WNY Physician Magazine

Western New York

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

VOLUME 1 / 2020

Home is Where the Heart Is: New Center Keeps More Cardio Care in Buffalo

Bariatric Surgery: A Successful Route to Reducing Comorbidities

Best Practices for Addressing Common Medication Safety Errors

Contents WESTERN NEW YORK PHYSICIAN I VOLUME 1 I 2020

Risk Management

03

Best Practices for Addressing

Common Medication Safety Errors

13 Managing Patient Noncompliance 14

What Medical Providers Need

to Know About the Link Between

Gum Disease and Stroke Risk

Practice Management

23 Results from HEALTHLINK Study

COVER STORY

shows Decreases in Patient

05 Home is Where the Heart Is: New Center Keeps More Cardio Care in Buffalo Heart failure patients requiring transplant experience a minimum of six months wait time during which they undergo numerous diagnostic tests and assessments. Through a new collaboration with the University of Rochester’s Advanced Heart Failure and Transplant Program, Buffalo-based patients and their families can avoid the excessive travel to Rochester and receive ongoing care in Buffalo.

Readmissions and Emergency Visits through Physician Practice Integration of Health Information Exchange

21 Want to Improve Patient Relationships?

Clinical Features

Let Them Express Their

20 Metabolic Pathway Can Be

18 Food Fight

Preferences

Effectively Targeted to Treat Prostate

The Role of Nutrition in Combating

Cancer, Roswell Park Team Shows

Diabetes

Two-drug combination effective

Research

15

Roswell Park Team Discovers New

07 Bariatric Surgery: A Successful

in lab studies against aggressive

Mechanism Driving Pancreatic Cancer

Route to Reducing Comorbidities

prostate tumors

16 Yale scientists find new way to

25 Cardiac Resynchronization

block cancer-causing HPV virus

Therapy Benefits Cancer Survivors with Heart Failure

15

How Chronic Stress Weakens

09

18 19

Roswell Park Team Helps Explain Immunity Against Cancer

08

16

Roswell Park Finds New Evidence That Inhaled Vitamin E Acetate Caused EVALI in Vapers

03

12

Editorial Calendar

27

What's New

WNYPHYSICIAN.COM VOLUME 1 I 2020 I 1

from the publisher

Western New York

Visit us Online www.WNYPhysician.com

PHYSICIAN the local voice of

practice management and the business of medicine

publisher

Welcome to the latest issue of Western New York Physician – where you will find informative stories and articles about and for physicians in western NY.

Andrea Sperry creative director

Lisa Mauro writers

Randi Minetor

Welcome Readers – No one could have imagined that our world would do such a speedy global 360!!

The healthcare landscape is quite different than when we first developed this issue of Western NY Physician magazine and surely infectious disease will be a headlining topic for some time as our neighborhoods, our communities, our country and the world move through this pandemic.

Our cover story highlights a newly developed regional collaboration which offers great benefit to Buffalo-area patients awaiting heart transplant at University of Rochester’s Advanced Heart Failure and Transplant Center. Dr. James Youssef, a cardiologist with Great Lakes Cardiology in Buffalo, offers options to receive necessary ongoing care, testing and management during the extended waiting period reducing the unnecessary travel to Rochester for patients and their families.

Coming up: • Telemedicine today • The Patient Experience: Engagement • Unraveling Shoulder Pain • Cataracts and Eye Disease Join the Conversation in 2020 Share your expertise in a relevant way with your medical colleagues and referring physicians when you contribute an article, take part in a Q&A or share your expertise in an interview. Please email or call me directly to discuss topic, timing and submission criteria. In the meantime, please enjoy the numerous other articles within the issue.

As always and especially during this time, we thank each of our supporting advertisers — your partnership ensures that all physicians continue to enjoy this regionally-based resource and benefit from this collaborative sharing of information.

With deep respect for all healthcare workers on the frontline during this time.

Thank you for all you do.

Stay safe and be well

Best,

2 I VOLUME 1 I 2020 WNYPHYSICIAN.COM

medical advisory board

Michael Silber, MD Chuck Lannon Thomas Hughes, MD

contributors

Randi Minetor Dan Porreca Jeff Jarvis Matt Chandler URMC Press RPCI Press Yale Press

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 obtain pricing for an open PDF License of articles appearing in the magazine, please contact the Publisher.

Although every precaution is taken to ensure the accuracy of 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 bi-monthly by Insight Media Partners.

best practices

Best Practices for Addressing Common Medication Safety Errors

Prevent missing or inaccurate patient weights and mix-ups between metric and non-metric units by • weighing each patient as soon as possible on admission and during each appropriate outpatient or emergency department encounter and • measuring and documenting patient weights in metric units.

The Institute for Safe Medication Practices (ISMP) released its “2020-2021 Targeted Medication Safety Best Practices for Hospitals,” a resource that can be adopted to address errors that impact patient safety. ISMP says that, despite prior warnings, the list reflects recurrent mistakes that are causing patient harm.

Hospitals and healthcare organizations are advised to prioritize timely implementation of the following best practices:

Prevent inadvertent administration by the intrathecal route by dispensing vinCRIStine and other vinca alkaloids in a minibag of a compatible solution, not in a syringe.

Avoid unintended intravenous administration of oral medications by ensuring that all oral liquid medications that are not commercially available in unit dose packaging are dispensed by the pharmacy in an oral or enteral syringe.

Avoid accidental daily dosing of oral methotrexate by • using a weekly dosage regimen default in electronic systems when medication orders are entered, • requiring a hard stop verification of an appropriate oncologic indication for all daily oral methotrexate orders and • providing specific patient and/or family education for all oral methotrexate discharge orders.

Avoid mix-ups between milliliters and non-metric units when measuring oral liquid medications by purchasing oral liquid dosing devices that only display the metric scale.

Prevent inadvertent administration of neuromuscular blocking agents to patients by segregating and differentiating all neuromuscular blocking agents from other medications.

WNYPHYSICIAN.COM VOLUME 1 I 2020 I 3

Prevent errors when administering intravenous medication infusions by • administering medication infusions via a programmable infusion pump utilizing dose error-reduction systems, • monitoring compliance with the use of smart pump dose error-reduction systems and • using a smart pump that allows programming a bolus or loading dose and continuous infusion rate with separate limits for each.

Avoid delay in administration or improper use of antidotes, reversal agents and rescue agents by ensuring all appropriate antidotes, reversal agents and rescue agents are readily available, having standardized protocols and/or coupled order sets in place that permit emergency administration.

Avoid accidental administration of an intravenous infusion of sterile water by eliminating all 1,000 mL bags of sterile water from all areas outside of the pharmacy.

Prevent errors during sterile compounding of medications by performing an independent verification to ensure that the proper ingredients and amounts are added.

Prevent inappropriate use of extended-release and longacting opioids and fentanyl patches by eliminating the prescribing of patches for opioid-naive patients and/or patients with acute pain.

Prevent serious tissue injuries and amputations from injectable promethazine use by eliminating injectable promethazine from the formulary.

Use information about medication safety risks and errors that have occurred in other organizations and take action to prevent similar errors.

Avoid removal of medications from automated dispensing cabinets (ADC) using the “override” feature by • limiting the variety of medications that can be removed from an ADC, • requiring an order prior to removing any medication and • monitoring ADC overrides to verify appropriateness, transcription of orders and documentation of administration.

Trinity Medical WNY welcomes Vascular & Endovascular Center of Western New York to its family of care.

For decades, Vascular & Endovascular Center (VEC) of Western New York has been a forerunner in vascular surgery, ranked in the top 3% of practices nationwide. Now, as Trinity Vascular & Endovascular Center, the group will continue to perform the most advanced procedures in the region for a range of conditions in its state-of-the-art facility at Sisters Hospital.

Locations in Buffalo, Amherst, Hamburg and Niagara Falls.

Call for an appointment: (716) 837-2400.

4 I VOLUME 1 I 2020 WNYPHYSICIAN.COM

cover story

Home is Where the (Healthy) Heart Is New Center Keeps More Cardio Care in Buffalo Matt Chandler

When Dr. James Youssef joined

he arrived with a mission — to ease

Buffalo-based General Physician, PC

the burden and improve the care

in 2019, as a cardiologist with their

heart transplant candidates and

affiliate Great Lakes Cardiovascular,

recipients currently receive in Buffalo.

WNYPHYSICIAN.COM VOLUME 1 I 2020 I 5

Dr. Youssef, who completed an advanced heart failure and cardiac transplantation fellowship with the University of Rochester Medical Center and Strong Memorial Hospital, saw a need.

“For patients who are candidates for a heart transplant, they have to travel to Rochester for the testing and multiple appointments,” he explains. “These are patients who are already facing significant health challenges, and who are often older patients. The stress and strain of making all of those trips to Rochester and back can take its toll.”

Additionally, with the continued expansion of the Buffalo Niagara Medical Campus, widely recognized as a vital cog in the rebirth of Buffalo, he saw an opportunity to bring another level of cardio care to the Queen City.

With that in mind, Dr. Youssef, who currently serves as a part-time faculty member at the University of Rochester’s Advanced Heart Failure and Transplant Program, set out to launch Great Lakes Cardiology’s Heart Failure Center.

“Heart disease is the leading cause of death in the United States with more than 600,000 deaths annually,” he says. “It is also a significant health concern in Western New York, and our goal is to raise our level of care to meet that rising need.”

Dr. Youssef, along with Cardiologist Dr. Thomas Cimato, who are both also part of UBMD’s Physicians’ Group, launched GLC’s Heart Failure Center earlier this year at Buffalo General Medical Center.

“We see patients with a spectrum of heart failure disease, and we provide them with a comprehensive evaluation as well as diagnostic and therapeutic treatment options,” he says.

Because of the stringent testing and criteria that must be met in order to qualify as a candidate for a heart transplant, many patients may not ultimately get the surgery. Having the Buffalo Heart Failure Center available for the advanced screenings lessens the burden on those who may never ultimately end up receiving a transplant.

“We are receiving more calls and referrals every week as doctors and patients learn about the program,” Dr. Cimato says. “We expect the numbers to continue to rise as referring physicians see the benefits of not having to send their patients to Rochester for much of this testing and monitoring.”

He says they also offer evaluations beyond heart transplant candidates.

“We see patients and offer evaluations and care for a number of other conditions including identifying whether they would benefit from, and are candidates for, left ventricular assist device implantation,” Dr. Cimato says.

Dr. Youssef says it is the collaboration behind the new Heart Failure Center that he is excited about.

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“The center may be located in downtown Buffalo, but at its core, this is really a regional Heart Failure Center born out of a collaboration between Great Lakes Cardiovascular (a General Physician, PC affiliate), Rochester General, and Strong Memorial Hospitals,” he says. “Rather than treating patients in silos, we are coming together to pool our skillsets and work together to deliver the best in heart care to every patient in the most accessible way possible.”

Though it is in its early stages, the team at GLC’s Heart Failure Center already have an eye on the future.

“In addition to working with the hospitals in Rochester, we have the benefit of drawing from our own pool of talented cardiologists that are part of the General Physician/Great Lakes Cardio team,” Dr. Cimato says. “That will allow us to grow and adjust this center to ensure we are meeting the specific needs of our community and when it comes to cardio care.”

Take These Numbers to Heart The need for quality heart care is unquestionable when you look at some of the eye-opening statistics related to not only heart failure, but cardiovascular disease overall.

6.5 million The number of Americans living with heart failure 550,000 The total number of new cases of congestive heart failure diagnosed Annually in the United States 1 in 8 The number of deaths where heart failure was a contributing factor $220 billion Annual cost of heart disease annually in the United States #1 Rank of Western New York in national study of regions with highest rates of heart disease *All data from the Centers for Disease Control and Prevention

special feature

Bariatric Surgery:

A Successful Route to Reducing Comorbidities

Photo courtesy of Rochester General Hospital.

Randi Minetor

Dr. Alok Gandhi and Bryan Spong, OR Assistant, Nikki Watts, NP, performing Gastric bypass surgery laparoscopically.

The fast food ads on television tout what appears to be a bargain: two breakfast sandwiches for four dollars, or a box with a sandwich, French fries, a drink and two cookies for six dollars.

Eager purchasers in the drive-through line probably have not stopped to look up the nutritional information for such meals, however—because if they did, they might rethink their understanding of the “meal deal” that they’re buying.

That two-sandwich breakfast? It contains as many as 1,200 calories, including 68 grams of fat, 360 milligrams of choles-

terol, and 54 grams of carbohydrates. The six-dollar lunch deal delivers at least 1,600 calories and as many as 2,000, depending on the size of the fries and whether the drink contains sugar. That’s more calories than the average adult should eat in a whole day, much less at one meal.

Yet this is what many people perceive their meals should look like, said Dr. Alok Gandhi, a bariatric surgeon at Rochester Regional Health. “We believe what we see on TV,” he said. “Is two sandwiches really a meal size? Our genetics were

WNYPHYSICIAN.COM VOLUME 1 I 2020 I 7

Photo courtesy of Rochester General Hospital.

Dr. Alok Gandhi performing Gastric bypass surgery laparoscopically.

built to conserve energy, because we did not know when or where our next meal would be. Our genetics have not changed, but our society and lifestyle have. The conveniences of a modern lifestyle, combined with fast and convenient prepared foods, and feeling compelled to eat every three or four hours is a perfect storm for obesity.”

This results in some staggering but not unfamiliar statistics: In New York State alone, 62.7 percent of adults were overweight or obese in 2018, up from 42 percent in 1997. Obesity among children and adolescents has climbed as well: Onethird of people under the age of 18 in New York are overweight or obese, a figure that has tripled in the last 30 years.

All of this extra weight affects every part of the body, causing everything from high cholesterol and high blood pressure to heart disease, type 2 diabetes, osteoarthritis, asthma, migraine headaches, sleep apnea, non-alcoholic fatty liver disease, infertility, and several forms of cancer. “Along with the risks for life-shortening chronic diseases, being overweight in a society that stigmatizes this condition contributes to poor 8 I VOLUME 1 I 2020 WNYPHYSICIAN.COM

mental health associated with serious shame, self-blame, low self-esteem and depression,” the New York State Department of Health reports. Indeed, society once thought that weight loss is a matter of will power, and obesity is proof of weakness, placing the blame firmly on the patient.

In the face of this stigmatization of people suffering from obesity, the American Medical Association moved in 2013 to classify obesity as a disease, rather than a behavioral issue.

This became the first step in changing the way the medical community views treatment for obesity. “It also reflects the medical community’s better understanding of the multifactorial causes of obesity,” said Dr. Gandhi. While exercise and nutrition are important elements in overall good health, the recognition of obesity as a disease opened the door to more effective treatment for weight loss, coordination of efforts between disciplines, and more resources to combat the problem.

Doctors across western New York are working to dispel the lasting stigma and improve outcomes for patients. At Bariatrics of Western New York at Rochester General Hospital, Dr.

Gandhi and his partners, Dr. Anthony DiBenedetto and Dr. Patricia Brogan Hughes, work to address all of the challenges that come with being extremely overweight, with bariatric surgery as one of the tools in their arsenal.

“We need to revisit what goes on our plate, when we eat, and when we stop,” said Dr. Gandhi. “We need to change the psychology of how you look at food. It’s Dr. Bala Gangadhara Reddy Thatigotla complicated—patients need education, support for nutrition, and ways to deal with the comorbidities that keep them from doing the things they need to do, like exercise.

Many people haven’t had any education in nutrition since grade school. They ask me, ‘What’s a carbohydrate?’

This part is about choices, about why we do what we do. When someone buys a fast food box meal, they may know it’s a bad choice, Dr. Alok Gandhi but they may still do it.

The medical community must continue to teach and educate patients about the significance one’s lifestyle will have on their downstream and overall health. So we have a lot of work to do.”

Just about all of Dr. Gandhi’s patients have tried to do the right thing, he said, and some have seen some success, but they slide back and regain the weight. “Short-term obesity therapy does not result in long-term weight loss,” he said. “As we learn more about obesity, we learn that there is an obesity set point.

The body wants to be a certain weight, and will return the person to that weight. That set point used to be at a healthy place, but the conveniences of the western lifestyle have changed where that set point is. Genetics loads the gun, but environment pulls the trigger.”

Changes to the set point also can come from life events, said John Rutkoski, MD, FACS, FASMBS, a bariatric surgeon with Trinity Bariatrics and the director of metabolic and bariatric

surgery at Sisters of Charity Hospital in Buffalo. “These are not simply willpower issues. They are powerful, innate drives with the capability of overcoming the efforts of even the most determined individuals,” he said. “If something disturbs that point of regulation: overeating, medications, lack of sleep, chronic stress, hormonal changes with puberty, pregnancy, childbirth, or menopause, the body doesn’t know that its regulatory point is set too high. It just knows that is the level that it wants to defend.”

This is not to say that the patient has no responsibility for weight gain, said Bala Gangadhara Reddy Thatigotla, MD, a bariatric surgeon at Trinity Bariatrics. “The number one

“Genetics loads the gun, but environment pulls the trigger.” cause of weight regain is noncompliance,” he said. “The body’s metabolism hasn’t reset, so they eat whatever they want, they don’t cut the carbohydrates and eat more protein, and they don’t exercise. They may start out strong, but they lose track.”

When patients have a body mass index (BMI) of 35 or greater and have one or more health issues related to obesity— diabetes, heart disease, high blood pressure, high cholesterol, sleep apnea, or a number of others—they become candidates for bariatric surgery. People with a BMI of 40 or higher also may be eligible for the surgery, even if they do not have one of these adverse health consequences.

The surgical procedures Weight loss surgery helps patients lose weight in one of two ways: by restricting the stomach’s capacity to hold food, or by shortening or bypassing a section of the small intestine, reducing the volume of calories and nutrients the patient’s body can absorb. There are several different surgical methods of achieving these goals. Consistent with national trends, Rochester Regional Health and Trinity Bariatric Surgery most commonly perform the vertical sleeve gastrectomy, a procedure in which the surgeon removes about 80 percent of the stomach, leaving a tube-shaped structure with a reduced capacity to hold food and produce ghrelin, the hormone that signals the body that it is hungry.

WNYPHYSICIAN.COM VOLUME 1 I 2020 I 9

“Sleeve gastrectomy is not just a restrictive procedure. It’s a metabolic surgery,” said Dr. Rutkoski. “It changes the gutbrain hormone interactions to adjust the set point. That’s why we see more durable weight loss following surgery than we do with lifestyle interventions alone. The nutrients are shuttled into the intestine quicker, it allows them to feel satisfied longer, and has a positive effect on blood sugar.”

Another procedure, biliopancreatic diversion with duodenal switch, begins with removal of most of the stomach, but leaves the pylorus intact, the valve that sends food to the small intestine. The surgeon “shuts off ” the middle of the intestine by attaching the last segment of the small bowel to the duodenum just below the pylorus. Bile and pancreatic enzymes continue to flow but do not mix with food until the last portion of the intestine, which limits the amounts of calories and nutrients the body can absorb.

The ability to perform surgery using robotics has made these procedures quicker and safer, said Dr. Thatigotla. “We can do the same kind of surgery—gastric bypass, duodenal switch— with better visualization over laparoscopy. The robotic surgery is much safer and the patient recovers much faster.”

“Surgery has traditionally been used as a ‘last resort’,” said Dr. Rutkoski, “But we know that the longer someone has any diagnosis or the more severe that condition is, the more difficult it’s going to be to treat which means that outcomes are going to struggle to meet our expectations in that model.

The transition from open to minimally invasive surgery has helped to make metabolic and bariatric surgery among the safest kinds of procedures we perform today. So although it’s not first line treatment, I think our patients would benefit from being offered the opportunity to consider surgery earlier in the game to improve their chance at remission.”

All of the surgeons Dr. Vikram Vattipally emphasize to their patients, however, that bariatric surgery is one tool in weight loss, not a cure—and it must be accompanied by changes in behavior.

“Maintenance of remission requires a holistic and multidisciplinary approach like we offer at the Sisters of Charity Hospital’s Metabolic Center for Wellness,” noted Dr. Rutkoski.

10 I VOLUME 1 I 2020 WNYPHYSICIAN.COM

The surgeons also work to counteract the misperception that bariatric surgery does not always work.

“Obesity is a chronic disease, so surgery is part of the disease process,” said Dr. Thatigotla. “We are able to fight the disease process for five to ten years, and give patients as much as ten years of good health. The surgery really changes their lives for them and prolongs Dr. John Rutkoski their quality of life, while reducing the damage from the disease process. In some people, the disease then advances again, and they may need a second surgery.”

Dr. Gandhi compares this to coronary bypass surgery.

“When you have heart surgery, you may need to stay on your

Our goal is to put the obesity – and its related diseases like diabetes – into remission, while improving the quality and longevity of the lives of our patients.” medications after the surgery, and you stay on a heart-healthy diet and you get exercise. Ten years later, you may still need another bypass or intervention, because that’s the progression of heart disease. But that is not viewed as a failure of the coronary bypass surgery or a failure of the patient. Rather, it is the progression of a chronic disease. Bariatric surgery is no different; it arrests the disease progression for a time, and then some weight may potentially come back. If the patient regains some weight, as about 15 percent of patients do, they say, ‘The

surgery didn’t work.’ It did work, but not permanently. There is no permanent cure. We must change this misconception.

Our goal is to put the obesity – and its related diseases like diabetes – into remission, while improving the quality and longevity of the lives of our patients.”

Bariatric surgery is not magic, noted Vikram R. Vattipally, MD, a general and bariatric surgeon with Trinity Bariatrics.

“Revision operations have picked up,” he said. “Most patients are turning back to us saying they are gaining weight after five or ten years. When they come for a second operation, we have to evaluate them thoroughly to determine why they gained weight. Those with new factors may be ideal candidates for a second surgery.”

New factors may be an illness or injury that temporarily incapacitated the patient, disrupting their exercise regimen and leaving them with weight they cannot seem to lose. A stressful life event also may contribute to the patient’s weight, leaving them with extra pounds that won’t come off.

“If we feel that they are non-compliant, however, they may not be a candidate for a second surgery,” said Dr. Vattipally. “We have to ask, did the surgery fail the patient, or did the patient fail the surgery?”

tions about bariatrics. “They think bariatric surgery is a drastic solution – very dramatic and invasive,” said Dr. Gandhi. “Also, there’s a misconception about what the surgery can and can’t do. Like any tool, it needs the right things: proper nutrition, exercise, education, multivitamins, and follow-up. There’s nothing more powerful than bariatric surgery to put obesity into remission, but it’s not a cure. It’s not a magic scalpel.”

In addition, Dr. Gandhi believes that it will be critically important for health care systems, in collaboration with insurance companies, to provide primary care providers more resources to better address the growing epidemic of obesity on the front lines. “The current data suggests that the resources we have now are inadequate to deal with the treatment of obesity. This is clearly reflected by the growing prevalence and costs of obesity. More resources are required to prevent this disease.”

Working closely with the patient’s primary care physician is a critical component of the plan, said Dr. Vattipally. “We always work with primary; we want shared decision-making.

We are there to help them.

Sometimes they only see obesity as bariatric, though it’s also metabolic. There’s a significant improvement in metabolic health when the patient loses weight. The patient’s primary care physician would be happy for the patient to take fewer medications or nothing at all, and that’s where we come in. We are helping them out to better manage their goal.”

Before patients can have joint surgeries like knee or hip replacement, they need to lose weight, said Dr. Thatigotla. “To make the patient lose weight for longer duration, surgery is much faster that diet and exercise,” he said. “The average stay in a hospital is one to two days, and the average time off work is ten to twelve days. Robotic and laparoscopic technologies make it much safer. We provide part of a holistic approach that helps the primary care physician achieve the goals for the patient.”

There’s nothing more powerful than bariatric surgery to put obesity into remission, but it’s not a cure.

It’s not a magic scalpel.”

Partnership with primary care providers Patients may feel that their weight issues should be solvable by working with their primary care physician, but some patients may require more specialized care, said Dr. Gandhi. “Look at what the primary care physician has to accomplish in every 15-minute visit: take the history of present illness, perform a medical exam, review labs and testing, review notes from other consultants, formulate a plan, review the patient’s meds, offer education about the patient’s conditions, do referrals, order screening tests, and procure prior approvals for treatment, all while documenting everything and showing compassion and empathy for the patient. We’re asking these physicians to do the hardest job in the world.

They often just can’t keep up – it’s like drinking out of the fire hydrant.”

It seems like an obvious move, then, to refer obese patients to a bariatric specialist, but some patients have misconcep-

Randi Minetor is a medical journalist and the author of Medical Tests in Context: Innovations and Insights (Greenwood, 2019).

WNYPHYSICIAN.COM VOLUME 1 I 2020 I 11

Editorial Calendar 2020

1

Volume 1 Regional Collaborations Obesity: Prevention & Treatment Sleep Disorders

Heart Disease

2

Volume 2 Infectious Disease Diseases of the Eye Stroke Signals

Men’s Health

3

Volume 3 Specialized Medicine Robotic Advances Endocrinology

4

Volume 4 Emerging Trends in Telemedicine Options in Pain Management The Therapeutic Frontier

5

Volume 5 Geriatric Health Coordinated Care in Chronic Disease Alzheimer’s & Dementia Orthopaedic’s: Hips and Knees

The Patient Experience: Engagement Women’s Health

The Patient Experience: Accountability Cancer Care in WNY

The Patient Experience: Safety Nets Special Columns of Interest

AI Success in Healthcare

Medical Innovations 2020

New Medical Products

Financial Insights on Retirement, Investing and Taxes

Risk Management

12 I VOLUME 1 I 2020 WNYPHYSICIAN.COM

Secure your advertising or editorial position in 2020 Andrea Sperry (585) 721-5238 or WNYPhysician@gmail.com

risk management

Managing Patient Noncompliance The Risk:

Patient noncompliance is one of the most difficult challenges for healthcare providers. Noncompliance may include missed appointments and the failure to follow a plan of care, take medications as prescribed, or obtain recommended tests or consultations. The reasons given by patients for noncompliance vary from the denial that there is a health problem to the cost of treatment, the fear of the procedure or diagnosis, or not understanding the need for care. Physicians and other healthcare providers need to identify the reasons for noncompliance and document their efforts to resolve the underlying issues. Documentation of noncompliance helps to protect providers in the event of an untoward outcome and allegations of negligence in treating the patient.

Recommendations:

Establish an office policy to notify providers promptly of all missed and canceled appointments. We recommend that this be done on a daily basis.

Formalize a process for follow up with patients who have missed or cancelled appointments, tests, or procedures. This process should include recognition of the nature and severity of the patient’s clinical condition to determine how vigorous follow up should be.

Consider having the physician make a telephone call to the patient as a first step when the patient’s condition is serious.

If the patient’s clinical condition is stable or uncomplicated, staff should call the patient to ascertain the reason for the missed or canceled appointment.

All attempts to contact the patient must be documented in the medical record.

If no response or compliance results, send a letter by certificate of mailing outlining the ramifications of continued noncompliance.

During patient visits, emphasize the importance of following the plan of care, taking medications as prescribed, and obtaining tests or consultations.

Seek the patient’s input when establishing a plan of care and medication regimen. Socioeconomic factors may contribute to the patient’s noncompliance.

To reinforce patient education, provide simple written instructions regarding the plan of care. Use the teach-back method to confirm that patients understand the information and instructions provided.

With the patient’s permission, include family members when discussing the plan of care and subsequent patient education in order to reinforce the importance of compliance.

When there is continued noncompliance, patient discharge from the practice may be necessary. The attorneys at Fager Amsler Keller & Schoppmann, LLC are available to discuss patient noncompliance and the discharge of a patient.

Reprinted with permission from Dateline, published by MLMIC, 2 Park Avenue, Room 2500, New York, NY 10016. All Rights Reserved. No part may be reproduced or transmitted in any form or by any means, electronic, photocopying, or otherwise, without the written permission of MLMIC.

ADVERTISERS Manning & Napier Advisors - inside back cover St. Ann’s Community - inside front cover MLMIC Insurance Company - back cover Plastic Surgery Group of Rochester - pg. 27 Catholic Health System - pg. 4 General Physicians, PC - pg. 14 Vascular & Endovascular Center of Western NY - pg. 22

WNYPHYSICIAN.COM VOLUME 1 I 2020 I 13

What Medical Providers Need to Know About the Link Between Gum Disease and Stroke Risk Two studies presented at American Stroke Association’s International Stroke Conference 2020 say treating gum disease, along with other risk factors, may reduce a patient’s likelihood of having a stroke. According to investigators, there is a potential link between gingivitis and a hardening of large arteries in the brain. Treating gum disease could help minimize “the severity of artery plaque buildup and narrowing of brain blood vessels” that lead to a stroke.

A Healthline article explains that strokes are a multi-factorial disease, and periodontal conditions could be a contributor. Thomas E. Van Dyke, of Harvard School of Dental Medicine, notes that gums are a common site for chronic inflammation. Because it doesn’t cause pain right away, he says that people often ignore it, but chronic inflammation can have “an impact on whole-body health” and “have systemic implications.” Lead author of the studies and professor at the University of South Carolina School of Medicine Dr. Souvik Sen says another indicator is confirmed cases of bacteria P. gingivalis present in the carotid arteries and gum infection bacteria Streptococcus sp DNA found in brain blood vessels.

Additional findings suggest that patients with periodontitis are: twice as likely to experience large artery strokes due to intracranial atherosclerosis; three times as likely to have a stroke involving blood vessels in the back of the brain; twice as likely to have moderately severe narrowed brain arteries from plaque buildup compared to those with no gum disease; and 2.4 times as likely to have severely blocked brain arteries.

Based on these results, Sen encourages providers to recognize that gum disease can be a risk factor for stroke and to work with patients on treating any periodontal conditions.

MLMIC recognizes this as an opportunity to expand communication across disciplines and promote the effective sharing of patient health information.

Including oral health in an assessment of patients’ medical histories presents an opportunity to evaluate their risk for additional health concerns. Conversely, dentists can also share their diagnoses and treatment plans with patients’ treating physicians to advance the overall health of their patients.

Introducing Our

Heart Failure Center at Buffalo General Medical Center

Call today for more information or to schedule an appointment

716.710.8266

GREATLAKESCARDIO.COM

Dr. Thomas Cimato and Dr. James Youssef can: • Evaluate patients for device implementation or transplants • Treat patients with cardiomyopathies • Offer post-care for device implementation and transplants • Manage remote monitoring of CHF devices The Heart Failure Center is established in collaboration with Rochester General and Strong Memorial Hospitals.

* Proud Partnership with

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medical research

Roswell Park Team Discovers New Mechanism Driving Pancreatic Cancer Length of some regions of messenger RNA plays key role in regulating gene expression, cancer growth Roswell Park Comprehensive Cancer Center researchers conducting the first large-scale analysis of a gene regulatory mechanism that, when altered, can lead to cancerous growth have found compelling evidence of the role it plays in the development of pancreatic cancer. They share these new findings in an article in the journal Genome Research.

Led by Michael Feigin, PhD, Assistant Professor of Oncology in the Department of Pharmacology and Therapeutics, the team studied a largely unexplored mechanism called alternative polyadenylation that recently has been found to play a significant role in regulating the expression of genes — particularly oncogenes, or genes known to be associated with cancer — in cells.

Michael Feigin, PhD, led new research showing that the length of key regions of messenger RNA may hold clues about the development of pancreatic cancer.

Oncogenes’ impact on cells is determined by how much protein they produce. The information encoded is transcribed to form a messenger RNA molecule, or mRNA, that when translated forms the protein.

Dr. Feigin, postdoctoral fellow Dr. Swati Venkat and colleagues set out to study what happens to the encoded information that doesn’t get translated, a phenomenon that, Dr. Feigin says, “remains completely unexplored in the context of pancreatic cancer and can provide understanding of how we target oncogenes that drive this debilitating disease.”

The length of this sequence of information at the end of a molecule, known as a 3 prime untranslated region or 3’ UTR, has been shown to influence the amount of protein produced: much shorter lengths cause increased protein production, leading to cancerous growth.

The team mined data from tissues from hundreds of people with pancreatic cancer as well as normal pancreas samples, searching for oncogenes that showed difference in 3’ UTR lengths between cancer and normal conditions.

“We found widespread, recurrently shorter 3’ UTR lengths of multiple oncogenes in pancreatic cancer patients,” says Dr. Venkat, first author on the new study. “This shorter length significantly increased gene expression of known pancreatic cancer oncogenes.”

The team also discovered a novel growth-promoting gene called casein kinase 1 alpha, whose mRNA exhibits a shorter 3’ UTR length in cancer cells that drives its increased expression and promotes cell growth.

“We conclude that 3’ UTR length changes drive widespread oncogene dysregulation in pancreatic cancer,” Dr. Feigin says.

“Our next step will be to unravel the protein machinery that regulates these length changes and target these proteins to explore possible therapeutic avenues.”

The study represents the first large-scale analysis of alternative polyadenylation events ever performed within a single cancer type.

Roswell Park Team Helps Explain How Chronic Stress Weakens Immunity Against Cancer Researchers identify new mechanism associated with aggressive growth in cancer tumors In 2013, researchers from Roswell Park Comprehensive Cancer Center became one of the first teams to report that chronic stress can encourage the development and proliferation of tumor cells by suppressing natural immunity against cancer. In a new study published in the Journal of Clinical Investigation, the same laboratory has revealed an important and previously unknown means through which chronic stress weakens immunity against cancer: through its effect on a specific cell type known as the myeloid-derived suppressor cell (MSDC).

The team, led by Elizabeth Repasky, PhD, Co-Leader of the Cell Stress and Biophysical Therapies Program and the Dr. William Huebsch Professor in Immunology at Roswell Park, has identified a new immunological mechanism through which chronic stress can increase the number of MSDCs in patients’ blood and tumors, which are associated with more aggressive cancer growth.

“Researchers have suspected for some time that chronic stress can lead to increased sicknesses,” says the paper’s first author, Hemn Mohammadpour, PhD, DVM, a postdoctoral research affiliate with Dr. Repasky’s lab. “Our data shows that if tumors are present, chronic stress can specifically activate myeloidderived suppressor cells, which are known to promote tumor growth.”

Based on these findings, a team of Roswell Park researchers are working together to develop and test the impact of several

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stress-reducing strategies, including exercise, meditation, yoga and reiki on immune activity. Offering a variety of options is important because it lets patients find the most enjoyable and useful strategies, based on their age and physical abilities.

“Our research strongly suggests that a reduction of chronic stress will improve the immune response against tumors. If reducing patients’ stress can block the activity of these cells,” says Dr. Repasky, “it could add to a more effective strategy to slow tumor growth.”

Roswell Park Finds New Evidence That Inhaled Vitamin E Acetate Caused EVALI in Vapers NEJM report confirms cutting agent in THC e-liquids as primary cause of deadly lung damage In August 2019, the first cases of an unknown lung injury associated with vaping products were reported to the U.S. Centers for Disease Control and Prevention (CDC). This initial cluster of cases would quickly grow to 2,807 cases across the country, leading to the deaths of 68 people, from e-cigarette, or vaping, product useassociated lung injury, or EVALI, by February 2020. A team of researchers from Roswell Park Comprehensive Cancer Center and the Environmental Health Laboratory in the CDC’s National Center for Environmental Health have published new evidence expanding on the initial conclusions from CDC-led analyses — that inhalation of vitamin E acetate (VEA) is strongly linked to EVALI. RESEARCH “We show conclusively that, when vaped, vitamin E acetate, which is often used as a cutting agent in ecigarette liquids containing THC, can reach the lung and cause severe damage to the lung,” says Dr. Thanavala.

The team tested for several different markers of pulmonary injury, finding that VEA exposure led to higher levels of serum albumin in the bronchoalveolar lavage (BAL) fluid and both increased numbers of leucocytes and lipid-laden macrophages in the lung — providing further strong evidence of a causal link between inhalation of vitamin E acetate and EVALI illnesses.

This new report represents an important companion to the CDC’s December 2019 study, also published in the NEJM. That study concluded that vitamin E acetate was present in lung fluid obtained from 94% of 51 people affected by EVALI, all of whom had used at least one product containing tetrahydrocannabinol (THC), but was not found in the lung fluid of healthy control-group participants. The new research letter 16 I VOLUME 1 I 2020 WNYPHYSICIAN.COM

from Dr. Thanavala and team, which included a CDC collaborator, reports similar findings from studies in a preclinical mouse model.

“The minute I recognized that there was an inflammatory response occurring in some of these patients with a component of these large, foamy macrophages that contained lipids,” Dr. Thanavala says, “the light bulb went off. I decided that we needed to test in the laboratory setting whether in fact we could establish a linkage between what was seen clinically and whether we could mimic it or replicate it with exposure to aerosols of vitamin E acetate.”

“The observation that BAL fluid from EVALI patients contained vitamin E acetate was an important step toward understanding the causes of recent vaping-related lung injuries,” says James Kiley, PhD, Director of the Division of Lung Diseases at the National Heart, Lung and Blood Institute (NHLBI). “This finding that animals exposed to vitamin E acetate aerosols demonstrate many of the biological characteristics of EVALI patients reinforces that vitamin E acetate should not be added to vaping products. This potential animal model of EVALI is critical to further investigate pathological mechanisms and develop therapies.”

The team’s findings hold important takeaways both for the general public and the medical community.

“Our work reinforces how important it is that people take great caution in what is being vaped and the source of the liquids they are vaping,” Dr. Thanavala notes. “And I hope medical professionals will be sure to ask their patients not only whether they are smoking cigarettes but also whether they are vaping — and what they are vaping. Because we need to do everything we can to prevent others from developing EVALI.”

Yale scientists find new way to block cancer-causing HPV virus The human papillomavirus (HPV) is the main cause of several cancers, including cervical cancer, which kills almost 300,000 women around the world each year. Although vaccines offer a proven first line of defense against HPV infection, researchers continue to look for additional options to guard against the virus.

In a new study published in the Proceedings of the National Academy of Sciences, Yale Cancer Center (YCC) researchers have demonstrated in principle a new biological approach that can stop HPV infection. This method may eventually aid in treating not only HPV, but other viruses, including non-viral diseases that are currently thought to be “undruggable,” said the researchers.

“We know very short peptides [fragments of a protein] can block the HPV virus from infecting cells,” said senior author

Daniel DiMaio, MD, deputy director of YCC, the Waldemar Von Zedtwitz Professor of Genetics, and professor of molecular biophysics and biochemistry and of therapeutic radiology.

“This research confirms our model for how HPV infects cells. It also shows that the intracellular trafficking of a virus could be the target for a new anti-viral approach.”

HPV is carried into the cell by a membrane-bound sac called an endosome. An HPV protein known as L2 contains a segment known as a “cell-penetrating peptide” that sticks through the membrane of the endosome into the cell’s interior. There, a sequence of L2 next to the cell-penetrating peptide binds to a cell protein called retromer. Retromer then delivers the virus into a cellular transport mechanism known as the retrograde pathway that drops off the virus in the nucleus, where it can begin making copies of itself.

Previous research by DiMaio’s lab found that the core machinery of the cell-penetrating peptide is surprisingly short.

Peptides are composed of amino acids, and a sequence of only six amino acids was needed for the peptide to penetrate cell membranes, while a sequence of only three amino acids was required to bind to the retromer protein.

“We realized that we could synthesize a short peptide that should be enough to get through the cell membrane, bind the retromer and block infection, so we decided to test that,” DiMaio said. “The first peptide we tried worked.”

When the investigators added the synthesized cell-penetrating peptides into a culture medium of human cells, they saw that the peptides did enter the cytoplasm and bind to the retromer. When the scientists then infected the cells with HPV, the virus could no longer bind to the retromer and leave the endosome because the retromer was tied up by the peptide, and infection was blocked.

The Yale researchers demonstrated that this peptide inhibition persists even after the peptides are removed. “We don’t actually know how long the peptide is active, but the effect may be irreversible,” DiMaio added. “It also looks like the virus disappears. The cell has some way to sense that the infection is not proceeding normally, so it gets rid of the virus.”

In follow-up experiments conducted with colleagues at the University of Wisconsin, the scientists showed that this cellpenetrating peptide also inhibited HPV infection in mice. This basic research may point toward new types of anti-HPV treatments, which are needed, DiMaio said.

Although vaccines will always be the best foundation to prevent HPV infections, DiMaio said, “the vast majority of people worldwide are not vaccinated, especially in the developing world where most cases of cervical cancer occur.” Additionally, current vaccines don’t guard against all strains of HPV, he said.

VALU E O F ADVE RTI S I N G Western NY Physician Magazine is the only regionally-focused publication reaching more than 6,500 physicians in the Buffalo and Rochester region.

Call or email to learn more about positioning your practice, service line or business in Western NY Physician Magazine.

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clinical

Food Fight

The Role of Nutrition in Combating Diabetes

By Matt Chandler

The average weight of an American, and the prevalence of diabetes in America share one thing in common: both are on the rise.

The U.S. Centers for Disease Control and Prevention's National Center for Health Statistics reports that Americans have increased their weight by an average of ten pounds in the last decade. Meanwhile, the American Diabetes Association says the number of Americans living with diabetes has ballooned to more than 34 million.

The connection between obesity and diabetes is not new, but the rate with which Americans are packing on the pounds and suffering the health ramifications from it is alarming some in the medical community.

A 2019 review by the Harvard T.H. Chan School of Public Health pointed to several factors researchers says are all on the rise, as major contributors to the diabetes epidemic. They include: • Obesity/rising BMI • Increasingly sedentary lifestyles • High blood pressure • Higher levels of “bad” cholesterol 18 I VOLUME 1 I 2020 WNYPHYSICIAN.COM

Millions of Americans walk less, sit for their jobs, skip the gym, and consume fast food and heavily processed foods, and the results are reflected in the significant rise in diabetes.

Losing weight can be a daunting task, as can be getting to the gym, moving around during your workday, and passing on the drive thru in favor of a healthy meal at home after a long day.

But those decisions may very well save your life.

Christine Wolniewicz is a Registered Dietitian with General Physician, PC. She specializes in working with patients who are looking to make nutritional changes in their life, often as it relates to diabetes or prediabetes.

She says the beauty of the top factors cited in the Harvard study, is that all can be significantly improved with the help of a nutritional counselor.

“For a lot of people, they have never been taught how to eat healthy,” Wolniewicz says. “They may have learned the ‘my plate’ guide, or been told to eat a balanced diet, but we know so much more today than ever before about how the science of proper nutrition impacts your overall health.”

“There are guidelines for healthy eating of course, but I work with my patients to get to know them, to understand the what, when, where, and why behind their food choices,” Wolniewicz says. “That allows me to tailor a nutrition plan that is right for their unique body and lifestyle.”

Another big advantage of working with a registered dietitian, is accountability.

“Too often, people lack a true accountability partner who will keep them on track with their nutrition goals,” she says.

“Having an objective dietitian to check in with, who will review your food app, monitor your weight, review your food logs, and give positive, feedback and direction, can make a big difference.”

She says one of the obstacles that keeps people from working with a registered dietitian is often a miscommunication about the service.

“Many people don’t realize that most insurance plans cover

nutrition counseling,” she says. “So many people have this option as part of the insurance coverage they are paying for, and never take advantage of it.”

At General Physician, the services covered by most insurances includes a fiveweek diabetes education series. The AADE accredited program is led by Certified Diabetes Educators, Registered Dietitians and Pharmacists, and the sessions, which are held bimonthly, regularly fill up.

Kelly Cardamone is a Certified Diabetes Educator, Registered Dietitian and the program coordinator as well as an instructor for the diabetes classes held in Williamsville and Buffalo.

Cardamone says there is no one size Christine Wolniewicz Kelly Cardamone fits all plan to manage diabetes once it is diagnosed.

“We work with our attendees to learn hands-on, practical tion services line to include classes in Dunkirk as well. ways they can improve their health. This includes helping “We all have a passion for sharing what we know about them understand the role proper nutrition and exercise plays nutrition and diabetes with our patients, and that comes in managing their diabetes, increasing knowledge about medithrough in these classes,” Cardamone says. “There is nothing cations, and how to monitor their A1C and glucose levels,” more satisfying as a registered dietitian than to see someone she said. “The emotional support the group dynamic offers is I’ve worked with have a breakthrough and make those lasting extremely beneficial.” lifestyle changes.”

Cardamone says the class even includes a group shopping Most importantly, for patients suffering from Type 2 Diabetrip to the grocery store to see first-hand how to shop with tes, weight loss can play a significant role in diminishing the nutrition in mind. health issues they face.

“We show participants “Reaching a healthy how to read nutrition weight is very important labels, what to look for, in terms of overall health,” and what to avoid,” she Cardamone says. “But we says. “It’s not enough to go beyond that. We don’t count calories, we teach teach dieting, we educate our patients how to make our patients on how to the best choices for their change their thinking, bodies when it comes to make lasting changes, and sugar intake, high fructose improve the quality of their corn syrup, carbohydrates, health and their lives.” and we show them some Kelly Cardamone MS, of the foods that have RD, CDE and Christine been marketed to them as Wolniewicz MS,RD are healthy, that really aren’t.” both accepting new patients.

She encourages people To learn more about the with diabetes to consider attending the series. General Physinutrition services and diabetes class offered through General cian recently expanded the education component of its nutriPhysician, PC, visit www.gppconline.com.

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clinical

Metabolic Pathway Can Be Effectively Targeted to Treat Prostate Cancer, Roswell Park Team Shows Two-drug combination effective in lab studies against aggressive prostate tumors

A Roswell Park Comprehensive Cancer Center research team has identified a novel combination therapy that demonstrates a new approach to treating prostate cancer, reporting their findings in the journal Nature Communications. This new therapeutic strategy is the first to target metabolic processes uniquely important to prostate cancer — specifically, two enzymes in the connected polyamine catabolic pathway and the methionine salvage pathway.

Dominic Smiraglia, PhD, Associate Professor of Oncology in the Department of Cancer Genetics and Genomics at Roswell Park, led the team that identified this new strategy for treating castration-recurrent prostate cancer, a highly aggressive and therapy-resistant form of the disease.

“The primary problem with prostate cancer therapy is that nearly all men recur after an initial response to androgen deprivation therapy, leaving patients and clinicians with no more good options,” says Dr. Smiraglia. “This new metabolic approach is completely independent of androgen-deprivation therapy. Ultimately, the hope is that it will prevent recurrence during traditional androgen deprivation.”

The new approach is a two-part strategy involving inhibition of the rate-limiting enzyme methylthioadenosine phosphorylase (MTAP) with simultaneous upregulation of spermidine/ spermine N1-acetyltransferase (SSAT). The research team hit upon this strategy after observing prostate cancer’s high rate of flux through the polyamine biosynthetic and catabolic pathways. The new treatment takes advantage of the prostate’s innate function of generating and secreting polyamines, key components in human reproduction.

“The prostate makes the highest amount of polyamines of any tissue, and this increases with prostate cancer,” Dr. Smiraglia notes. “This unique but normal state means metabolism of the prostate is uniquely tuned.”

The Smiraglia lab in 2019 developed a new bioinformaticsbased approach to monitoring changes in cancer cells, which it employed in the current study. The lab’s previous studies showed that prostate cells are hypersensitive to changes in metabolism that relate to polyamines, resulting in loss of cell growth. The team imagined the engine of metabolism in the cell driving the clinical problems of cancer therapy resistance and metastasis.

In laboratory studies using cancer cell lines, the team then used one drug to force the prostate cancer cells to make even 20 I VOLUME 1 I 2020 WNYPHYSICIAN.COM

Dr. Dominick Smiraglia and team has identified a therapeutic strategy to target metabolic processes important to prostate cancer. more polyamines, creating metabolic stress, while using a second drug to inhibit a stress-relief pathway to recycle metabolic resources needed to make polyamines.

“Metabolic stress-relief pathways are the oil that lubricates the engine, resolving stress and allowing smooth functioning,” says Dr. Smiraglia. “If we rev the engine by up-regulating polyamine metabolism with one drug, while at the same time blocking the oil needed to lubricate the engine with a second agent, perhaps we can seize the engine, thereby preventing therapy resistance and metastasis. This is a conceptually different approach from the more typical strategy of removing the fuel from the engine. When those strategies have been tried, the cancer becomes adept at finding new fuels to use.”

The novel combination was able to block cancer growth in prostate cancers, including castration-recurrent prostate cancer, he says, and “offers a potentially fruitful alternate therapeutic direction.”

Prostate cancer remains the leading cause of cancer-related incidence and the third-most-common cause of cancer-related mortality in men in the United States.

These findings were recently highlighted in an article from Science Translational Medicine.

This work was supported in part by several grants from the National Cancer Institute, or NCI (project nos. R01CA197996; CA21245501; R01CA204345, R01CA235863 and P30CA016056, Roswell Park’s Core Grant from the NCI).

practice management

Want to Improve Patient Relationships?

Let Them Express Their Preferences Jeff Jarvis Selecting preferences is commonplace in our digital world.

Users subscribe or unsubscribe from email lists, request notifications from their favorite brands, and update their privacy settings on social media networks. It’s a win-win for both parties; consumers receive relevant communications when they are given a voice regarding their areas of interest, preferred frequency, and preferred communication channel. Likewise, businesses get better ROI on their campaigns and build trust and loyalty with their customer base. These principles apply to healthcare organizations and their patients as well.

Healthcare marketing teams are granted first-hand insight to unique customer characteristics and interests- the ultimate opportunity to give patients exactly what they want and to enhance relationships. And patients now expect it; especially in view of strict regulations including TCPA and CCPA. However, while preference collection is important, how a business manages that information is critical to maintaining compliance. Unfortunately, many organizations still miss the mark.

The first step is for healthcare marketing executives to understand their needs. Not all preference management platforms are created equally; yet many companies try to take the easy way out, choosing to leverage an existing system that is not designed to meet the needs of complex organizations.

For example, the majority of SMS and email service providers have built-in preference collection interfaces, where data is stored within the system and provides access to administrators. While this approach provides basic functionality and may meet the needs of healthcare facility offices with a sole communication channel, larger healthcare organizations or providers face complex challenges, requiring more robust and integrated technology. All too often, large healthcare companies with multiple departments and communication touch-

points require a more sophisticated solution to better service their patients and avoid compliance risk. They are simply unaware of the risks they assume, and opportunities forgone by relying on a simple preference collection webpage.

Surprising to many organizations, preference and consent collection is not a simple issue to tackle. DIY solutions lack proper governance that drives preference management capabilities and fail to distribute information across the entire enterprise, leaving each business unit with varied perspectives of a patient and their preferred communications. Without a unified view of the patient, each department risks sending impersonal communications to those who have made the effort to share their preferences. Further, compliance is jeopardized by the systems’ inability to record consent history and track changes to preferences. In the wake of a violation accusation, patient consent and preference history is essential to defend your company. As the amount of data escalates and regulations continue to evolve, employing an oversimplified preference collection webpage heightens the potential for legal battles and presents more alarming issues than it attempts to solve.

Patients view their healthcare providers, like most companies, as a single entity, but basic preference collection webpages prevent providers from behaving like one. They behave as siloed systems, information systems that isolate data from the rest of the healthcare organization. By resorting to a simple preference webpage, healthcare companies are missing out on the opportunity to communicate more effectively. When patient preference information is shared across the organization, marketing efforts can be customized to effectively deliver a personalized and consistent message. Instead, customers experience inconsistent interactions, unwanted emails or texts, and phone calls; they are turned away feeling unheard.

WNYPHYSICIAN.COM VOLUME 1 I 2020 I 21

For example, many doctor offices today offer cosmetic ships. On the other hand, investing in a preference manageservices or product offerings that may not be covered by ment system integrates information company-wide and insurance. However, some of their patients may prefer to only continuously evolves with data privacy regulations to protect receive communications related to their regular visits and your company and remain compliant. These systems allow you desire minimal marketing communications offering additional to optimize your communications and patient relationships. services to them. Having a more intelligent system that can manage the preferences of all individual patients makes it Jeff Jarvis serves as SVP, Strategy & Consulting at PossibleNOW easier to understand what each one wants and needs. where he brings an extensive background in domestic and interOnce healthcare organizations are aware of the dangers national business environments helping companies drive business associated with oversimplified or DIY systems, they realize growth, develop high-performance sales and service organizations the value of comprehensive enterprise preference management and implement process best practices. solutions. A centrally located management system is necessary to minimize risk; integration across the whole organization guarantees all units are in-sync with the patient, communicating with them accordingly. These systems build trust, enhance vital patient relations and ROI. Additionally, if compliance is called into question, robust preference management systems protect legal authority through following regulatory rules, recording data, and providing healthcare organizations with a full history of each consent permission to date.

Many healthcare organizations build their own internal solution for consent and preference collection in an attempt to save money or retain control; ironically, they are losing money and missing the mark. When decidThe experts at the Vascular & Endovascular Center of Western New York provide minimally invasive surgical care and superb diagnostic testing ing whether to build or buy, utilizing state-of-the-art technology. these organizations must be aware of the differences with • Five board-certified vascular surgeons each approach. Preference • Minimally Invasive Vein Care in both Buffalo and Niagara Falls • Seamless care coordination with specialty providers webpages collect fragmented • Top 3% nationally-ranked vascular surgery practice data and fail to integrate information provided by the Affiliations with Catholic Health, Kalieda Health and Catholic Medical Partners patient. As a result, organizations open themselves up

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practice management

RESULTS FROM HEALTHELINK STUDY SHOW DECREASES IN PATIENT READMISSIONS AND EMERGENCY VISITS THROUGH PHYSICIAN PRACTICE INTEGRATION OF HEALTH INFORMATION Practices also realized that patient wait times in offices decreased up to 40 minutes BUFFALO, NY – A recent study conducted by HEALTHeLINK in cooperation with a researcher at University of Connecticut and Brookings Institution’s Center for Technology Innovation, demonstrates that provider offices effectively utilizing health information exchange (HIE) technology can help save their patients and the greater health care community both time and money. The results of the study of integrating HIE into workflow practice were published in the January 2020 Information Systems Frontiers which according to its website “examines new research and development at the interface of information systems and information technology from analytical, behavioral, and technological perspectives.”

The study examined whether integration of HIE services into medical practices’ workflow would have an impact on emergency department (ED) visits and unplanned 30-day readmission amongst patients who were treated at the practice.

When practices were trained on how to efficiently utilize and integrate the HIE into their daily workflow, the pilot concluded that the rate of unplanned hospital readmissions was reduced 10.2% and the rate of ED visits was reduced 13.3%.

“The study demonstrates that HIE can significantly enhance patient care if incorporated into practice workflow,” said study author Niam Yaraghi, an assistant professor of Operations and Information Management at the University of Connecticut's School of Business and a non-resident fellow in the Brookings Institution's Center for Technology Innovation. Yaraghi’s research is focused on the economics of health information technologies.

Yaraghi went on to say that, “The ability of a provider office having immediate access to review a hospital discharge summary or the results of a recent test can result in fewer redundancies and better medical decisions for the patient and naturally less time that patient has to wait in the reception area, all of which lead to costs savings in the health system.”

Prior to the start of the pilot study, HEALTHeLINK first shadowed several practices to observe current workflows and gain insight into how they were currently gathering clinical information and potential ways HIE utilization, especially notifications, could save time in obtaining relevant patient records and test results. This resulted in the development and implementation of a training program at the pilot practices.

“This is now the fourth study conducted by HEALTHeLINK that demonstrates greater efficiency in the health care setting, better care for patients and the overall cost savings through the region’s HIE and another example of how HEALTHeLINK is working when utilized by providers,” said Dan Porreca, executive director, HEALTHeLINK. “In addition to utilizing HIE to reduce unplanned hospital readmis-

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sions and ED visits, participating study practices also reported to us increased ease of obtaining patient information and proactively supporting office visits. By accessing patient test results and records in advance, the practices saved up to seven hours a week in chart preparation and pre-visit planning and experienced a reduction of up to 40 minutes in patient cycle time.”

As a result of this study, HEALTHeLINK has developed a practice workflow toolkit to assist practices with increased integration of HIE into their office workflow.

“This study illustrates that in order for providers and practices to fully realize the significant impact and value HIE can have on patient care, it needs to be properly incorporated into their office workflow,” concluded Porreca. “As part of the Statewide Health Information for New York (SHIN-NY), the value HIE organizations like HEALTHeLINK provide is enhanced with the ability to connect providers and their patients’ data from across the state. If not being used properly, HIE and HEALTHeLINK can’t achieve its full potential in improving the quality and efficiency of care.”

Recently, the New York eHealth Collaborative (NYeC) announced that the Statewide Health Information Network for New York (SHIN-NY), which is comprised of health information exchanges (HIE) across the state, if fully leveraged, would reduce unnecessary spending on health care by one billion dollars annually.

HEALTHeLINK, the HIE for Western New York, has one of the highest utilization rates among providers in this network and is significantly contributing to these cost savings. The methodology used to determine the cost savings in the NYeC analysis was in three categories: duplicate testing, avoidable hospitalizations and readmissions and avoidable emergency room visits.

Through the years, HEALTHeLINK has conducted its own studies in these focus areas, including our most recent on HIE utilization within physician practices. Other studies have looked at unnecessary duplicate CT scans and querying HEALTHeLINK in local emergency departments to reduce ordering of laboratory tests and radiology exams. It’s not only a cost saving issue, but also a patient safety issue due to levels of radiation exposure associated with exams such as CT scans.

These studies all demonstrate that when HEALTHeLINK is fully utilized by providers it results in greater efficiency in the health care setting and better care for patients, further validating that HIE is working.

Daniel Porreca is HEALTHeLINK’s executive director.

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Live life to the fullest. Help others do the same.

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clinical

Cardiac Resynchronization Therapy Benefits Cancer Survivors with Heart Failure

A pacemaker-like device restored heart function in a group of cancer survivors — mostly women with breast cancer — who had suffered from heart failure as a result of chemotherapy, a study in the Journal of the American Medical Association (JAMA) reports.

The device was evaluated in a small observational clinical trial, led by the University of Rochester Medical Center, at 12 cardio-oncology programs across the U.S., including at UR Medicine’s Wilmot Cancer Institute.

Ties between cancer and heart disease have been in the news lately. Researchers not only suggest that heart disease and cancer risk may be linked, but also that doctors should be aware of heart disease as a side effect of cancer treatment.

Vicki Dennis, 64, of Moravia, NY, was a participant in the study and credits it with saving her life.

In the space of a few months, Dennis went from being a healthy, eight-year breast cancer survivor to suddenly having cancer-related heart disease serious enough to land her on a transplant list.

“I proved them all wrong,” Dennis said. “I made it through the cancer and now I’ve made it through this. I think I’ve

astounded everybody in Rochester. I know they’ve done everything they could for me and now it’s just a question of hanging in there — which I intend to do for a long time.”

Known as the MADIT-CHIC study, it was the first of its kind to assess whether cardiac resynchronization therapy (CRT) could improve heart function in patients with congestive heart failure and cardiomyopathy, an enlargement of the heart due to chemotherapy side effects.

After six months with the implanted CRT devices, the 30 patients who received cardiac resynchronization therapy experienced significant improvement. The study, which took place between 2014 and 2018, was designed to address a problem that impacts more than half of people who receive anthracycline chemotherapies.

These patients are prone to heart muscle damage, and about five percent go into full heart failure, said the study’s principal investigator and senior author, Valentina Kutyifa, MD, PhD, associate professor of Medicine at the University of Rochester

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Clinical Cardiovascular Research Center. Like Dennis, all of the trial participants did well during six months of follow-up care, Kutyifa said.

“Not only did their heart function improve, but they were able to take care of themselves, enjoy life, and do just about everything they were able to do before the illness,” Kutyifa said. “It really gives hope to patients who have survived cancer.”

JAMA published an editorial supporting the study and calling for a more “harmonized approach” to cardiac care for cancer survivors.

Heart problems can arise early on — from six months to two years after cancer treatment — or as far as 15 to 20 years, said Eugene Storozynsky, MD, PhD, who directs the CardioOncology clinic associated with Wilmot Cancer Institute, the only such program in upstate New York.

Vicki Dennis’ “Remarkable” Story

In 2008 at 53 years old, doctors diagnosed Dennis with breast cancer after a routine mammogram. Because she lives about 80 miles southeast of Rochester, Dennis opted to be treated in Auburn, NY. She had a mastectomy, and then six months of chemotherapy.

She bounced back from the treatment fairly easily.

For years she lived well. In February of 2016, in fact, Dennis had an annual oncology checkup and got another clean bill of health. But weeks later she developed a bad cold and cough.

Doctors near her hometown believed it was bronchitis, then pneumonia, and prescribed a variety of medications. She couldn’t sleep and had trouble breathing.

“People were telling me I had no color. I didn’t know what was happening,” Dennis said. She assumed the shortness of breath was part of the respiratory illness. But when her feet and ankles swelled, she called her sister-in-law, a nurse, who urged Dennis to go to the nearest emergency room.

An x-ray revealed a damaged and enlarged heart with fluid buildup. “I was in total shock. It was pretty scary,” Dennis said.

“At one point they weren’t sure I would make it through the night.”

An ambulance rushed her to UR Medicine’s Strong Memorial Hospital in Rochester, where she was placed in Storozynsky’s care. After a week of tests and medical therapy, Dennis learned about Kutyifa’s clinical study on cardiac resynchronization therapy.

“I figured that if it could help somebody else, go for it,” Dennis said. “I also knew that I would be doing everything that I could to keep myself alive.”

On Nov. 1, 2016, the CRT device was implanted in her chest, providing the powerful electrical stimulation needed to synchronize her erratic, weak heart contractions.

Kutyifa said it’s important to note that women are more susceptible to heart damage as a chemotherapy side effect.

However, women typically represent only about one-third of participants in cardiology studies evaluating implanted devices. For the MADIT-CHIC trial, a concerted effect was made to enroll more women: 87 percent of the participants were females with a mean age of 63, and most had been treated for breast cancer.

Research Makes a Difference

The trial’s main objective was to evaluate each patient’s ejection fraction (EF), a measurement of how much blood is pumped as the heart beats. A healthy person’s EF is typically 60 percent. The study participants had an EF of less than 35 percent when they enrolled — less than 40 percent is evidence of heart failure — and Dennis’ EF was a mere 28 percent.

But six months after cardiac resynchronization therapy, Dennis and others in the study saw their symptoms ease and as their EFs rose into the normal range.

In Dennis’ case, 18 months after the start of the trial, her heart had completely normalized in size and function, even at a microscopic level, said Storozynsky, associate professor of Medicine in cardiology.

“I’ve seen this only rarely in the 10 years I’ve been following cancer patients,” he said. “She does have a very remarkable story in the sense that if it wasn’t for this clinical trial… she may be really struggling.”

The opportunities to help patients with cancer and heart problems are growing and the study adds another tool for the future, Storozynsky said. He works with oncologists and internists to identify patients who may be at greater risk, and to minimize the heart’s reaction to chemotherapy.

“You always want to be aware,” Storozynsky said. “If something doesn’t seem right, if the heart rate is suddenly higher, that may be an early warning sign. The heart doesn’t change from the size of your fist to a football overnight.”

“People were telling me I had no color. I didn’t know what was happening.”

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Several cancer therapies can impact the heart. In addition to anthracyclines (doxorubicin), which can build up unwanted calcium in the heart muscle, immunotherapy and tyrosine kinase inhibitors can cause left-ventricle damage. Radiation therapy may lead to a thickening of the heart valves, inflammation, and artery blockages.

UR Medicine doctors established a database to track lymphoma patients treated at Wilmot, who may face risks due to the newer classes of targeted medications that stop the cancer but might induce heart problems, said Ilan Goldenberg, MD, director of UR Medicine’s Clinical Cardiovascular Research Center.

“Right now, this is an understudied area,” Goldenberg said.

“Our plans include collaborating more closely and focusing on how to manage and reverse heart damage caused by many of the newer medications.”

The latest research builds on the legacy of renowned UR cardiologist Arthur J. Moss, who pioneered a vast field of science aimed at preventing and treating sudden death, often with implantable cardiac resynchronization devices. Moss designed and led many successful studies using CRT in different patient populations. Before he died in 2018, Moss launched the study that saved Dennis’ life. He designed the MADIT-

CHIC trial in 2014 with the JAMA corresponding author Jagmeet Singh, MD, PhD, professor of Medicine at Harvard Medical School.

Boston Scientific, the device maker, funded the trial with an investigator-initiated research grant. The Brigham Women’s Hospital in Boston served as the central echocardiography core laboratory.

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WHAT’S NEW

in

Area Healthcare

URMC All 6 UR Medicine Hospitals Have Earned Joint Commission Gold Seal of Approval®

All six UR Medicine hospitals have earned The Joint Commission’s Gold Seal of Approval® for Hospital Accreditation by demonstrating continuous compliance with its performance standards. The Gold Seal is a symbol of quality that reflects a health care organization’s commitment to providing safe and quality patient care.

This is the first time multiple UR Medicine facilities were examined as part of the same survey, as one system, a request made by the University of Rochester Medical Center to The Joint Commission to better compare quality and safety across its Upstate New York health care network. UR Medicine includes Strong Memorial, Highland, F.F. Thompson, Noyes Memorial, St. James, and Jones Memorial hospitals. All participated but St. James, which was surveyed in 2018. It will join the system survey process in 2022.

The Joint Commission standards focus on patient safety and quality of care, with more than 250 criteria that address such things as patient rights and education, infection control, medication management, provider verification, and the condition of the facility. The organization is the nation’s oldest and largest standards-setting and accrediting body in health care.

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“The Joint Commission’s process involves in-person, onsite inspections at each facility, with extensive examination of hundreds of measures that assess our safety and quality,” said Robert J. Panzer, MD, chief quality officer of URMC and Strong Memorial Hospital. “That rigorous process provides us with an independent evaluation that is respected across the health care industry.”

Requesting that all UR Medicine hospitals be evaluated on the same schedule afforded an opportunity to see, through the lens of Joint Commission standards, how our hospitals compare to one another and how working together has improved safety and quality, said Bilal Ahmed, MD, chief medical officer for Noyes and St. James and associate medical director for Highland.

Affiliations over the past five years – Noyes and Jones in 2015, and most recently St. James in 2018 – have resulted in all six UR Medicine affiliates being able to further improve quality and patient safety by sharing and employing best practices, such as approaches to high-level disinfection for infection prevention, while providing their communities a wider range of services that in the past smaller hospitals could not accomplish alone.

CATHOLIC Jim Millard Rejoins Catholic Health to Support COVID-19 Incident Command

Former President & CEO of Kenmore Mercy Hospital Coming Out of Retirement Jim Millard, former President & CEO of Kenmore Mercy Hospital, is coming out of retirement to rejoin Catholic Health to support the health system’s COVID-19 initiatives. He will serve as Executive Leader and Incident Commander of the system Staffing Center, which has been established in response to the COVID-19 crisis.

Millard, who retired in 2018, was at the helm as Kenmore Mercy was increasingly recognized for its innovative approach, excellent safety profile and exceptional quality. Prior to that, he served as President & CEO of St. Joseph Hospital and spearheaded the fight to save the hospital from closure, as well as led efforts to support its consolidation into Sisters of Charity Hospital in 2008. He was instrumental in bringing together associates, physicians and the entire community to advocate for the hospital, which is now in the process of being transformed into a COVID-19 treatment facility.

“Jim’s connection to Catholic Health and his love of community run deep, so he is a natural fit for this new role,” said Mark Sullivan, President & CEO, Catholic Health. “His knowledge of our system and expertise will be invaluable as we diligently work to address this public health crisis.”

Millard will be responsible for the overall leadership and strategy of the Staffing Command Center, working directly with ministry leadership to assess, project, and implement changing staffing needs for all facilities and disciplines. He will also lead the core team who will ensure each location is properly, effectively, and expeditiously staffed as the COVID-19 pandemic places fluctuating demands on the system as a whole.

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