outstanding care our nurses provide and the quality patient outcomes they help achieve,” said Cheryl W. Hayes, MS, ANP, NEA-BC, vice president of Patient Care Services. Magnet recognition reflects the highest standards of nursing professionalism, collaboration and teamwork. It distinguishes Kenmore Mercy Hospital as a premier destination for healthcare in the region. Hospitals attain Magnet status by going through a multi-year, rigorous, voluntary application process. The Magnet Model, with a focus on transformational leadership, structural empowerment, exemplary professional practice, new knowledge, innovations, and improvements, supports outstanding patient outcomes.

UBMD UBMD Physicians’ Group Opens Family Medicine Practice in Conventus Building New location enhances primary care services on the Buffalo Niagara Medical Campus UBMD Physicians’ Group, the largest 26 I VOLUME 3 I 2017 WNYPHYSICIAN.COM

Left to right: Amanda Kramer, Amber Mazurek, Heather Telford, Cheryl Hayes, Anne Hedges-Creighton. medical group in Western New York, has opened its newest UBMD Family Medicine location in the Conventus building on the Buffalo Niagara Medical Campus. UBMD Family Medicine provides complete primary care services, including obstetrics, gynecology, pediatrics, adolescent and adult medicine and geriatrics. The new location is part of UBMD’s effort to enhance the scope of its services and provide better, convenient access to comprehensive health care in Western New York. At the UBMD Family Medicine Conventus location, Priyanka Patnaik, MD serves as the medical director, seeing patients two days a week. Dr. Patnaik is also a clinical assistant professor at the Jacobs School of Medicine and Biomedical Sciences at the University at Buffalo (UB). She is joined by Diane Cozzo, RN, ANP Starting in July, Sarah Abdelsayed, MD, will provide addiction medicine

services as part of the practice. “UBMD Family Medicine is proud to be a part of the medical campus transformation and excited to be opening another practice option in the Conventus building,” said Daniel J. Morelli, MD, president of UBMD Family Medicine and practicing family medicine physician, and professor and chair of the Department of Family Medicine in the Jacobs School of Medicine and Biomedical Sciences at UB. “This location offers convenience for primary care and addiction medicine services, and multiplies opportunities for collaborative medicine among UBMD and other providers to offer the very best in Western New York healthcare.”

ROSWELL PARK CANCER INSTITUTE Dr. Khurshid Guru Named Chair of Urology at Roswell Park Cancer Institute


Renowned robotic surgeon, educator will lead a team of more than 50 clinicians, researchers and staff

performed more than 2,500 robotassisted surgical procedures. He has performed live surgeries in 10 countries, and earlier this year performed his 500th robotic radical cystectomy, or surgery to remove the bladder. He leads the International Robotic Cystectomy Consortium, which includes more than 50 surgeons in 23 countries, and is founder of the Guru Charitable Foundation, which has supported health- and educationrelated programs in Kashmir since 2007.

Dr. James Mohler named to new role of Chief of Inter-Institutional Academics James Mohler, MD has assumed the new role of Chief of InterInstitutional Academics and will act as Roswell Park’s point person and liaison for translational research collaborations between Roswell Park and the University at Buffalo. He remains Senior Vice President for Translational Research at the Institute, and will continue to help shape and inform clinical practice nationally and internationally as Chair of the National

Khurshid Guru, MD, one of the most experienced and accomplished robotic surgeons in the world, has been named Chair of the Department of Urology at Roswell Park Cancer Institute. Dr. Guru, who was recruited to Roswell Park in 2005 to direct the Institute’s robotic surgery program, will lead a team of more than 50 faculty members, clinicians, researchers and staff who provide care for patients with various genitourinary diseases, including prostate, bladder and kidney cancer. “Khurshid is one of the most creative and energetic people I’ve ever met,” says Roswell Park President and CEO Candace S. Johnson, PhD. “In his work as a surgeon, educator, researcher, entrepreneur and volunteer, he always seems to blend the best of science and human compassion together. He will be an outstanding leader for this very dedicated team.” Dr. Guru previously served as Vice Chair of the Department of Urology, a role he’d held since April 2016. He was one of a select group of surgeons who had completed a fellowship in robotassisted surgery under the “father of robotic surgery,” Dr. Mani Menon of Henry Ford Health System’s Vattikuti Urology Institute. After completing this training, Dr. Guru performed one of the first robot-assisted radical cystectomies in the world. Regarded as one of the top robotic surgeons in the world, Dr. Guru has WNYPHYSICIAN.COM VOLUME 3 I 2017 I 27


Buffalo, N.Y., comprehensive cancer center was ranked 169th on the media organization’s list of 300 Best Midsize Employers across 25 industries. “This recognition is special for us because our employees were among those who participated in the survey, and the feedback they shared reflects the working environment they experience every day,” says Roswell Park Cancer Institute President and CEO Candace S. Johnson, PhD. Companies were selected for this distinction based on an independent and anonymous online survey of nearly

30,000 U.S. employees working for companies employing a tleast 1,000 people in their U.S. operations. The willingness to recommend one’s own employer was considered to be the most important dimension of the assessment. “Our 3,300-plus employees are important ambassadors for our mission,” adds Errol Douglas, SPHR, SHRMSCP, Vice President of Human Resources Management at Roswell Park. “We take their satisfaction and their input very seriously because their energy and ideas help us to become a better, more effective cancer center.”

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Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology Panel for Prostate Cancer. In March 2017, Dr. Mohler was awarded the Rodger Winn Award from the NCCN. “I thank Jim for the leadership he has provided to the Department of Urology since he was recruited to Roswell Park in 2003,” notes Dr. Johnson. “Dr. Mohler has set a high standard for integrity, superb clinical care and cutting-edge research, and the robust translational research program at Roswell Park has benefited significantly from his executive leadership.”

Offering the community the best kidney care.

Forbes Names Roswell Park Cancer Institute One of America’s Best Employers Cancer center ranked among list of 300 Midsize Employers based on independent online survey In 2016, ECMC established the highest level of kidney transplant activity in the hospital’s history with a record of 119 kidney transplants (from both living and deceased donors) and 13 pancreas transplants at our Regional Center of Excellence for Transplantation and Kidney Care. This growth is possible thanks to our dedicated, compassionate caregivers; selfless donors through the state’s Donate Life registry; our industrious partners at Unyts; and state-of-the-art technology that positions ECMC in the forefront of major innovations in transplantation.

Roswell Park Cancer Institute has been named to Forbes’ 2017 list of America’s Best Employers. The 28 I VOLUME 3 I 2017 WNYPHYSICIAN.COM

The difference between healthcare and true careTM

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©2017 ECMC

We appreciate the trust the Western New York community has shown in giving us the opportunity to produce positive transplantation outcomes for patients and their families.

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5/1/17 3:32 PM


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Heart Center physicians from L to R: Joseph Gelormini, MD, FACC, FSCAI, Medical Director of Catholic Health Cardiac Services; Harsh Jain, MD, FACS, cardiothoracic surgeon with Mercy Hospital Cardiothoracic Surgical Associates; Aravind Herle, MD, FACC, Chief of Cardiology at Mercy Hospital; and Stephen Downing, MD, FACC, FACS, Chair of Cardiothoracic Surgery at Mercy Hospital and Medical Director of the hospital’s TAVR program.

Quality is at the Heart of Everything We Do For the second year in a row, Mercy Hospital has received the GWTG Platinum Performance Achievement Award from the American College of Cardiology NCDR Action Registry. One of only 193 facilities nationwide to achieve this distinction, Mercy and its dedicated team of highly skilled physicians, nurses and other clinical staff deliver advanced, quality comprehensive cardiac care.

Catholic Health

Heart Center at Mercy Hospital of Buffalo

chsbuffalo.org/heartcare | (716) 447-6205

WNY Physician Buffalo & Great Lakes  

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