minnesota physician august 2011

Around the country, fewer physicians are graduat-ing from medical schools with an interest inprimary care practice. This trend occurs in the

setting of an aging baby boomer population, an increasein the number of individuals with chronic disease, andan influx of newer, more complex medication regimensfor common chronic illnesses such as dia-betes. In addition, studies have documentedthat physician satisfaction in primary careis decreasing.

The medical home primary-care re-design has the potential to help primarycare physicians work at the top of their skilllevel and transfer non-physician work toappropriate levels of support staff. Thiswork redistribution is important not onlyfor preventing physician burnout but also

MEDICAL HOMES to page 10

PRSRTSTDU.S.POSTAGE

PAIDDetriotLakes,MNPermitNo.2655

Volume XXV, No. 5

August 2011

Health careadministrationRecognizing outstandingachievement

Every seven years, MinnesotaPhysician recognizes healthcare administrators who have

exhibited exceptional leadership andenhanced the effectiveness of healthcare delivery in their practices. As inthe past, we solicited nominationsfrom their peers and the MinnesotaMedical Group Management Asso-ciation. Among the guidelines forconsideration were how the individ-ual’s work contributed to the organi-zation’s growth; dedication toimproving health care delivery; andparticipation in professional associa-tion activities. (We did not includephysician administrators.)

Many health care administratorsclearly are doing excellent work intheir organizations and communi-ties, and we were unable to includeall of those who were nominated forthis feature. The 23 administratorsprofiled here represent a cross-sec-tion of the excellent work being donethroughout the state in a range ofadministrative positions and types ofhealth care organizations—fromsmall, independent clinics to hospi-tals, clinic networks, and large

ADMINISTRATION to page 20

The Independent Medical Business Newspaper

MedicalhomesEasing the burdenof primary care

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MEDICUS 7

INTERVIEW 8

CARDIOLOGYAll heart 12By Daniel J. Garry, MD, PhD

PROFESSIONAL UPDATE:NEUROLOGYDiagnosingAlzheimer’s disease 16By David S. Knopman, MD

PROFESSIONAL UPDATE:NEUROLOGYNormal pressurehydrocephalus 26By Charles R. Watts, MD, PhD,and Edward G. Hames III,MD, PhD

MENTAL HEALTHFirst-episode psychosis 28By Claudia Campo-Soria

HOSPITALSBlood transfusionpractices 32By Seymour Handler, MD

DEPARTMENTS

C O N T E N T S AUGUST 2011 Volume XXV, No. 5

AUGUST 2011 MINNESOTA PHYSICIAN 3

Minnesota Physician is published once a month by Minnesota Physician Publishing, Inc. Ouraddress is 2812 East 26th Street, Minneapolis, MN 55406; phone (612) 728-8600; fax (612) 728-8601;email [email protected]. We welcome the submission of manuscripts and letters for possible pub-lication. All views and opinions expressed by authors of published articles are solely those of theauthors and do not necessarily represent or express the views of Minnesota PhysicianPublishing, Inc., or this publication. The contents herein are believed accurate but arenot intended to replace legal, tax, business, or other professional advice and counsel. Nopart of this publication may be reprinted or reproduced without written permission ofthe publisher. Annual subscriptions (12 issues) are $48.00. Individual issues are $5.00.

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TheIndependentMedicalBusinessNewspaper

Medical homes 1Easing the burden of primary careBy Mary Sue Beran, MD, MPH; Elizabeth A.Kind, MS, RN; Cheryl E. Craft, RN;and Jinnet B. Fowles, PhD

Health care administration 1Recognizing outstanding achievement

Recognizing health careadministrators 20

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MINNESOTA HEALTH CARE ROUNDTABLEMINNESOTA HEALTH CARE ROUNDTABLE

Background and focus:Created as part of nation-al health care reform,accountable care organi-zations (ACOs) are nowpart of every health carepolicy discussion. Asdefined by the 111thCongress, ACOs areorganizations that includephysicians, hospitals, andother health care organi-zations with the legalstructure to receive anddistribute payments to par-ticipating physicians andhospitals to provide carecoordination, invest ininfrastructure and redesigncare processes, andreward high-quality andefficient services.

Exactly what this meansis unclear, and a confusing

array of levels and qualifications for ACOs has been proposed. With2012 as a start date for Medicare reimbursement through ACOs,Congress is developing firm definitions at this time. Some say ACOsturn physicians into insurance companies; others say they are a wayfor physicians to take a leadership role in fixing a broken system. Ashealth care organizations race to join, create, or redefine themselvesas ACOs, they all face more questions than answers.

Objectives: We will review the history, goals, and rationale behindthe ACO model. We will review the latest federal guidelines definingwhat an ACO can be. We will discuss how the ACO will affect healthinsurance companies, employers, and the pharmaceutical industry.We will illustrate what must not be allowed to happen if the modelis expected to succeed. We will examine who decides if ACOs aresuccessful and how those decisions will be made. We will explore whyso many people, representing very different perspectives on healthcare, are opposed to the idea and what can be done for it to achieveits best potential.

T H I R T Y - S I X T H S E S S I O N

Please send me tickets at $95.00 per ticket. Mail orders to MinnesotaPhysician Publishing, 2812 East 26th Street, Minneapolis, MN 55406.Tickets may also be ordered by phone (612) 728-8600 or fax (612) 728-8601.

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4 MINNESOTA PHYSICIAN AUGUST 2011

State Ranks 32ndIn Obesity ReportMinnesota ranks as the 32ndmost obese state in the country,according to an annual reporton obesity in the United States.“F as in Fat: How Obesity

Threatens America’s Future2010” was released by Trustfor America’s Health (TFAH)and the Robert Wood JohnsonFoundation. It found that adultobesity rates increased in 28states last year, includingMinnesota, with obesity ratesdropping in only the Districtof Columbia. Officials say theongoing obesity epidemic alsohas troubling racial, regional,and income disparities. Forexample, 10 out of the 11 stateswith the highest obesity rateswere in the South, with Miss-issippi having the highest ratesfor all adults (33.8 percent) forthe sixth year in a row.“Obesity is one of the

biggest public health challengesthe country has ever faced, andtroubling disparities exist basedon race, ethnicity, region, andincome,” said Jeffrey Levi, PhD,

executive director of TFAH.“This report shows that thecountry has taken bold steps toaddress the obesity crisis inrecent years, but the nation'sresponse has yet to fully matchthe magnitude of the problem.Millions of Americans still facebarriers—like the high cost ofhealthy foods and lack of accessto safe places to be physicallyactive—that make healthychoices challenging.”The report says Minnesota

could do more to address theobesity epidemic by takingsteps such as setting nutritionalstandards for school meals orfor food sold in schools throughvending machines. The statealso lacks requirements forbody mass index (BMI) screen-ings of children and adolescentsor other forms of weight-relatedassessments in schools.The report also credits

Minnesota with passing “Com-plete Streets” legislation, whichaims to encourage more healthyactivities by promoting safeaccess to streets for pedestrians,bicyclists, and transit riders.

Minnesota HMOsSee Record ProfitsDespite a troubled economyand rising health care costs,HMOs in Minnesota saw theirmost profitable year ever in2010, a new report from AllanBaumgarten shows.The record profits were a

result of strong margins onboth government and privateplans, the report says. In addi-tion, health plan enrollmentgrew for the second consecutiveyear.The new report, part of the

twice-yearly analysis on hospi-tals and health plans in Minne-sota provided by Baumgarten,focuses on HMO plans inMinnesota, and finds thatHMOs and county Medicaidplans in Minnesota had a netincome of $264 million, or 3.6percent of operating revenues of$7.3 billion. The report found anet income from operations of$194 million plus investmentincome of $69.8 million.Baumgarten notes that in thepast 15 years, HMOs inMinnesota had posted a 3 per-

cent margin only once.The data show the health

insurance companies overallhad strong results. Blue Crossand Blue Shield of Minnesotahad a net income after taxes of$100 million, and its Blue Plusplan had a profit margin of6.9 percent in 2010. MedicaInsurance company had a netincome of $44 million. AndHealthPartners’ health plansshowed a 3.7 percent marginfor 2010.As in past years, health

plans showed good profits onstate government plans, thereport says. “In 2010, state pub-lic programs (Medical Assis-tance and MinnesotaCare arethe largest) accounted for about46 percent of revenues but 78percent of health plan profits,”the report says. “On averageHMOs collected $77 more inpremiums from the state permember per month than theypaid out in medical expenses.Losses on MinnesotaCare offsetpart of that profit.”These findings are likely to

add to the debate on whetherMinnesota should regulate pub-

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lic HMOs more closely sincethey are funded by the state butrun by private health insurancecompanies. Last year, legisla-tors debated the idea of requir-ing more public accounting ofHMO finances, and Gov. MarkDayton took several steps toaddress the perception that pri-vate HMOs were profiting fromadministering state plans at atime when the governmentfaced a budget crisis. One ofthose steps was a one-year dealthat will require health plans togive back to the state any prof-its above 1 percent from publichealth plans in 2011.The report says that

although enrollment in employ-er-based HMOs continues todecline, overall enrollment inHMOs increased, driven largelyby growth in Medicare andMedicaid plans.The report also finds that

health premiums in Minnesotaare growing faster than medicalclaims, inflation, and the over-all economy. The average pre-mium increase for HMOemployer-based plans was 7.6percent in 2010, which is downfrom 9.5 percent in 2009 and8.6 percent in 2008. Medicalexpenses increased in 2010 by4 percent.

DHS Website toReport on QualityMeasurementsThe Minnesota Department ofHuman Services (DHS) haslaunched a website that givesthe public easy access to meas-urements of the agency’s per-formance in priority areas suchas home health care, access toinsurance, and effective use ofhospital services.The DHS “dashboard” is

designed to be a user-friendlytool that will show DHS goalsand how well the agency isdoing in meeting those goals,officials say. The effort is oneof several launched after Gov.Mark Dayton called for addi-tional steps to make govern-ment services transparent andaccountable.“The Department of

Human Services is committedto giving Minnesotans the best

possible value for their publicdollars,” says DHS Commiss-ioner Lucinda Jesson. “Thedashboard is one easy way forMinnesotans to check on bothour priorities and ourprogress.”Officials say that over the

past six months, the agency hasbegun to compile data andmark goals for areas of majorimportance in its different serv-ice areas. Depending on themeasure, goals are set annually,quarterly, or by specific dates.More information is avail-

able at the dashboard website,dashboard.dhs.state.mn.us.

MN Report FindsDisparities Persistin Quality of CareA report from MN CommunityMeasurement finds that dispar-ities in health care have nar-rowed in Minnesota but remaina problem.The new report, produced

in collaboration with theMinnesota Department ofHuman Services, looks at thequality of care provided to peo-ple in public plans comparedwith people with employer-based insurance. It finds that innine of 12 areas of measure-ment, health care quality scoresare lower for people with publicprogram coverage versus thosewith private coverage.“Although the report shows

that there has been some nar-rowing of disparities in qualityof care, serious gaps stillremain,” says Human ServicesCommissioner Lucinda Jesson.“Reports like this are vital bothfor helping us focus on wherewe need to improve as well asfor helping the public keep usaccountable for that improve-ment. As we move forward withour payment and delivery sys-tem reforms, tracking improve-ment in disparities reductionwill be an area we keep oureye on.”

CAPSULES to page 6

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Beacon ProgramTracks FluVaccination EffortsA project designed to encouragepeople to get vaccinated forinfluenza and to improve flushot reporting in southeasternMinnesota was successful, offi-cials with Mayo Clinic say.The Beacon Program in

southeast Minnesota is one of 17Beacon initiatives nationwide.Created by the U.S. Departmentof Health and Human Servicesto better use information tech-nology in health care delivery,the Beacon Program is run inMinnesota by Mayo Clinic,Winona Health Systems, andOlmsted Medical Center.The influenza program

targeted people with type 2diabetes and children with asth-ma. The Beacon Program sentletters to people within thosegroups stressing the importanceof getting vaccinated for influ-enza and asking recipients toreport where they had beenvaccinated.

The study found that whilemore than half of the letterrecipients had gotten flu shotsprior to the letter, an additional50 people were vaccinated afterreceiving the letter.“It was important that we

were able to get some of our tar-geted population vaccinatedthrough our proactive lettereffort,” says Lacey Hart, pro-gram director of SE MN BeaconCommunity. “But even morevaluable for our group was therealization that there were somereal gaps in who was actuallyreporting immunization data tothe Minnesota ImmunizationInformation Connection’s data-base.”Officials say next plans are

to assess reporting practices ofvarious immunization providersand focus on educating andcommunicating with them.

Allina, Life TimeAnnounce PartnershipTo Promote FitnessAllina Hospitals and Clinics andLife Time Fitness have created a

new partnership that will pro-mote wellness, health educa-tion, and fitness in Minnesota.The new initiative was

announced by top executives ofthe two groups at a press con-ference on June 30 at Allina’sMercy Hospital in Coon Rapids.They said the collaboration willconsist of several elements thatstress wellness and health pro-motion, both at the two compa-nies and in the communitiesthey serve.The first element will be

myHealthCheck, a Life Timehealth and wellness assessmentprogram, which will be availa-ble to Allina’s physicians, nurs-es, and other employees of thehealth system. Allina staff alsowill connect with Life Timelocations to provide medicaleducation to Life Time mem-bers and staff, and medicalservices for athletic eventssponsored by Life Time. Thetwo groups will work togetherto promote health and fitnessexpertise in health care delivery,promote health and wellnessprograms, and improve accessto preventive health and well-

ness services.Officials stressed the impor-

tance of wellness in the work-place and said the introductionof myHealthCheck will promotethe adoption of improved healthand wellness practices for Allinaemployees, supported by meas-urable health assessments andemployee incentives.“Historically, the health

care industry has focusedalmost exclusively on illness,”says Kenneth Paulus, presidentand CEO of Allina Hospitalsand Clinics. “While this hasresulted in outstanding acutecare, little focus has beenplaced upon the impact ofpreventive health and fitnessmeasures on the health of thecommunity. Core to the launchof our partnership is theintroduction of Life Time’smyHealthCheck wellness pro-gram to our employees. Thecomprehensive nature of thisprogram makes it an outstand-ing solution for Allina and webelieve the results provided toour employees will translateinto actionable behaviorchange.”

Capsules from page 5

Penny Wheeler, MD, chief clinical officer of Allina Hospitals &Clinics, and Pamela Jo Johnson, MPH, PhD, of Allina’s Center forHealthcare Innovation, have been selected to participate in a year-long executive leadership program designed to tackle racial and eth-nic disparities in health care. The Disparities Leadership Program isthe first program of its kind in the nation for health care leaders andis led by the Disparities Solutions Center at Massachusetts General

Hospital in Boston. Wheeler and Johnson aretwo of only 34 individuals from 16 health careorganizations from around the United States tobe selected for the 2011–2012 Disparities Lead-ership Program.

Jason Alexander, MD, vascular surgeonwith the Minneapolis Heart Institute at AbbottNorthwestern Hospital, has begun seeing pa-tients at the Alexandria (Minn.) Clinic. He alsoprovides care at Minneapolis Heart Institute’s

Minneapolis and Waconia locations, and at Children’s Hospital inMinneapolis. He attended the University of Minnesota MedicalSchool and completed his residency at Huntington Memorial Hospi-tal in Pasadena, Calif., followed by a fellowshipat the Vascular and Endovascular Surgery divi-sion of the University of Southern California.Alexander is a former site director of the gen-eral surgery residency program at University ofCalifornia, San Francisco–East Bay.

Joseph Petronio, MD, has joined the neu-rosurgery practice at Children’s Hospitals &Clinics of Minnesota and will lead the neuro-surgery program at Children’s–St. Paul. Petroniohas performed neurosurgery at Children’s and other Twin Citieshospitals since 1999. A graduate of Northwestern University MedicalSchool in Chicago, Petronio completed residencies at the Hospital ofthe University of Pennsylvania, Philadelphia, and Children’s Hospitalof Philadelphia. He completed a clinical fellowship in neuro-oncologyand a postdoctoral fellowship in the molecular biology of braintumors at the University of California, San Francisco. Petronio alsocompleted a fellowship in pediatric neurosurgery and an additionalpostdoctoral fellowship in the molecular biology of brain tumors atthe University of Utah. A major focus of his practice will be treatinghydrocephalus and related disorders, as well as the treatment andmanagement of epilepsy and of brain, spine, and skull tumors.

Lee W. Wattenberg, MD, has received the 2011 American Asso-ciation for Cancer Research (AACR) Award for Lifetime Achieve-ment in Cancer Prevention Research for his role in launching thefield of chemoprevention and his work to understand the potentialmechanisms of action of chemopreventive compounds. Wattenbergis a professor at the Masonic Cancer Center at the University ofMinnesota and past president of the AACR. The AACR award citedWattenberg as a “trendsetting, innovative cancer research leaderwhose early thinking and insights in cancer prevention put thespotlight on the potential of the field to save lives from cancer.”

Michael Verneris, MD, of the University of Minnesota MasonicCancer Center, has received the Relentless for a Cure Award fromthe Minnesota chapter of the Leukemia and Lymphoma Society.The award is given “in recognition of excellence in service that hasimproved the quality of life of patients and families.”

Hennepin County Medical Center (HCMC) has named JonCole, MD, as the new medical director of the Hennepin RegionalPoison Center. Cole will replace Dave Roberts, MD, who has led thecenter since 2004 but is reducing his hours in anticipation of retire-ment. The Poison Center serves as a statewide poison control centerthat Minnesota residents can call 24 hours a day. Cole, a staff physi-cian at HCMC’s emergency department, completed his emergencymedicine residency at HCMC and recently completed a two-yeartoxicology fellowship at Regions Hospital and Hennepin RegionalPoison Center.

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� What is CaringBridge?

CaringBridge provides a personal space where peo-ple can communicate to their friends and familyabout a significant health challenge. It helps thepatient and the caregiver let everybody knowwhat’s going on, but just as importantly it “bridges”back the love and support that they can have whilethey’re going through their health journey.

� Have you learned anything from your membersabout how they like to be treated by doctors,for instance, in presenting medical information?

We don’t ask a lot of specific questions of familiesabout physician relationships. However, by andlarge, patients and caregivers who use Caring-Bridge do seek out additional information andlike to be able to ask their physicians about otherinformation they’re receiving, either by their ownresearch or research from other sources.

There’s the idea of the “e-patient”; while not allof the people who use CaringBridge are technologi-cally savvy, they do have the electronic world avail-able to them. I think most patients and caregiversdo look up information on theirown and physicians should beable to speak to that.

� What have you learned aboutwhat your members do and donot want to hear from familymembers or friends?

What I’ve heard from patientsand caregivers is that the last thing they reallywant to hear is, “Everything will be all right.” Theyfeel that’s patronizing. They do want to hear love,support, and compassion. And they do want to beable to be helped, in a number of ways—whetherthrough the messages that people leave or theproactiveness of friends and family helping out, oneverything from logistics to whatever it takes, evena fundraiser.

What CaringBridge allows them to do is breakdown the barriers so that friends and familiesknow what’s happening and can have an ongoingunderstanding of what that family’s going through.

� It seems like a very focused form of socialnetworking.

It is. CaringBridge started in 1997, light yearsahead of the social networking term—even a yearbefore Google was founded!

Bringing together friends and family is not anew idea when someone’s going through an impor-tant event. What CaringBridge does is lend newtechnology, i.e., the Internet, to allow those connec-tions to happen any time, around the clock,whether you’re across the street or around theworld. So it brings together that circle of friendsand family in a very easy-to-use, accessible manner.

� How do people find out about CaringBridge?

About 60 percent find out through word of mouth,through families telling families, friends tellingfriends. The other 40 percent find out through thehealth care experience itself. We do a lot of veryproactive outreach to health care professionalsthrough conferences, to hospitals, and to otheragencies that are associated with health, like theAmerican Cancer Society.

We have a program called “RecommendCaringBridge”—you can find it at caringbridge.org.It’s targeted toward health care professionals, togive them tips not only on CaringBridge but alsoon other information to help patients and theirfamilies as they’re going through a crisis.

We also do outreach to professionals suchas social workers, chaplains, and hospitaladministrators.

� Is there a perception that CaringBridge is onlyfor terminal patients? Can you address this?

I do think that is a perception, because it is truethat for the last 14 years, CaringBridge has focused

on acute events: a diagnosis ofcancer, a car accident, a prema-ture birth. And certainly themajority of those events do notend up as end-of-life, but thereare some that do.

It is for serious conditions,though. As we continue to look atwhat CaringBridge can do and

how it can have a broader impact, we are lookingto have a wider variety of things that people can doto help amplify the kind of care that’s needed dur-ing a health experience. We’ve made progress inhaving it be much broader than that.

People use CaringBridge for many years, some-times—if it was an end-of-life event—almost as amemorial. But more often than not, it’s used as acelebration: the five-year anniversary of beingcancer-free, things like that. Even with prematurebirth—there can be lifelong complications, butmore than that there’s just the miracle of these verypremature infants. Some people have even postedpictures of when they enroll in their first day ofkindergarten—it becomes almost a kind of legacy.

� Have there been studies that provide data onthe effectiveness of services like CaringBridge inhelping patients?

We’ve commissioned some studies, not medical,double-blind studies, but ones to show how muchCaringBridge helps. A couple studies have docu-mented that well over 80 percent of the peopleusing CaringBridge feel it helps them heal, and 90percent indicated it is easy to use, saves time andemotional energy, and helps not only them but anentire network of individuals to understand the sit-uation and to have a very positive experience.

Sona MehringCaringBridge

Sona Mehring is thefounder and CEO of

CaringBridge, an onlineresource that allowspatients and familiesto create personalizedwebsites to keep others

informed aboutserious health events.Since CaringBridge wasfounded in 1997, morethan 273,000 personalsites have been created,and 1.7 billion visitshave been made to

CaringBridge websites.The Eagan-based non-profit company has67 employees and 72

volunteers.Mehring is a member

of the Minnesota Councilof Nonprofits, the

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Industry Foundation, andthe National Health

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CaringBridge: a way to connect with those who care


I N T E R V I E W

To me, a servicelike this should

be integrated intoevery care plan.

� Tell us about the relationship of this serv-ice with the health care delivery system.

To me, a service like this should be integrat-ed into every care plan. It should be pre-scribed just as much as any medicine.Physicians and their support teams shouldask, “How are you going to let others knowwhat’s going on? How are you going to gainsupport from your family and friends?”Those are important questions to ask, and aservice like CaringBridge helps provide that.It’s part of a more holistic approach.

� Data privacy is a huge concern for physi-cians. How can they participate in anorganization that makes sensitive healthcare data as public as yours does?

That is something we have not solved. WithCaringBridge, the families are providingtheir own content; it’s user–generated con-tent. So that does not fall within the HIPAAumbrella because it’s not the physician orthe staff that’s speaking about this health ormedical information.

I do know that many times patientsbring in their CaringBridge journal to let thephysician know. But it certainly isn’t replac-ing the dialogue between the physician andthat patient.

� Do you ever wish there was a day wherea CaringBridge member is talking to theircommunity and the physician weighs in

and says, “Here’s what I think?” Thatdoesn’t happen now, right?

No, it is not that type of forum. That wouldbe a different kind of service, and one thatwould be under the HIPAA guidelines. But Ithink using CaringBridge as a portal or aconduit into other important health systems,everything from patient medical records tovirtual visits with their doctor—that is a veryreal and tangible future that CaringBridgecould support.

� What else do you see in the future forCaringBridge?

As social networks have exploded in the lastthree to four years, the opportunity to reallybring caring as a part of the social networkis something we want to do, and go beyondthat significant health challenge. It shouldbe broader than that, and there should betimes in life where staying connected withyour friends and families for other caringreasons is a great option.

We’d like to broaden the continuum ofwhere CaringBridge-type services can beused, as well as continue to deepen what wedo today. So a care calendar where peoplecould do some type of scheduling is a possi-bility. Maybe more ways to have a privatejournal or a private conversation—we’relooking at things like that to deepen the cur-rent CaringBridge experiences.

� What advice can you give physiciansto share with patients with significanthealth challenges?

Empower patients by letting them knowabout CaringBridge. Shrinking away fromthe informed patient is not the way to go.You need to empower patients and honorthat they feel empowered, because they arethe ones in control of their treatment andtheir experience.

� Do you encounter physicians who say,“Oh, you heard this on the Internet. ...”Do they put up walls about that?

I haven’t experienced this personally; mostof the physicians I come across are very pos-itive towards this. But at various confer-ences and seminars there is a backlasharound the empowered patient. Because,you know, you can Google anything, andsometimes it’s false information.

So there is that image of doctors whodon’t want their patients to go out and findout information on their own—they want toprovide that, because it’s more credible.They’re coming from their own knowledgebase, versus opening up to another knowl-edge base. So they’re losing a lot of control.And I can relate to that, but again, I think anempowered patient is going to be a morepositive, more active patient.


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for promoting physician andpatient satisfaction.

Previous studies havereported mixed physician viewson implementing the medicalhome model in their clinic. Ourresearch group sought to under-stand the physician perspectiveat an exploratory level to gain

insights into how the medicalhome model affects physicianpractice on a personal, dailylevel. Our main hypothesis wasthat physicians would reportincreased satisfaction with theirpractice after implementationof the medical home. The sec-ondary hypothesis was that theincrease in physician satisfac-

tion would be primarily relatedto working with the chronic dis-ease nurses in caring for med-ically complex patients overother aspects of the care re-design.

Participants and methods

In 2007, one internal medicineclinic that is part of a large,multispecialty group practice

within Park Nicollet HealthServices reorganized as amedical home. The medicalhome pilot was implemented inphases, with key componentstaken from National Committeefor Quality Assurance and theMinnesota State Department ofHealth criteria for medicalhome certification. At the time

of our research study, the clinichad 17 physicians and onenurse practitioner and sawapproximately 17,000 patientseach year. Key components ofthe medical home that shapedreorganization of the clinicwere patient-centered care with24-hour access and communica-tion, patient tracking and dis-

ease registry management, caremanagement and coordination,patient self-management sup-port, electronic prescribing,test and referral tracking, andperformance reporting andquality improvement. Becausethe pilot clinic was part of alarge multispecialty group,some components of the med-ical home, such as 24-houraccess and communication andelectronic prescribing, werealready part of the daily work-ings of the clinic.

Among the practicalchanges in implementing themedical home at the clinic werea restructuring of the physi-cians’ and nurses’ work spacesinto co-located care teams con-sisting of four physicians, onechronic disease nurse, onedepartment assistant, one med-ical information nurse, and twoor three medical assistants. Acare coordinator worked withall four of the clinic teams toidentify and assist with barriersto care such as transportationissues and mental health prob-lems. The goal for each teamwas to know and care for a setpopulation of patients. Prior torestructuring into teams, theclinic had functioned as onelarge group.

In addition to the restruc-turing, chronic disease nurseswere trained to assist with carefor the medically complexpatients for each team. Thesenurses received individualizedtraining in chronic disease

management and motivationalinterviewing. Patients arereferred to the chronic diseasenurses at the discretion of thephysician, typically at the timeof a physician visit. Eligiblepatients are those with hyper-tension, type 2 diabetes, conges-tive heart failure, or coronaryartery disease. The nurses alsoassist physicians with manage-ment of patient registries. Theseregistries focus on type 2 dia-betes, hypertension, and coro-nary artery disease and aredesigned to track performancemeasures such as the propor-tion of a physician’s patientswho meet blood pressure orhemoglobin A1c goals.

Interview script. We askedphysicians questions about thekey components of the medicalhome model as well as aboutwork culture and job satisfac-tion. The interview script wasdesigned to be interactive, withopen-ended questions and vari-ation in discussions based onphysician responses.

Data collection. BetweenOctober 2009 and April 2010,we contacted all 17 physiciansin the department by email andinvited them to be interviewed.Three of the 17 physicians didnot respond to our request afterthree attempts, and thereforewere not interviewed. Two inter-viewers from a team of threeexperienced interviewers con-ducted hour-long, in-personinterviews with 14 physicians.Interviews were taped, tran-scribed, and imported into aqualitative analysis softwaredatabase.

Results

Definition. When we askedphysicians to define the medicalhome, we found that manybelieved the term was vagueand difficult to define. They hada much easier time defininggood primary care; a recurringtheme was that the medicalhome design facilitated bettercare. As the following interviewexcerpts illustrate, the term“integrated care” resonated withphysicians more than the term“medical home.”

“Maybe this is vaguebecause doctors think thatthe medical home is reallynot a new concept but the

Medical homes from cover


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Physicians reportedincreased satisfactionwith their practices afterimplementation of themedical home model.

fulfilling of their goal of goodprimary care. They now havethe resources to help educatepatients, manage chronic dis-ease … the support structure isin place for them to feel likethey can deliver good primarycare. They are satisfied becausethey feel like they are in a sys-tem that allows them to do thekind of good primary care theywant to do.”

“Medical home, the way Isee it, is pretty much anextension of the care wegive here from our office …I think of the medical homemodel as extensions of our-selves as providers to helpincorporate and integratepatient care a little bit bet-ter where we are able tocommunicate with patientsoutside of the office. I thinkit provides better integratedcare, especially patientswho have chronic condi-tions, like diabetes.”Access. Physicians com-

mented on how patients couldeasily reach the chronic carenurse if needed.

“She [chronic diseasenurse] has a direct phoneline with voicemail so mypatients with chronic condi-tions can call in and leave avoicemail message … andthey know who they’re talk-ing to. I can’t say enoughhow important that is.”Care coordination. The

most significant theme in thephysician interviews was theteam approach to managingpatients with complex medicalproblems. Physicians defined“team” as each clinician with asupport staff comprising achronic disease nurse, depart-ment assistant, medical infor-mation nurse, and medicalassistant. They described havingmore resources to manage med-ically complex patients and feltas if the burden of caring forthese complex patients was dis-tributed throughout the teamrather than resting solely ontheir shoulders.

“In internal medicine andprimary care in general,we’re just overwhelmedwith stuff we have to dowith meds and forms anddictations, and so as much

as that can be taken away, Ifeel more energized.”“I feel like I’m not out therealone.”“From a physician perspec-tive, for me it means work-ing as a team; it means nolonger having patients comein for 30-minute visits everythree months. It means tak-ing care of them all of thetime and doing that in waysthat aren’t necessarily justabout the clinic visit. Itmeans having some extrastaff to help do things thatthey’re better at than I’mbetter at; it means commu-nicating with patients onthe phone and through elec-tronic means rather thandriving to the clinic just tohave a phone conversation.I think it’s a whole new wayof delivering health care.”Physicians felt that the

team approach allowed them toprovide more individualizedcare and higher quality care forpatients with chronic disease.This resulted in increased satis-faction for physicians.

“… I think right now … I’mgiving better care. I can’thonestly say it’s making meso efficient I can see morepeople in a day. I think it’sthat the people I see, they’regetting better care.”“I would say medical homeis a model of a care teamthat’s working for thepatient with a physician tointensify treatment and todo checks that wouldn’totherwise happen necessar-ily in a busy doctor’s prac-tice. To make sure that yourdiabetes or your chronicdisease of any sort is goingin the right track and youdon’t get lost and that youhave more people and moreresources to help you.”Physicians repeatedly men-

tioned physical proximity asimportant to team communica-tion and functioning. Theydescribed the importance ofhaving the chronic diseasenurse and other support staff inclose proximity as a way tofacilitate informal communica-tion about patients. Close prox-imity enhanced trust betweenthe physician and chronic care

nurse—in effect, encouragingthem to see the nurse as anextension of their care, ratherthan as a referral outside theircare.

Physician satisfaction.Overall, physicians describedhigher levels of satisfaction withtheir practice compared tobefore the medical home wasimplemented. Some describedimproved efficiency; many,however, felt that while theywere not shortening their workday, they were able to providehigher quality care. Manyphysicians described less paper-work and feeling less alone in

caring for medically complexpatients. They felt able to moreoften work at the top of theirskill level because they hadadditional resources for non-physician work.

“I really rely on these peo-ple. I hand things off. Thereason I got excited aboutthis project was with ourformer leader talking aboutthe burnout in internalmedicine and primary care,and how we have too muchon the plate of the primarycare doctor and the default


MEDICAL HOMES to page 38

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Main 320.252.4414

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GPMLAW.COM

Gray Plant Mooty Health Law GroupWe’re on a mission to help our clients fulfill theirs.

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Agile, practical, and collab-orative, the Gray Plant Mooty Health Law Group builds high-value partnerships with clients that empower them to pursue their missions with confidence. We can do the same for you.

C A R D I O L O G Y

It’s an exciting time for thefield of cardiovascular medi-cine. Emerging technologies

that include genomics, cell ther-apy, and new devices fuel inno-vation and continue to revolu-tionize the way we treat and pre-vent cardiovascular disease, bothfor today and in the future.

Research provides a plat-form to launch these new dis-coveries and technologiestoward treatment of patientswith heart disease. Despite ouradvances, cardiovascular diseaseremains the No. 1 cause of deathin the United States, and wespend more than $260 billiontreating heart and heart-relatedconditions each year.

In the next decade, I believecardiology research will centeron three main areas:• Improved technologies and

devices• Cellular and molecular treat-

ments• Personalized medicine

Device advances

Devices will continue to berefined (i.e., miniaturized) andimproved. An example of device

refinement is the ventricular-assist devices that supportpatients with end-stage heartdisease, which have been re-duced in size compared to thefirst generation of pumps. In thefuture, I believe we will see thesedevices become entirely internal-ized without an external drive-line. The internalization of thesepumps will be possible with theimproved battery technology.These advances in battery tech-nology will allow the left ventric-ular devices to be managedmore like pacemakers.

Cardiovascular surgical pro-cedures will continue to evolve,with more emphasis on develop-ing minimally invasive tech-niques for procedures that oncerequired open heart surgery. Forexample, at the University ofMinnesota, cardiac surgeon Ken

Liao has pioneered the use ofrobotic surgical heart proce-dures. This robotic surgical tech-nology is beneficial in olderpatients that have advanced dis-ease, and results in shorter hos-pital stays. An increasing num-ber of surgical procedures willutilize catheter-based strategiesin valvular replacements andseptal defect closures.

Imaging technology

Imaging will continue to playa role in how we care for cardio-vascular disease. Facilities suchas the University’s Center forMagnetic Resonance Researchwill become even more vital indeveloping high-resolutionimages of the heart and vessels,which will guide both physiciansand researchers in developingnew regenerative therapies in

patients with heart failure.

Pediatric heart defectpatients become adults

Congenital heart disease re-mains the most common birthdefect in live born babies today.Due to the surgical advancespioneered by Lillehei, Varco, andothers at the University of Minn-esota and elsewhere in treatingcongenital heart defects, manyof our youngest patients are nowroutinely living into adulthood. Ibelieve that the future willinclude more clinics like ourAdult Congenital Heart DiseaseClinic, which provides compre-hensive patient care that willinclude molecular analysis andwhole genome sequencing forour patients.

We don’t yet know whetherthese adult patients with con-genital heart disease will faceother heart-related issues as theyage. Research in survivorshipwill become critical as we con-tinue to care for these pioneer-ing patients who helped us learnmore about childhood heartdefects.

All heartMinnesota builds on its legacy

of cardiac research

By Daniel J. Garry, MD, PhD


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MINNESOTA PHYSICIAN

Indications and Usage

PRADAXA (dabigatran etexilate mesylate) capsules is indicated to reduce the risk of stroke and systemic embolism in patients with non-valvular atrial fibrillation.

IMPORTANT SAFETY INFORMATION ABOUT PRADAXACONTRAINDICATIONS

PRADAXA is contraindicated in patients with active pathological bleeding and patients with a known serious hypersensitivity reaction (e.g., anaphylactic reaction or anaphylactic shock) to PRADAXA.

WARNINGS AND PRECAUTIONS

Risk of Bleeding

PRADAXA increases the risk of bleeding and can cause significant and, sometimes, fatal bleeding.

Risk factors for bleeding include:

— Medications that increase the risk of bleeding in general (e.g., anti-platelet agents, heparin, fibrinolytic therapy, and chronic use of NSAIDs)

—Labor and delivery

Promptly evaluate any signs or symptoms of blood loss, such as a drop in hemoglobin and/or hematocrit or hypotension. Discontinue PRADAXA in patients with active pathological bleeding.

Temporary Discontinuation of PRADAXA

Discontinuing PRADAXA for active bleeding, elective surgery, or invasive procedures places patients at an increased risk of stroke. Lapses in therapy should be avoided, and if PRADAXA must be temporarily discontinued for any reason, therapy should be restarted as soon as possible.

Effect of P-gp Inducers and Inhibitors on

PRADAXA Exposure

The concomitant use of PRADAXA with P-gp inducers (e.g., rifampin) reduces dabigatran exposure and should generally be avoided. P-gp inhibitors ketoconazole, verapamil, amiodarone, quinidine, and clarithromycin, do not require dose adjustments. These results should not be extrapolated to other P-gp inhibitors.

ADVERSE REACTIONS

In the pivotal trial comparing PRADAXA to warfarin, the most frequent adverse reactions leading to discontinuation of PRADAXA were bleeding and gastrointestinal (GI) events. PRADAXA 150 mg resulted in a higher rate of major GI bleeds and any GI bleeds compared to warfarin. In patients ≥75 years of age, the risk of major bleeding may be greater with PRADAXA than with warfarin. Patients on PRADAXA 150 mg had an increased incidence of GI adverse reactions. These were commonly dyspepsia (including abdominal pain upper, abdominal pain, abdominal discomfort, and epigastric discomfort) and gastritis-like symptoms (including GERD, esophagitis, erosive gastritis, gastric hemorrhage, hemorrhagic gastritis, hemorrhagic erosive gastritis, and GI ulcer). Drug hypersensitivity reactions were reported in <0.1% of patients receiving PRADAXA.

Other Measures Evaluated

The risk of myocardial infarction was numerically greater in patients who received PRADAXA 150 mg than in those who received warfarin.

RISK REDUCEDStroke in non-valvular AF

PRADAXA® is a registered trademark of Boehringer Ingelheim Pharma GmbH & Co. KG and used under license.

COPYRIGHT © 2011 BOEHRINGER INGELHEIM PHARMACEUTICALS, INC. ALL RIGHTS RESERVED. PRINTED IN U.S.A. [07/11] PX108201PROF

For additional information, visit www.PRADAXAPRO.com

PRADAXA 150 MG TWICE DAILY—REDUCES THE RISK

OF STROKE IN NON-VALVULAR ATRIAL FIBRILLATION (AF)1

References:1. Pradaxa [prescribing information]. Ridgefield, CT: Boehringer Ingelheim Pharmaceuticals, Inc.; March 2011. 2. Wann LS, Curtis AB, Ellenbogen KA, et al, writing on behalf of the 2006 ACC/AHA/ESC Guidelines for the Management of Patients With Atrial Fibrillation Writing Committee. 2011 ACCF/AHA/HRS focused update on the management of patients with atrial fibrillation (update on dabigatran): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2011;57:1330–1337.

All images are patient portrayals.

Please see brief summary of full Prescribing Information on the adjacent page.

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MINNESOTA PHYSICIAN

PRADAXA® (dabigatran etexilate mesylate) capsules for oral use

BRIEF SUMMARY OF PRESCRIBING INFORMATION

Please see package insert for full Prescribing Information.

INDICATIONS AND USAGEPRADAXA is indicated to reduce the risk of stroke and systemic embolism in patients with non-valvular atrial fibrillation.

CONTRAINDICATIONSPRADAXA is contraindicated in patients with:

Active pathological bleeding [see Warnings and Precautions and Adverse Reactions]. History of a serious hypersensitivity reaction to PRADAXA (e.g., anaphylactic reaction or anaphylactic shock) [see Adverse Reactions].

WARNINGS AND PRECAUTIONSRisk of Bleeding: PRADAXA increases the risk of bleeding and can cause significant and, sometimes, fatal bleeding. Risk factors for bleeding include the use of drugs that increase the risk of bleeding in general (e.g., anti-platelet agents, heparin, fibrinolytic therapy, and chronic use of NSAIDs) and labor and delivery. Promptly evaluate any signs or symptoms of blood loss (e.g., a drop in hemoglobin and/or hematocrit or hypotension). Discontinue PRADAXA in patients with active pathological bleeding. In the RE-LY (Randomized Evaluation of Long-term Anticoagulant Therapy) study, a life-threatening bleed (bleeding that met one or more of the following criteria: fatal, symptomatic intracranial, reduction in hemoglobin of at least 5 grams per deciliter, transfusion of at least 4 units of blood, associated with hypotension requiring the use of intravenous inotropic agents, or necessitating surgical intervention) occurred at an annualized rate of 1.5% and 1.8% for PRADAXA 150 mg and warfarin, respectively [see Adverse Reactions]. Temporary Discontinuation of PRADAXA: Discontinuing anticoagulants, including PRADAXA, for active bleeding, elective surgery, or invasive procedures places patients at an increased risk of stroke. Lapses in therapy should be avoided, and if anticoagulation with PRADAXA must be temporarily discontinued for any reason, therapy should be restarted as soon as possible. Effect of P-gp In-ducers and Inhibitors on Dabigatran Exposure: The concomitant use of PRADAXA with P-gp inducers (e.g., rifampin) reduces exposure to dabigatran and should gen-erally be avoided. P-gp inhibitors ketoconazole, verapamil, amiodarone, quinidine, and clarithromycin do not require dose adjustments. These results should not be extrapolated to other P-gp inhibitors.

ADVERSE REACTIONSClinical Trials Experience: The RE-LY study provided safety information on the use of two doses of PRADAXA and warfarin. The numbers of patients and their exposures are described in Table 1. Limited information is presented on the 110 mg dosing arm because this dose is not approved.Table 1 Summary of Treatment Exposure in RE-LY

PRADAXA 110 mg twice

daily

PRADAXA 150 mg twice

dailyWarfarin

Total number treated 5983 6059 5998Exposure

> 12 months 4936 4939 5193> 24 months 2387 2405 2470

Mean exposure (months) 20.5 20.3 21.3Total patient-years 10,242 10,261 10,659

Because clinical studies are conducted under widely varying conditions and over varying lengths of time, adverse reaction rates observed in the clinical studies of a drug cannot be directly compared to rates in the clinical studies of another drug and may not reflect the rates observed in practice. Drug Discontinuation in RE-LY: The rates of adverse reactions leading to treatment discontinuation were 21% for PRADAXA 150 mg and 16% for warfarin. The most frequent adverse reactions leading to discontinuation of PRADAXA were bleeding and gastrointestinal events (i.e., dyspepsia, nausea, upper abdominal pain, gastrointestinal hemorrhage, and diarrhea). Bleeding [see Warnings and Precautions]: Table 2 shows the number of patients experiencing serious bleeding during the treatment period in the RE-LY study, with the bleeding rate per 100 patient-years (%). Major bleeds fulfilled one or more of the following criteria: bleeding associated with a reduction in hemoglobin of at least 2 grams per deciliter or leading to a transfusion of at least 2 units of blood, or symptomatic bleeding in a critical area or organ (intraocular, intracranial, intraspinal or intramuscular with compartment syndrome, retroperitoneal bleeding, intra-articular bleeding or pericardial bleeding). A life-threatening bleed met one or more of the following criteria: fatal, symptomatic intracranial bleed, reduction in hemoglobin of at least 5 grams per deciliter, transfusion of at least 4 units of blood, associated with hypotension requiring the use of intravenous inotropic agents, or necessitating surgical intervention. Intracranial hemorrhage included intracerebral (hemorrhagic stroke), subarachnoid, and subdural bleeds. Table 2 Bleeding Events* (per 100 Patient-Years)

PRADAXA 150 mg twice daily

N (%)

Warfarin N (%)

Hazard Ratio (95% CI**)

Randomized patients 6076 6022Patient-years 12,033 11,794

Intracranial hemorrhage

38 (0.3) 90 (0.8) 0.41 (0.28, 0.60)

(Table 2, Cont’d.) PRADAXA 150 mg twice daily

N (%)

Warfarin N (%)

Hazard Ratio (95% CI**)

Life-threatening bleed

179 (1.5) 218 (1.9) 0.80 (0.66, 0.98)

Major bleed 399 (3.3) 421 (3.6) 0.93 (0.81, 1.07)Any bleed 1993 (16.6) 2166 (18.4) 0.91 (0.85, 0.96)

*Patients contributed multiple events and events were counted in multiple categories.**Confidence intervalThe risk of major bleeds was similar with PRADAXA 150 mg and warfarin across major subgroups defined by baseline characteristics, with the exception of age, where there was a trend towards a higher incidence of major bleeding on PRADAXA (hazard ratio 1.2, 95% CI: 1.0 to 1.4) for patients 75 years of age. There was a higher rate of major gastrointestinal bleeds in patients receiving PRADAXA 150 mg than in patients receiving warfarin (1.6% vs. 1.1%, respectively, with a hazard ratio vs. warfarin of 1.5, 95% CI, 1.2 to 1.9), and a higher rate of any gastrointestinal bleeds (6.1% vs. 4.0%, re-spectively). Gastrointestinal Adverse Reactions: Patients on PRADAXA 150 mg had an increased incidence of gastrointestinal adverse reactions (35% vs. 24% on warfarin). These were commonly dyspepsia (including abdominal pain upper, abdominal pain, abdominal discomfort, and epigastric discomfort) and gastritis-like symptoms (including GERD, esophagitis, erosive gastritis, gastric hemorrhage, hemorrhagic gastritis, hemorrhagic erosive gastritis, and gastrointestinal ulcer). Hypersensitiv-ity Reactions: In the RE-LY study, drug hypersensitivity (including urticaria, rash, and pruritus), allergic edema, anaphylactic reaction, and anaphylactic shock were reported in <0.1% of patients receiving PRADAXA. The risk of myocardial infarction was numerically greater in patients who received PRADAXA (1.5% for 150 mg dose) than in those who received warfarin (1.1%).

DRUG INTERACTIONSThe concomitant use of PRADAXA with P-gp inducers (e.g., rifampin) reduces exposure to dabigatran and should generally be avoided. P-gp inhibitors ketocon-azole, verapamil, amiodarone, quinidine, and clarithromycin do not require dose adjustments. These results should not be extrapolated to other P-gp inhibitors.

USE IN SPECIFIC POPULATIONSPregnancy: Pregnancy Category C: There are no adequate and well-controlled stud-ies in pregnant women. Dabigatran has been shown to decrease the number of implantations when male and female rats were treated at a dosage of 70 mg/kg (about 2.6 to 3.0 times the human exposure at maximum recommended human dose [MRHD] of 300 mg/day based on area under the curve [AUC] comparisons) prior to mating and up to implantation (gestation Day 6). Treatment of pregnant rats after implantation with dabigatran at the same dose increased the number of dead offspring and caused excess vaginal/uterine bleeding close to parturition. Although dabigatran increased the incidence of delayed or irregular ossification of fetal skull bones and vertebrae in the rat, it did not induce major malformations in rats or rab-bits. Labor and Delivery: Safety and effectiveness of PRADAXA during labor and delivery have not been studied in clinical trials. Consider the risks of bleeding and of stroke in using PRADAXA in this setting [see Warnings and Precautions]. Death of offspring and mother rats during labor in association with uterine bleeding occurred during treatment of pregnant rats from implantation (gestation Day 7) to weaning (lactation Day 21) with dabigatran at a dose of 70 mg/kg (about 2.6 times the human exposure at MRHD of 300 mg/day based on AUC comparisons). Nursing Mothers: It is not known whether dabigatran is excreted in human milk. Because many drugs are excreted in human milk, caution should be exercised when PRADAXA is admin-istered to a nursing woman. Pediatric Use: Safety and effectiveness of PRADAXA in pediatric patients has not been established. Geriatric Use: Of the total number of patients in the RE-LY study, 82% were 65 and over, while 40% were 75 and over. The risk of stroke and bleeding increases with age, but the risk-benefit profile is favor-able in all age groups [see Warnings and Precautions and Adverse Reactions]. Renal Impairment: No dose adjustment of PRADAXA is recommended in patients with mild or moderate renal impairment. Reduce the dose of PRADAXA in patients with severe renal impairment (CrCl 15-30 mL/min). Dosing recommendations for patients with CrCl <15 mL/min or on dialysis cannot be provided.OVERDOSAGE

Accidental overdose may lead to hemorrhagic complications. There is no antidote to dabigatran etexilate or dabigatran. In the event of hemorrhagic complications, initiate appropriate clinical support, discontinue treatment with PRADAXA, and inves-tigate the source of bleeding. Dabigatran is primarily excreted in the urine; therefore, maintain adequate diuresis. Dabigatran can be dialyzed (protein binding is low), with the removal of about 60% of drug over 2 to 3 hours; however, data supporting this approach are limited. Consider surgical hemostasis or the transfusion of fresh frozen plasma or red blood cells. There is some experimental evidence to support the role of activated prothrombin complex concentrates (e.g., FEIBA), or recombinant Factor VIIa, or concentrates of coagulation factors II, IX or X; however, their usefulness in clinical settings has not been established. Consider administration of platelet con-centrates in cases where thrombocytopenia is present or long-acting antiplatelet drugs have been used. Measurement of aPTT or ECT may help guide therapy.

©Copyright 2011 Boehringer Ingelheim Pharmaceuticals, Inc.

ALL RIGHTS RESERVED

Revised: March 2011 PX-BS (3-11) PX91425PROF

Cellular andmolecular treatments

Stem cells will also have a seis-mic impact on the cardiovascu-lar field in the coming years.While the world’s first stem-celltreatment (in the form of bonemarrow transplants) occurredmore than 40 years ago at theUniversity of Minnesota, othertypes of stem cells, includingadult and induced pluripotentstem cells, are just beginning toshow their therapeutic promise.

The power of inducedpluripotent stem-cell technologylies in the ability to transform apatient’s skin cell to form a heartcell. This technology potentiallyallows us to generate an unlim-ited number of heart cells froma patient who has heart failure.Not only would this technologyallow an unlimited number ofheart cells for transplantation; italso would provide us with heartcells where drugs can be testedin the laboratory setting beforethey are given to a patient, thusminimizing the potential adverseeffects of various medications.This strategy allows us to pro-

vide personalized treatment toeach patient.

The right treatment forthe right patient

Cellular and molecular treat-ments also show potential interms of personalizing medicine.The idea that we can grow somenew heart muscle cells for a par-ticular patient by using some oftheir skin cells will become areality.

In addition, molecular treat-ments, like the “molecular BandAid” developed by the U of M’sJoe Metzger will continue to rev-olutionize heart failure thera-pies. These molecular treatmentswill be introduced into the bodyand used to unlock the heart’sability to repair itself. Whilethese technologies are still in thelaboratory, the results are prom-ising in animal model studies.

Personalized medicine willdevelop in terms of medicationsas well. Often the treatments wehave for heart disease work, but

they come with a laundry list ofside effects that are hard forpatients to deal with. Using eachpatient’s genetic information tofind a medicine that will workthe best with minimal sideeffects will become more com-monplace, as research into whatworks best for various geneticprofiles moves forward.

Getting ahead of the problem

Prevention will be a growingarea of cardiovascular disease.Instead of waiting for patients topresent with symptoms, we willbe working to reduce the riskfactors for cardiovascular dis-ease before these symptoms leadto costly and at times risky orinvasive interventions.

Personalized medicine willplay a huge role in preventionefforts. Today the RasmussenCardiovascular Disease Preven-tion Program at the Universityof Minnesota can identifypatients that have early stages ofcardiovascular disease and

implement therapies beforepatients have an adverse event(heart attack or stroke). Thisintervention not only improvesthe quality of life for ourpatients and our community, butalso results in both healthier cit-izens and the expenditure offewer health care dollars.

The Minnesota advantage

We are on the cusp of an excit-ing period in cardiovascularresearch and care. And we arelucky to be in Minnesota. Toge-ther with the next generation ofcardiovascular specialists (cardi-ologists and cardiothoracic sur-geons) who are training in ourstate, we will continue to buildon the legacy of cardiac researchand the cardiac biotechnologyindustry that our state has builtand make a palpable impact inour patients’ lives and on ourhealth care system.

Daniel J. Garry, MD, PhD, is director ofthe Lillehei Heart Institute and chief of theCardiovascular Division at the University ofMinnesota.


Heart from page 12 Personalized medicine will play ahuge role in prevention efforts.

P R O F E S S I O N A L U P D A T E : N E U R O L O G Y

As of the summer of 2011,there are no effectivetherapies that arrest or

reverse the symptoms of Alzhei-mer’s disease (AD), nor arethere any proven preventivestrategies for people at risk. Forthe clinical diagnosis of demen-tia due to AD, a practitionerarmed with a history, examina-tion, routine CT or MR scan,and some simple blood workcan do a reasonably good job.So, do practicing physiciansneed imaging or cerebrospinalfluid (CSF) biomarkers for thediagnosis of AD? At present, theanswer is no. However, in thefuture, treatments for AD willbe aimed at prevention, whenat-risk individuals are stillasymptomatic or at the veryearliest symptomatic stages.

We now believe that thepathological processes of ADhave a long lead-in phase, yearsbefore dementia occurs. There-fore, physicians will need todiagnose and treat AD in peoplewhile they are asymptomatic orhave, at most, subtle or mini-mal symptoms. Clinical diag-noses alone will be inadequate;

biomarkers of preclinical patho-physiology are needed.

Defining AD dementia

First, let’s be clear about thedistinction between AD as apathophysiology, and cognitiveimpairment (or dementia) as theclinical manifestations of thedisease. AD refers to the biologi-cal processes that lead to thecharacteristic brain pathology ofAD. In contrast, cognitiveimpairment and dementia aredescriptive terms for loss ofmental abilities from mild tosevere. Biomarkers are for de-tecting the biological changes ofAD, but only clinical acumencan establish whether or not aperson has cognitive impair-ment.

The diagnosis of acquiredcognitive impairment in middle-aged and elderly people hasundergone a major shift in thepast decade, in the direction ofincreasing confidence in mak-ing diagnoses at milder stagesof impairment. Cognitiveimpairment includes difficultieswith thinking, memory, mentalagility, and language functions.Some-times, but not always, thecognitive impairment is accom-panied by substantial alter-ations in personality, interper-sonal relationships, and behav-ior. The term dementia refers tocognitive or behavioral impair-ment that interferes with dailyfunctioning. In contrast, theterm mild cognitive impairment(MCI) is used to describe cogni-tive impairment that does not

substantially interfere withdaily functioning.

Usually, distinguishingbetween MCI and dementia isstraightforward, but sometimesin mildly affected patients, thedistinction is academic. What isnot academic is the very impor-tant identification of whether ornot a patient with cognitiveimpairment needs assistance indaily life or not. That decisionhas nothing to do with bio-markers. It has everything to dowith taking a good history andassessing the patient’s cognitivestatus objectively. That said, thefuture of AD therapeutics willundoubtedly focus on preven-tion of the cognitive symptomsof AD, and biomarkers will playa central role in that approach.

New diagnostic criteriareflect advances in AD

The diagnostic criteria fordementia due to AD were re-cently revised, as the result ofwork by three expert work-groups spearheaded by theAlzheimer’s Association and theNational Institute on Aging

DiagnosingAlzheimer’s diseaseClinical and biomarker convergence

By David S. Knopman, MD


ALZHEIMER’S to page 19

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(NIA) of the National Institutesof Health (NIH). The updatedcriteria (published in Alzhei-mer’s and Dementia, May 2011)did not make any dramaticchanges in the clinical criteriathat have been used since 1984,when the first iterationappeared. Indeed, the clinicaldiagnosis of AD dementia hasproved to be reasonably accu-rate compared to the pathologi-cal gold standard of the autop-sied brain, but advances in thepast 25 years led to the need forthe update. Then and now, thecore definition of AD demen-tia—based on information fromthe history and examination—isthat it is a dementia in whichthe onset is gradual; the symp-toms are steadily progressive,more or less; and difficultieswith learning and short-termmemory are usually the initialand most obviously debilitatingproblems.

The new criteria acknowl-edge that AD dementia has abroader spectrum of cognitivedifficulty than was understoodin 1984, but with that broaderspectrum has come the realiza-tion that identification of theAD pathophysiological processmay be difficult on clinicalgrounds alone. For example,there are a number of patients,usually with onset of theirsymptoms prior to age 70 years,whose initial symptoms areaphasic (prominent word-find-ing difficulty), visuospatial (dif-ficulties recognizing objects andfaces or understanding geo-graphical knowledge), or execu-tive (what used to be called“frontal lobe” syndrome). Eachof these syndromes may becaused by AD as well as non-ADdiseases.

The role of biomarkersin AD research, diagnosis

Biomarkers don’t add a lot ofvalue in patients with clear-cutdementia. Even in providingincreased certainty about thediagnosis of AD, positive bio-markers don’t change therapynow; nor do they clarify howfast a person will decline. Whentherapeutic options becomeavailable for mildly impairedpatients and in those who might

be at risk for AD, biomarkerswill be essential for defining theunderlying disease.

Therapeutic research in ADwill increasingly rely on bio-markers for selecting subjectsfor participation. The addedcertainty of underlying etiologyis reassuring to drug developersand federal regulators that adrug under study is targetingAD, not some non-specific tar-get. Especially in situationswhere the research subjects arevery mildly affected, the addeddiagnostic certainty provided byAD biomarkers will greatlyenhance confidence in theresearch. And, if AD therapeuticresearch can actually deliver apotent intervention, biomarkerswill justifiably enter clinicalpractice.

Biomarkers can identifychanges of AD biology in twoways. The first is to demon-strate abnormalities of the pro-tein β-amyloid. The second is toprove that there is neurodegen-eration in a pattern typical ofAD. In the most widely acceptedmodel of AD pathophysiology,β-amyloidosis is the first andnecessary step in the AD cas-cade, and is entirely asympto-matic. Neurodegeneration—neuron and synapse loss—follows, with symptomaticcognitive impairment occurringthereafter. Brain imaging andcerebrospinal fluid (CSF) analy-sis are the two approaches tobiomarkers.

The amyloid story goesback to the first description ofAD, more than 100 years ago,by German psychiatrist andneuropathologist AloisAlzheimer, who showed thatthere was an abnormal accumu-lation of a protein with thestaining characteristics of amy-loid. The unique β-amyloid pro-tein in AD was first sequencedin 1984. By the mid-1990s, CSFassays for amyloid had beendeveloped. Low CSF β-amyloidwas shown to correlate with ADdementia.

Positron emission tomogra-phy (PET) imaging of β-amyloidwas first introduced in 2004.The radiotracer known asPittsburgh compound B (PiB)used carbon-11 as its radio-label. Unfortunately, because

carbon-11 has too short a half-life, C-11 PiB will never beavailable commercially. How-ever, several companies aredeveloping commercially practi-cal fluorine-18 amyloid imagingcompounds. One company, nowowned by Lilly, has made apresentation before the FDA inorder to gain regulatoryapproval for clinical use of amy-loid PET imaging. At present,brain amyloid imaging is notavailable, and if the FDAapproves its use, the indicationsfor this expensive imaging testhave yet to be determined.

There is a very stronginverse correlation between lev-els of β-amyloid in the CSF andlevels measured by PiB PET.Thus, the two biomarkers areprobably interchangeable. CSFβ-amyloid assays are currentlyavailable for clinical use, butthe test is performed infre-quently. No insurance carrierscover the test. Patients’ fears oflumbar punctures may be a lim-iting factor in the use of CSFamyloid, but that fear is unwar-ranted. Lumbar puncture is a


ALZHEIMER’S to page 36

Alzheimer’s from page 16

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P R O F I L E S I N A D M I N I S T R AT I O N

Joel BeiswengerTri-County Health Care, Wadena

Title: Presidentand chief execu-tive officer(since 2008)Background:Previouslycontroller(1986–1988)

and director of financial services(1998–2008) at Tri-County.Challenges: Successfully imple-menting Epic System to completeour conversion to an electronicmedical record system. Providerrecruitment. Access to outreachspecialty care, especially in short-age areas (e.g., dermatology,rheumatology, neurology). Econo-mic challenges (state budget, gen-eral economy, federal healthreform). Continuing to developas an integrated health system toachieve the maximum benefitfor the community. Adapting topatients’ and families’ changingand expanding expectations.Change: To eliminate or simplifythe unnecessary, duplicative, over-whelming administrative issuesthat frustrate and hinderproviders’ ability to provide high-quality, patient-focused care.

Paul BerrisfordFamily HealthServices

Minnesota, PA

Title: CEO(since 2002)Background: In asenior leadershipcapacity withFHSM for thepast 19 years.Challenges:

FHSM is an independent familypractice group of 12 clinics and70 providers in the east metroarea. Current challenges revolvearound restructuring care deliveryto effectively coordinate anddeliver care with the greatestvalue. Worked closely with thepayers to structure payment andincentives to align with the TripleAim (low cost, high quality, andpatient satisfaction). Transitioningfrom a volume-based to a care-based payment mechanism isextremely problematic, as wehave had to invest ahead ofappropriate payment structures.Change: The payment-per-codesystem. If at an appropriate level,global payment for populationcare with incentives around theTriple Aim allows us to allocateresources more efficiently.

Debra BoardmanFairview Range, Hibbing

Title: Presidentand CEO (since2010)Background:Twenty years ofCEO experiencein the health caresector.

Challenges: Solving new questionsand challenges under health carereform. With the unknowns ofhealth care reform, the accele-rated rate at which new proce-dures are available, and the avail-ability of advanced technologies,we are paving the way for a newgeneration of health care deliveryoptions.Change: To provide care in themost patient-friendly, time-sensitive manner possible. Oftenour patients are forced to jumpthrough hoops and make re-visitsto obtain care. This system isoften driven by the manner inwhich we get paid. One of thegood things about health carereform is greater focus on provid-ing quality health care in moreinnovative ways.


health care systems. All ofthem have contributed to theirorganization’s developmentand to improving health caredelivery. Many have also par-ticipated in professional asso-ciation and/or legislative andgovernment activities.

In addition to informationabout title/background, weasked each administrator torespond to two questions:• What current challenges isyour practice addressing?

• If you could change onething about the health caredelivery system, what wouldit be?Their responses are

excerpted below.We are confident that the

comments of these adminis-trators reflect the concernsand viewpoints of their peers,in Minnesota and across thenation. We congratulate themon their achievements in thehealth care community, andthank them for participatingin this feature.

Administration from cover

Discover ourpersonal side.

Check out our discoveracmc.com

blog where you’ll � nd personal stories on

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Matt C. BrandtMulticare Associates, Fridley

Title: Chief finan-cial officer(since 2008)Background:Three yearswith MulticareAssociates; heldpositions with

HealthPartners Central Minne-sota Clinics and with BrandtMedical Management.Challenges: To be paid equitably,as an independent primary careclinic. We are attempting to con-vince health care purchasers toinvest in independent primarycare groups that can deliver highquality care at a lower cost.Change: Eliminate the misuse ofthe terms “accountable” and“community need.” Are we really“accountable” if we continue toraise health care costs by greaterthan 10 percent every year? Doesthe community really “need” hos-pital lobbies with grand pianosand water fountains or anotherjoint replacement center with anMRI machine?

Lia ChristiansenBethesda Hospital

(HealthEast Care System)

Title: Operationsexecutive (since2010)Background:Fifteen yearsof experience inhealth care.Challenges: One

opportunity is continuing educa-tion about what a long-term acutecare hospital (LTACH) is andwhat its place is in the care con-tinuum. Bethesda is the only non-profit LTACH in the community.Bethesda has a case mix indexthat is higher than many localICUs. We look for opportunitiesto educate physicians aboutBethesda’s high quality outcomes.Change: Tighter coordination ofcare—better handoffs during tran-sitions for patients. We hearabout that from our patients atBethesda and from the commun-ity as we work with short-termacute care hospitals, clinics, homecare, and skilled nursing facilities(SNFs).

Eric CrockettMayo Clinic Health System

Title: Operationsadministrator(since 2010)Background:Center forDiagnosticImaging,1996–2006;

Mayo Clinic, Rochester 2006–present. Member, AmericanCollege of Healthcare Executives;president-elect, MinnesotaMedical Group ManagementAssociation.Challenges: Delivering a consis-tent, high-quality patient experi-ence across the Mayo ClinicHealth System’s 71 locations.Integrating primary, secondary,and tertiary care across our sys-tem and delivering the right carein the appropriate setting acrossour various locations.Change: To change from a fee-for-service model to a system thatpays for good outcomes deliveredwith good service in a safe envi-ronment. Care decisions shouldalways be made with the patient’sbest interest in mind.

Barb DaikerNorthwest Eye Clinic, Minneapolis

Title: Executivedirector (since2000)Background:Fellow in theAmerican Coll-ege of MedicalPractice Execu-

tives. Past experiences in healthcare consulting, managed care,and innovative health care servic-es development.Challenges: Preparing for changesin health care delivery that mightinclude remote consultations,social media engagement withpatients, and electronic sharingof data with other independentproviders.Change: To eliminate the require-ments by payers and governmentthat add cost without value to thepatients. Regulatory compliancecomes at a cost that often addsexpense without improving thedelivery of care to patients.Providers need to focus on whatis important to patients and staff;with that in mind, they will beable to deliver extraordinary serv-ices at an affordable price.


Read usonlinewherever you are!

www.mppub.com


Tony DavisDermatology Specialists, PA

Title: Clinicadministrator(since 2009)Background:Certified medicalpractice execu-tive. Member,Medical Group

Management Association. Princi-pal, health care, LarsonAllen(1995–2009).Challenges: The current mandatefor independent medical clinics todevelop an electronic infrastruc-ture in areas such as medicalrecords, prescribing, and qualitymeasurement puts significantstress on our financial, technolog-ical, and human resources.Managing through these opera-tional changes without compro-mising the quality of patient careand interrupting the patient flowis very challenging.Change: Create open-access com-munication among the providers,patients, and payers. It confoundsme that the key players in design-ing and implementing the healthcare system (patients, doctors,and insurance companies) rarelytalk to each other!

Mike DelfsRiverwood Healthcare, Aitkin

Title: COO(since 2006)Background:Prior to 2006worked forMeritCareHealth Systemsin Fargo, N.D.,

in administrative and manage-ment roles ranging from familymedicine and psychiatry to neu-rology and general surgery.Challenges: All hospitals needto establish how we can leveragetechnology and practice redesignto support wellness and preven-tive medicine while simultane-ously producing better qualityoutcomes in a more cost-effectivemanner. This will require funda-mental changes in how we carefor patients and deliver services.Change: The health care deliverysystem. We need to align paymentwith quality outcomes. With thepayment system we have today,exceptional management of apatient’s health could drivehealth care organizations out ofbusiness.

Bonnie A. FranciscoNeurosurgical Associates, Ltd.,

Minneapolis

Title: Adminis-trator (since2000)Background:In health careadministrationsince 1982.President of

Minnesota Medical Group Man-agement Association (MMGMA)in 2000.Challenges: Preserving and pro-moting our independent, specialtypractice in the marketplace.Providing exceptional, personalcare to our patients has becomeincreasingly challenging as we areconstantly implementing state andfederal policy requirements. Beingcost-conscious in an environmentdemanding expenditures for elec-tronic medical records, evidence-based clinical score cards, andclinical and technical advances.Change: Identify the patients withchronic conditions who generatethe largest costs, and work withthese patients and their familiesso they see the right doctor at theright time and comply with theadvised plan of care.

Steve GerberdingAdult & Pediatric Urology (APU)and Central Minnesota Surgical

Center (MSC), Sartell

Title: CEO/administrator,APU; administra-tor, MSC (since2003)Background:Board member,Minnesota Medi-

cal Group Management Associa-tion. Chair, Central MinnesotaClinic Manager’s Association.Challenges: Private practices/surgical centers face increasedregulation, increasing consolida-tion in the industry, decliningreimbursements, uncertaintyregarding health reform, andphysician angst regarding thechanging nature of medicalpractice.Change: To establish an economi-cally sustainable, high-quality,market-based health care deliverysystem where the government’srole is limited to providing aneeded safety net; patients have ahigh degree of personal responsi-bility for behavior; and providersare rewarded for managing out-comes and overall cost of care.


Congratulations Barb Daiker

p. 763.416.7600 www.nweyeclinic.com

Congratulations to

Matt Brandt for being

Recognized for outstanding

achievement in

Health Care Administration.


Mary L. JenkinsPartners in Pediatrics, Ltd.

Title: Clinicadministrator(since 1976)Background:Career at PIPhas spanned 35years. Duringthat time, the

practice has grown from a groupof four providers and six staffmembers into a group of 38providers and 150 staff membersat five sites.Challenges: The transition to elec-tronic medical records. We areexploring all aspects of the systemwith a number of other groupsand our hospital partner. We arecertain that, together, we can cre-ate a community system that willbe mutually beneficial to all par-ticipants.Change: To improve access tohealth care for all children. Ascaregivers to the smallest andmost vulnerable patients, this isalways a concern. Most currentmodels focus on adult medicalcare issues and not the uniqueneeds of children. There is a hugeneed for behavioral and mentalhealth care for children.

Sandra KaminObGyn Specialists, Edina

Title: Adminis-trator (since1988)Background:Twenty-threeyears in currentposition.Challenges:

Trying to guide our organizationin the right direction in an effi-cient and effective manner as thechaos continues to unfold. It isharder than ever to predict whathealth care will be in the nextthree to five years. We havealways tried to stay ahead of thecurve. Innovation has led usthrough a successful divisionalmerger, involvement with theInstitute for Clinical SystemsImprovement (ICSI)—as the onlyindependent ob-gyn group—andother collaborative efforts withhospital systems and payers.Change: Creating a true under-standing and appreciation forwhat our physicians do every day.I would love to see a closer linkbetween patient and physicianswithout third-party involvement(which often serves to complicateand add cost to the system).

Sharon OhlandMidwest Spine Institute

Title: Adminis-trator (since2009)Background:Twenty-fiveyears’ experiencein health careadministration.

Current president, MinnesotaMedical Group ManagementAssociation.Challenges: 1) Out-of-controlcosts incurred in our fragmentedhealth care system. 2) Meaningfuluse requirements written with pri-mary care providers, not specialtygroups, in mind. 3) E-prescribingthat unnecessarily duplicatesefforts and expense. 4) Account-able care organizations. 5) Peergrouping program development.Change: Federal reform thatwould develop a nationwideinfrastructure for electronic healthrecords for interoperability in-stead of providing funding tononprofits to develop their ownsystems. Patients would then beable to access their medicalrecords anywhere, anytime, forboth traditional and complemen-tary health services.

Mark PottengerNorthwest Family Physicians,

Crystal

Title: Adminis-trator (since1990)Background:Thirty years inhealth care, inboth hospitaland clinic set-

tings; nearly 22 years at NWFP.Challenges: Working on meaning-ful use certification to qualify forfederal funds and on health carehome certification. Building anew, $15 million medical officebuilding, new imaging center, andadministrative/business offices.Change: Improve our paymentsystem. Our clinic is paid 25 to35 percent less than is paid to thelarge systems based on fee sched-ule payments. Our clinic has con-sistently delivered what is mostdesired in today’s market: highquality at a low cost, according tothe health plans’ quality and costreported data. Ongoing underpay-ment to independent clinics willultimately result in a loss of qual-ity and increased costs throughless competition.


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Thomas F. ReekCuyuna Regional Medical Center,

Crosby

Title: CEO(since 1980)Background:Joined the med-ical center in1974. On theboard of direc-tors of Central

MN Diagnostic, Inc. and SISUMedical Systems. Member of theAmerican College of HealthCareAdministrators, Brainerd LakesCommunity Foundation, andBrainerd Lakes Chamber ofCommerce.Challenges: Recruitment of physi-cians and other professional stafffor our level III trauma hospital,as well as current economicchanges.Change: Our communities wantquality, compassionate, affordablehealth care. To better meet theirexpectations, I would like tostreamline the whole health caresystem for our patients and cus-tomers by continuing to developquality relationships with otherproviders and systems.

Tim RiceLakewood Health System, Staples

Title: President/CEO (since1980)Background:Thirty-sevenyears in healthcare administra-tion.

Challenges: Reforming physicianpractice into value/quality empha-sis. Including patients in theircare. Using personnel at the topof their licenses. Developing edu-cation to enable patients to makegood choices. Understandingpatients’ life/health choices andkeeping them aware of healthdelivery changes and choices.Getting the right mix of qualitycare and quality measurementsfor provider buy-in. Developingpayment systems and incentivesbased on value. Recruiting pri-mary care and specialists. Acces-sing capital for capital needs.Balancing desired practice withcustomer expectations. Gettingenough time to educate/trainphysician leaders.Change: Changing reimbursementto provide the incentives to dowhat is best for providing evi-dence-based medicine to patients.

Candace SimersonMinnesota Eye Consultants, PA,

Bloomington

Title: President/COO (since1999)Background:More than 30years of practicemanagementexperience. Past

president of Minnesota MedicalGroup Management Associationand American Society ofOphthalmic Administrators.Challenges: The unpredictabilityof health care reform, governmentmandates, and market response.Independent practices’ fears ofbeing forced to consolidate orjoin an integrated delivery system.Dealing with flat or decliningreimbursement levels as businessexpenses continue to increase.State and federal mandates thatare increasing the administrativeburden and cost of providingcare.Change: Create a system that en-gages the patient to be motivatedand inspired to live a healthylifestyle, proactive about preven-tion, compliant with care recom-mendations, and a good stewardwhen using health care resources.

Joanne StadnikNorth Clinic, Twin Cities

Title: Executivedirector (since2004)Background:Twenty-fiveyears of experi-ence in primarycare and speci-

alty operations.Challenges: Physician recruitment.Physicians are in short supply andoften choosing to work in largersystems, due in part to financialincentives being offered to newrecruits. This makes it more diffi-cult for independent practices tocompete.Change: The disparity in reim-bursements! Hospitals and largerhealth care systems receive higherreimbursements for delivering thesame services provided by smallerindependent practices. As a result,many independent practices arebeing acquired by larger systems,at the expense of patient satisfac-tion. If the insurance industrywould shift the focus from vol-ume to outcomes, and reimburseservices equitably, the patientswould ultimately win.


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Mel SullivanSt. Croix Orthopaedics, PA

Title: COO(since 1999)Background: Inhealth care formore than 20years; at St.Croix Orthopae-dics for 12 years.

Challenges: Negotiating the vari-ous regulatory issues while man-aging patient expectations andmaintaining profitability. Thereare many large initiatives on thehorizon (e.g., ICD-10, meaningfuluse criteria, electronic healthrecords). Successfully navigatingand implementing these items, inaddition to the day-to-day opera-tional expectations, creates a sig-nificant challenge for independentpractices.Change: Reducing the complexityof the health care system andstandardizing the things thatmake sense to support a morestreamlined patient experience.Many of the proposed and ongo-ing health care regulations placeinvisible barriers between physi-cians and patients, which hamperthe ability to focus on humaninteractions.

Terry ToneAffiliated Community Medical

Centers, PA

Title: Adminis-trator (since1998)Background:Director of oper-ations at ACMCfrom 1994 to1998.

Challenges: Strategically, the pri-mary challenge is managing tran-sitional change from an episodichealth care model to a perform-ance-based health care system.Operationally, the challenges arebalancing patient demands withphysician lifestyle, managing theintegration of technology intophysician practices, and maintain-ing the overall health and vitalityof our practice.Change: To develop a more coor-dinated approach to health carereform, versus the present unco-ordinated discussion dominatedby special interests. For the mostpart, we are seeing a situation ofworrying more about whose ox isgetting gored, as opposed to look-ing at the broader picture. Thisdilutes the voice of all health careproviders.

Jeffrey TuckerIntegrity Health Network, LLC

Title: Presidentand CEO(since 2005)Background:With the organi-zation since1997.Challenges: Our

network of independent clinicsfaces a bias by federal, state, andcommercial payers toward bigcorporate medicine in reimburse-ment. Recruitment is a challenge,as new physicians are selectingreduced hours and the security ofemployment by big systems overthe excitement of practicing in anindependent environment. Ever-growing government regulationson health care practice.Change: To allow true competitionin the health care delivery systemand remove regulatory and reim-bursement barriers that discour-age competition on an even foot-ing. Then we would quickly seewhere the patient truly comes firstin action and practice—not just inmarketing.

Diana WhiteSt. Cloud Medical Group

Title: Adminis-trator (since2006)Background:Director offinance forBrainerd MedicalCenter 2004–

2006; controller, then administra-tor, for St. Cloud Orthopedics,1992–2004.Challenges: Implementing an elec-tronic health record as a small,physician-owned clinic. We beganinstalling the new practice man-agement system in July 2010 andthe electronic chart in October2010. We are continuing toimprove on workflows and get-ting all the interfaces completedto be able to deliver servicesefficiently.Change: We need to 1) make somevery difficult decisions about end-of-life care; 2) work more closelywith patients on healthy lifestylechoices, 3) emphasize nutritioneducation (which is a societalissue as well as a health careissue); and 4) simplify the systemand/or provide guidance in navi-gating it.


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P R O F E S S I O N A L U P D A T E : N E U R O L O G Y

This disease was what theancients called hydro-cephalus from water which

is stored in the head and gradu-ally collects. In this case, how-ever, the water had not collectedbetween the skull and its outersurrounding membrane or theskin but in the cavity of thebrain. This cavity and breadth ofthese had so increased—and thebrain itself was so distended—that they contained about ninepounds of water of threeAugsburg wine measures.”

—Andreas Vesalius (1514–1564 AD),first accurate anatomic description ofventricular dilation and hydrocephalus

An estimated 14 percent ofthe United States populationover age 70 will suffer from de-mentia. The incidence increaseswith age, with the most preva-lent etiologies being Alzheimer’sdementia (69.9 percent) and vas-cular dementia (17.4 percent).The remaining 12.7 percent ofcases are due to a variety ofcauses, including Parkinson’sdementia, frontal dementias,post-traumatic dementia, alco-holic dementia, and normalpressure hydrocephalus.

Normal pressure hydro-cephalus (NPH) accounts forapproximately 5 percent of thepopulation diagnosed withdementia. Although this repre-sents a small portion of the pop-ulation affected, the diagnosis isimportant because of the possi-bility of effective treatment withexcellent results. This translatesinto improved quality of life,decreased need for supervisedcare, and potentially significantcost savings for the health caresystem.

Diagnosing NPH

The diagnosis of hydrocephalusas a malady of the cerebral spi-nal fluid (CSF) space was initi-ally described from an anatomic

perspective in the mid-16th cen-tury. However, the physiology ofCSF production, circulation, andabsorption was not elucidateduntil the late 19th and early 20thcenturies. Despite continuedprogress, the development ofsafe and effective treatment didnot occur until the mid-20thcentury with the development ofthe ventriculo-peritoneal andventriculo-atrial shunts.

Hydrocephalus was initiallyconsidered to be a condition ofCSF overproduction, underab-sorption, or ventricular obstruc-tion that resulted in elevatedintracranial pressures with asso-ciated neurological decline ofthe patient, and, eventually,death. In 1965, the Columbianneurosurgeon Salomon Hakimidentified and published a caseseries of patients presentingwith gait disturbance, cognitivedecline, and urinary inconti-nence with normal intracranialpressures who improved withplacement of a ventriculo-peri-toneal shunt, coining the termnormal pressure hydrocephalus.

Making the correct diagno-sis of NPH can be a difficulttask. The number of conditionsthat may present with gait insta-bility, cognitive decline, and uri-nary incontinence are myriadand should be included in thedifferential diagnosis and evalu-ation. These include: neurode-generative disorders (Alzheimer’sdementia, Parkinson’s dementia,etc.), vascular dementias, infec-tious diseases (Lyme disease,HIV, syphilis, etc.), urologic dis-orders, psychological disorders(depression), spinal disorders(cervical myelopathy and lum-bar stenosis), and other hydro-cephalic disorders. In order toacknowledge the differingdegrees of diagnostic certainty, aclassification system of probableNPH, possible NPH, and improb-

able NPH has been proposed.The diagnosis of probable

NPH is based on clinical history,brain imaging (CT or MRI), neu-rologic examination, and physio-logic data. The patient should beolder than 40 years with an in-sidious onset of symptoms thathas been progressive over thelast three to six months in theabsence of other neurologic, psy-chiatric, or general medical con-ditions that may explain thesymptoms. Brain imagingshould demonstrate ventricularenlargement not entirely attrib-utable to cerebral atrophy orcongenital ventricular enlarge-ment. Examination of gaitreveals decreased step height,length, and cadence with awidened standing base, oftendescribed as “magnetic gait.”

Cognitive impairment mayinclude psychomotor slowing,decreased fine motor speedand accuracy, difficulty main-taining attention, and impairedrecall (memory). The MiniMental Status Exam (MMSE) isoften used for evaluation.Urinary symptoms should bedocumented as being eitherepisodic or persistent and notattributable to other primaryurologic disorders. Urgency, fre-quency, nocturia, and associatedfecal incontinence should alsobe documented. A urinalysis/urine culture (UA/UC) is oftenbeneficial. Although formal uro-logic examination with bladderelectromyogram and cystomet-rogram (EMG/CMG) is some-times performed, this level ofinvestigation is usually notrequired. A lumbar puncturewith opening pressure measuredin the lateral decubitus positionshould be obtained (5–18 mmHgis compatible with NPH) androutine CSF studies sent forevaluation (cell count with dif-ferential, protein, glucose, aero-bic and anaerobic cultures, fluo-rescent treponemal antibody,and lyme titre). The CSF studiesshould be within expected nor-mal ranges.

Patients who are unlikelyto have a diagnosis of NPH typi-cally do not have any of the clas-sical clinical triad of NPH symp-toms (gait instability, cognitivedecline, and urinary inconti-nence). Their presenting symp-toms and complaints may be

Normal pressurehydrocephalusDiagnosis and treatment of areversible cause of dementia

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explained by other, more plausi-ble diagnoses. Imaging studiesof the brain may vary based on alikely differential diagnosis.Neurologic examination thatdemonstrates evidence ofincreased intracranial pressureis also incompatible with thediagnosis of NPH. Thesepatients will often require fur-ther neuropsychological, neuro-logical, medical, and imagingstudies to determine the etiologyof their symptoms.

Another population ofpatients will have a diagnosis ofpossible NPH. These are general-ly individuals who present withone or two symptoms of theclassical clinical triad and have abrain imaging study consistentwith hydrocephalus and no evi-dence of increased intracranialpressure on neurologic examina-tion or lumbar puncture.

Treating NPH

Once a potential diagnosis ofprobable or possible NPH hasbeen made, a decision should bemade for possible treatment.Traditionally, neurologists andneurosurgeons have used a vari-

ety of tests to confirm the diag-nosis of NPH and determinewhether the placement of eithera ventriculo-peritoneal or ven-triculo-atrial shunt would be ofbenefit. These tests have includ-

ed radionucleotide cisternogra-phy, single large-volume LPs andserial LPs with post-LP neuro-psychological and gait assess-ment, as well as inpatient CSFdiversion with a lumbar drain.

None of these tests, with theexception of prolonged CSFdrainage with a lumbar drain,have very high sensitivities orspecificities. The disadvantageof the lumbar drain is that itrequires a hospital admissionwith the associated risk of draindislodgement, infection, anduncontrolled drainage. Becauseof the inadequacy of currenttesting methods and the require-ment of hospital admission forprolonged lumbar drainage,many groups, including ourown, have opted to surgicallyimplant a shunt system as thebest choice of a definitive diag-nostic test and treatment of thepatient. We generally implant aprogrammable valve set to ahigher draining pressure andgradually “dial the pressuredown” over several months toprevent potential overdrainage-associated complications.

The shunt system (Fig. 1)consists of a proximal ventricu-lar catheter that passes throughthe skull, dura, and cortex of thebrain to give access to the ven-tricular system where CSF is


NPH to page 31

FIGURE 1. Diagram of an implanted ventriculo-peritoneal or ventriculo-atrialshunt system. (Illustration used with permission of Medtronic)FIGURE 2: An 84-year-old female with a six-month history of gait instability,cognitive decline, and urinary incontinence. Top image, CT of the head demon-strating significant ventricular enlargement. Bottom image, six months post-placement of ventriculo-peritoneal shunt (manufactured by MedtronicNeurologic Technologies) with good decompression of the ventricular system.The patient experienced excellent results with a near total return of normalcognitive and ambulatory function.

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E.M. is a 26-year-old malewho presents with asix-month history of delu-

sions and auditory hallucina-tions, in addition to erratic sleeppatterns. His past medical historyincludes alcohol abuse in college(where he also attended AA meet-ings and completed a treatmentprogram), drug use, and mildsocial anxiety. He does not havea psychiatrist or psychologistand has never taken neurolepticmedication.

E.M. began having delusionsthat his upstairs neighbor—whom he had never formallymet—was trying to kill him. Hewould hear shuffling of feet, as ifmany people were walking about,and gunshots emanating from theupstairs condo. He was so fright-ened one night that they weregoing to shoot into his condo,he curled himself under his coffeetable the entire night and didnot sleep. On another occasion,he decided to seek help at Henne-pin County Medical Center at 3a.m., but soon after checking indecided to leave.

His family states that hisdelusions have become worse, to

the point that he has hired profes-sional electronic bug sweepers tocome to his unit to make surethey removed all the bugs that hesays his neighbor has planted tospy on him. E.M. has also con-fronted the neighbor about hisintentions to harm E.M. and hascalled the police on him. E.M’sfamily is concerned that he willbe thought of as a menace in hisbuilding and this may have nega-tive repercussions for him.

E.M. is a successful softwareengineer at a large firm, butrecently his work performanceand attendance have declined.He recently broke up with hisgirlfriend and states that he start-ed drinking one scotch per day.

First-episode psychosis(FEP) is defined as the first pres-entation of psychotic symptoms,

which usually occur in adoles-cents and young adults. LikeE.M., FEP patients often presentas confused, scared, depressed,socially isolated, and devastatedby the changes to their lives andgoals. Most often patients suffertrauma related to their disturb-ing symptoms and increasedphysical and psychological risks,including suicide.

Early intervention in FEPhas been found to be valuable inalleviating the distress and anxi-ety related to psychotic symp-toms, in addition to reducingsuicide risk and rates. Yet treat-ment delays are common, eitherbecause the individual fails toseek help or because health carepractitioners fail to recognizepsychotic symptoms.

Understandingfirst-episode psychosis

First-episode psychosis patientsare frequently adolescents oryoung adults, more often male.They usually have a historyof unemployment and/or drop-ping out of school due to symp-toms and can often be sociallyisolated.

These patients typicallypresent to the emergency depart-ment of a hospital with manytroubles, such as aggression, sui-cidal tendencies, and/or historyof substance abuse, and oftenbecome involuntary patients.

Symptoms of psychosis canrange from delusions to halluci-nations to erratic behaviors anddisorganized thoughts. Peoplewith FEP can present with allor some of these symptoms andmay appear agitated or de-pressed. They may or may nothave insight into their behavior.

Risk factors for first-episodesuicidal behavior

The single most significant phys-ical threat to FEP patients issuicide. It is the leading causeof death in patients with schizo-phrenia, and it is estimated that

two-thirds of these suicidesoccur within six years of theappearance of initial symptoms.

Notable risk factors forsuicidality (i.e., the likelihoodof an individual completing sui-cide) in individuals with FEPhave been identified as elicitingsymptoms of psychosis, femalegender, depression, alcohol andsubstance abuse, traumatic orstressful events in the firstmonths before psychosis onset,poor social support, family his-tory of suicide, and previous sui-cidal attempts. Early age of psy-chosis onset is associated withsignificantly increased rates oflifetime suicidality. These strongassociations between risk factorsand suicidal plans/attemptshighlight the need for specialcrisis programs and interven-tions focused on suicidalideation and behavior that aredesigned for individuals experi-encing first-episode psychosis.

Gender differences

Though the onset of psychoticsymptoms can be preceded bynonspecific changes in behavior,emotional, and cognitive states,frequent signs and symptoms ofthe early phases of psychosis canalso manifest as sleep distur-bance, anxiety, anger/irritability,depressed mood, functionaldecline, social withdrawal, poorconcentration, suspiciousness,avolition, and anergy. Males gen-erally have an earlier onset ofpsychotic symptoms and a moresevere form of the disease, indi-cated by greater cognitive andsocial impairment, whereasfemales are more likely toendure anxiety and affectivesymptoms.

Choi et al. (J Korean MedSci 24, 2009) demonstrated thatthe frequency of prodromalsymptoms of FEP tends to differbetween males and females.Typically, males demonstratemore frequent negative symp-toms (e.g., flat affect, poverty ofspeech, inability to experiencepleasure, lack of motivation) andattenuated positive symptoms(e.g., delusions; disorderedthoughts and speech; tactile,auditory, visual, olfactory, andgustatory hallucinations) andfemales usually experienceattenuated positive symptomsand mood symptoms (e.g.,

First-episode psychosisThe effects of early intervention

on suicide risks and rates

By Claudia Campo-Soria, MS


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depression and mania). It hasalso been reported that the pro-dromal (pre-onset) period isusually longer in females thanmales, and the duration ofuntreated psychosis has beenshown to be significantly longerin males than females. This sug-gests that the greater degree offunctional impairment—bothcognitive and social—seen inmales may be influenced by theextended duration of exposureto negative symptoms and therelatively younger age of onsetof the prodromal phase inmales.

Considering the manifesta-tion of neurobiological differ-ences between men and womenin FEP, it is important for clini-cians to consider the role genderplays in assessing nonspecificsymptoms in the presence ofattenuated positive symptomsand in determining treatmentmodalities for FEP patients.

Prevalence and characteristicsof suicide in FEP

People who suffer from psy-chosis during their lifetime tendto be at significant risk for sui-cide, with the highest peakoccurring in their first episode.

This period of greater riskof suicidality usually occursbefore the person seeks orreceives treatment. In addition,it is a time when behaviors thatheighten suicide risks, such asdepression and substance use,are prevalent. Compared to peo-ple with psychosis who haveundergone treatment, untreatedpatients tend to undergo moreviolent suicide attempts.Robinson et al. (Aust NZ JPsychiatry 43, 2009) found thatthe most common method ofsuicide in FEP was hanging;other methods were lying orjumping in front of a train,jumping off a bridge, gunshotwound, overdose, and drowning.

Studies have found that 14percent to 28 percent of FEPpatients have attempted suicidebefore undergoing their firsttreatment for psychosis and 6.5percent to 11.3 percent of FEPpatients have attempted suicideor engaged in self-injuriousbehavior in the time betweentheir psychosis onset and initia-tion of treatment, also known as

the duration of untreated psy-chosis (DUP). A study by Barrettet al. (Schizophr Res 119, 2010)showed that prolonged DUP wasassociated with an increasedrisk of suicide attempts. It hasbeen postulated that this associ-ation could be due to a longeropportunity time to attempt sui-cide or a prolonged exposure topsychotic symptoms, which istraumatic and distressing. Manypatients with FEP encounterfeelings of loss of hope and aspi-rations, disruption of their lives,and social isolation. In addition,it has been found that a pro-longed DUP is related to adiminished quality of life. In astudy by Cougnard et al.(Psychol Med 34, 2004), FEPpatients who demonstrated poorpremorbid functioning and at-risk behavior (e.g., substanceabuse) were more apt to delaytreatment.

The relationship betweensuicide attempts and DUP iscrucial. Early intervention inFEP may not only reduce andalleviate the psychosocial andphysical anguish of psychosis,but may also help prevent suici-dal behavior. This correlationbetween DUP and suicide riskwas examined by Melle et al.(Am J Psychiatry 163, 2006),who developed an early detec-tion program for FEP patients.This program formed a “catcharea” where FEP people cameinto treatment at an earlierphase of their disorder andwith lower symptom levels. Theresults showed that areas offer-ing the early detection programtended to have less severe suici-dality reports than areas thatdid not incorporate an earlydetection program.

Pathways to care:accessing early intervention

Roger and Cortes (Am JPsychiatry 150, 1993) definedpathways to care as “thesequence of contacts with indi-viduals and organizationsprompted by the distressed per-son’s efforts and those of his orher significant others to seekhelp.” It is important to recog-nize the various types of path-ways to care and their accessi-bility and effectiveness to FEP

AUGUST 2011 MINNESOTA PHYSICIAN 29PSYCHOSIS to page 30

patients, given the correlationbetween poor functional/clinicaloutcomes and delayed treat-ment. Factors that influencecare pathways include socialand cultural circumstances,accessibility of health services,and identification of andresponse to symptoms of theindividual experiencing FEP.Studies have also shown thatthe process of seeking help andreferral delays the impact ofDUP, but that referral delaysmay be the greatest impedanceto prompt treatment.

Well-known pathways ofcare for FEP patients rangefrom general practitioners andpsychiatrists to emergency serv-ices, social services, police,school counselors, and religiousorganizations. However, therehave been frequent reports ofnegative experiences with policeand emergency services, whichresult in poor treatment adher-ence and/or disappointmentwith treatment services, causingindividuals to discontinue seek-ing help.

Interestingly, Norman et al.(Psychol Med 34, 2004) foundthat patients who were alreadyreceiving mental health carefrom a psychiatrist and/or psy-chologist at the time of onset ofpsychotic symptoms experienceda referral delay about four timesgreater than the referral delayfor patients who sought careafter the onset of symptoms.This may be attributed to thedifficulty health care providersface in either recognizing thesymptoms of the early phases ofpsychosis or in teasing thesesymptoms out from other psy-chiatric conditions the patientmay be experiencing. It may alsobe related to the challenge prac-titioners face in persuadingpatients to take medication for adifferent disease.

Families of FEP patientsfrequently seek help eitherthrough non-physician contactsor personal contacts. Each ofthese resources plays an impor-tant role in linking the patient topsychiatric services and/orresources to expedite the help-seeking process.

Increasing methods anddeveloping better systems forFEP patients to access aid canpotentially improve overall out-comes of the disorder and pre-vent significant disability anddelay in accomplishing social,educational, and career mile-stones. It can also reduce thepsychological distress experi-enced by both family membersand patients.

Benefits of early intervention

Collectively, the data have shownthat the suicide rate in the FEPpopulation is substantially ele-vated, about 24 times greaterthan similarly-aged members ofthe general population. Thishighlights the need to create sys-tems to reduce suicidal behaviorin FEP patients. Research hasshown that FEP patients whowere treated by an early inter-vention specialist showed lowersuicide rates for the length ofthe treatment than those whowere not treated by specializedservices.

It would also be beneficialto implement streamlined dis-charge processes that involve a

thorough risk assessment and aseamless referral process. A sys-tem of routine screening andevaluation for suicide risk, evenat the point of discharge, couldreduce suicidal behavior, consid-ering the strong correlation thatthe data indicate between suici-dal ideation and attempts, andfuture risk of suicidality.

For patients like E.M., earlyintervention can help themunderstand their illness anddevelop skills that can help themlive healthier and happier lives.Multidisciplinary services aimedat providing comprehensiveassessment and treatment ofpsychotic illness as soon as pos-sible after the development of afirst episode of psychosis canrelieve the burden of mental ill-ness for both patients and theirfamilies.

Claudia Campo-Soria, MS, is a fourth-year medical student at the University ofMinnesota, Minneapolis.


Psychosis from page 29

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produced. This is attached to aprogrammable valve that allowsthe rate of CSF drainage to becontrolled. Many modern shuntvalves incorporate anti-siphondevices to prevent overdrainageof CSF while patients are in theupright position. The valve isconnected to a distal catheterthat is tunneled under the skinto drain into either the superiorvena cava/right atrium of theheart (ventriculo-atrial shunt) orthe peritoneum (ventriculo-peri-toneal shunt). Under ideal cir-cumstances (Fig. 2), the shuntedpatient will experience bothradiographic and neurologicimprovement in symptoms, withthe last symptom to appearbeing the first to improve.Patience on the part of the fami-ly and treating physician is thekey to post-shunt evaluation andmanagement since it may takeupwards of a month for thepatient and family to notice achange in symptoms. Thisshould also be kept in mind anytime the shunt valve pressure isaltered.

Complications of shuntplacement include shunt infec-tion, intracranial hemorrhage,subdural hematoma (over-drainage), seizures, abdominalor cardiac injury (from place-ment of the distal catheter), andshunt malfunction. These com-plications can be mitigatedthrough appropriate preopera-tive planning, surgical tech-nique, and postoperative evalua-tion and management. Patientstaking anticoagulants for med-ical conditions will need to havethese medications held and havenormal coagulation laboratoryvalues on the day of surgery.Antiplatelet agents such asaspirin and clopidogrel (Plavix)will need to be held for sevendays prior to surgery. Theseagents usually can be restartedwith 48 hours of surgery if thepostprocedure CT of the headdoes not demonstrate a hemor-rhage. If hemorrhage is noted,anticoagulants and antiplateletagents may need to be withheldfor a longer period of time.

The risk of hemorrhage andshunt malfunction may also bereduced through the use of

image guidance systems andneuro-endoscopy to ensure accu-rate anatomic placement of theventricular catheter. Appropriatepreoperative prophylactic antibi-otics, sterile technique andchecking a UA/UC may help inpreventing shunt infections.Overdrainage complications areavoided through the use of pro-grammable valves with anti-siphon devices. The overall peri-operative complication rateshould be under 5 percent.

For those patients with adiagnosis of probable NPH orpossible NPH, the overall successrate for shunt placement,as defined by symptomatic im-provement, is approximately60 percent to 75 percent. Asmaller portion of the remainingpatients may experience moreminimal benefit, worsening ofsymptoms, or no benefit at all.The lack of clinical responseraises the question of potentialundershunting (the valve isdraining at too high a pressure),shunt malfunction, incorrectdiagnosis, or the presence ofother significant neurologiccomorbidities. In our practice,

shunted patients are generallyfollowed with a CT of the headon a monthly basis until theoptimal shunt pressure is deter-mined, and on a yearly basisthereafter, to ensure that theshunt remains functional andthat overdrainage and subduralfluid collections are not a prob-lem. Patients who improve ini-tially with shunting but subse-quently decline should be inves-tigated for a potential shuntmalfunction or subduralhematoma.

Although NPH accounts foronly a small portion of the popu-lation affected by neurologicdecline and dementia, the abilityto provide a treatment paradigmwith good results and maintainpatient independence and func-tionality should prompt physi-cians to consider it in their dif-ferential diagnosis.

Charles R. Watts MD, PhD, andEdward G. Hames III, MD, PhD,practice with the Spine and Brain Clinicat Fairview Southdale Hospital and areemployed by University of MinnesotaPhysicians through the Department ofNeurosurgery at the University ofMinnesota.


NPH from page 27

Sioux Falls VA Medical Center“A Hospital for Heroes”

Working with and for America’s Veterans is a privilege and we

pride ourselves on the quality of care we provide. In return for

your commitment to quality health care for our nation’s Veterans,

theVA offers an incomparable benefits package.They all come

together at the Sioux Falls VA Medical Center.

www.siouxfalls.va.gov

To be a part of our proud tradition, contact:

Human Resources Mgmt. ServiceP O Box 5046Sioux Falls SD 57117605-333-6852

• Pulmonologist

• Orthopedic Surgeon

• Emergency Department Physician

• Psychiatrist

Family Medicine

St. Cloud/Sartell, MN

We are actively recruiting exceptional part-time or full-time BC/BE

family medicine physicians to join our primary care team in Sartell,

MN. This is an out-patient only opportunity and does not include

labor and delivery or hospital call and rounding. Our current primary

care team includes family medicine, adult medicine, OB/GYN and

pediatrics. Previous electronic medical record experience is preferred

but not required. We use the Epic electronic medical record system

at all of our clinics and admitting hospitals.

Our HealthPartners Central Minnesota Clinics – Sartell moved

into a new primary care clinic in the summer 2010. We offer a

competitive salary, an excellent benefit package, a rewarding practice

and a commitment to providing exceptional patient-centered care.

St Cloud/Sartell, MN is located just one hour north of the Twin

Cities and offers a dynamic lifestyle in a growing community with a

traditional appeal.

For more information, please contact [email protected] or call Diane at 800-472-4695 x3. EOE

h e a l t h p a r t n e r s . c o m

H O S P I T A L S

Two recent studies pub-lished in the Oct. 13, 2010,issue of the Journal of the

American Medical Associationcompared intraoperative andpostoperative transfusion prac-tices in patients undergoingcoronary artery bypass graft(CABG) surgery. The studiesaddressed the use of replace-ment blood transfusions in twopatient groups. The “liberal”group received transfusionswhen the hemoglobin droppedbelow 10 gm/dl (hematocrit 30percent); the “restrictive” groupwas transfused when the hemo-globin dropped below 8 gm/dl(hematocrit 24 percent). The30-day outcome between the twogroups revealed no difference inmortality or complications. Thesole difference was that the “lib-eral” group received three timesas many blood transfusions.

The above reports, repre-senting a subject of intenseinterest to me, left me incredu-lous, as both studies appearedto be a reinvention of the wheel.We at North Memorial hadaddressed the subject of surgicalblood replacement more than

three decades ago. Through aseries of CME conferences andtransfusion peer review, we wereable to reduce the number ofblood transfusions to a levelunmatched in the Twin Citiesor, to the best of our knowledge,anywhere else.

Developing a new approach

The recent studies constitutedrepetition of attempts to placenumbers on measured surgicalblood loss or the level of postop-erative anemia as indicationsfor blood replacement. Usingthese numbers appeared to pro-vide simple (though arbitrary)indications to gauge the need forblood replacement. The resultsof this unthinking approach,used in hospitals nationwidethroughout the mid-20th cen-

tury, was the reason for exces-sive blood replacement with itsinherent adverse effects andincreased costs.

Beginning in the early1970s, the approach we followedat North Memorial was to studythe impressive compensatorymechanisms occurring inpatients with active surgicalblood loss or postoperative ane-mia and then replace bloodphysiologically. The compensa-tion occurs in a stepwise fash-ion, as shown in the abundantexperimental data available fromVietnam battle experience and insurgery on Seventh DayAdventists (a group unwilling tobe transfused). Generous utiliza-tion of balanced electrolyte infu-sions serves to maintain ade-quate tissue perfusion despite

heavy surgical blood loss orsevere postoperative anemia.The initial compensation con-sists of active and passive con-traction of the vascular bed.That reduction preserves ade-quate venous return to the heart,thereby maintaining cardiac out-put. The next 24 to 36 hoursinvolve restoring the preopera-tive blood volume by extracellu-lar fluid, a process readily sup-plemented by generous infusionsof electrolyte solutions. After 24to 36 hours, erythrocyte concen-tration of organophosphates,notably 2,3 DPG (the substancein the red blood cells thatenhances the movement of oxy-gen from red blood cells to bodytissues), is increased, furtherenhancing oxygen release fromred cells to tissues.

The above compensatorymechanisms are very significant,far greater than most cliniciansappreciate, as they enable main-tenance of adequate tissue per-fusion despite major surgicalblood loss or profound postoper-ative anemia. The adequacy ofcompensation can be ascer-

Blood transfusionpractices

Re-inventing the wheel?

By Seymour Handler, MD


TRANSFUSIONS to page 34

www.mankato-clinic.com

Mankato Clinic is looking for BC/BE physicians for our Urgent CareDepartment. Urgent Care is three rotations of 3–12-hour shifts in a week,and one rotation of 2–12-hour weekday shifts plus a Satur-day 8 a.m.— 5 p.m. and Sunday 11 a.m.— 5 p.m. Thereare no Call or hospital privileges required for Urgent Care.Service lines that support our group include our own lab,sleep center, nuclear medicine, Medicare Certified endo-scopic center and radiology department with a 128 slice CTand co-ownership in an ambulatory surgery center.

Opportunity highlights:

• Market competitive compensation guarantee to start,followed by RVU based production income thereafter

• Fully integrated Allscripts electronic medical record

• 35 PTO / CME Days + paid holidays; generous CME allowance

• Practice connects to a regional, 270 bed, not-for-profit Mayo-affiliatedhospital, Level 3 Trauma Center

• State university with 14k students; 150 undergraduate / 100 graduate /4 PhD programs; 1800 Faculty / Staff

• Named one of America’s Promise “100 of the Best Places for Youth”

• Essential retail in the community; Target, Best Buy, Lowe’s, Sears, Old Navy

• Affordable housing: 4-bed, 4.5 bath, 3,572 Sq/Ft. home - $264,900

• 50 miles of local, paved trails / hundreds of acres of community parks

Contact Dennis Davito,Director of Physician Placement,Mankato Clinic, 1230 East Main Street,P.O. Box 8674, Mankato, MN, 56002-8674;phone: 507-389-8654; fax: 507-625-4353;email: [email protected]

URGENT CARE

St. Cloud VA Health Care Systemis accepting applications for the following full or part-time positions:

• Internal Medicine(Alexandria, Brainerd,St. Cloud—Nursing Home)

• Family Practice(Alexandria, Brainerd,St. Cloud)

• Psychiatrist (Brainerd,St. Cloud)

• ENT (St. Cloud)

• Geriatrician(Nursing Home—St. Cloud)

• Hematology/Oncology(St. Cloud)

• Neurology (St. Cloud)

• Dermatology (St. Cloud)

• Disability Examiner(IM or FP) (St. Cloud)

• Weekend MedicalOfficer of the Day(IM or FP) (St. Cloud)

US Citizenship required or candidates must have proper authorizationto work in the US.

J-1 candidates are now being accepted for the Hematology/Oncology positions.

Physician applicants should be BC/BE. Applicant(s) selected for a position maybe eligible for an award up to the maximum limitation under the provision of theEducation Debt Reduction Program. Possible relocation bonus. EEO Employer.

Excellent benefit package including:

Sharon Schmitz ([email protected])4801 Veterans Drive, St. Cloud, MN 56303

Or fax: 320-255-6436 orTelephone: 320-252-1670, extension 6618

Favorable lifestyle26 days vacation

CME daysCompetitive salary

13 days sick leaveLiability insurance

Interested applicants can mail or email your CV to VAHCS


PHYSICIANUniversity of Wisconsin Stout is recruiting for

Physician to join our team of professionalmedical staff. Clinic provides ambulatorymedical care to a campus of over 9300

students. This is a 9 month position, noweekends, holiday, or on call duty.

Send Application to:Janice Lawrence Ramaeker

103 1st Avenue West, Menomonie WI 54751 Send Electronic Transmission of Application

to: [email protected] call 715-232-2114 or visit

http://www.uwstout.edu/geninfo/empop.htmlfor more information.

UW-Stout is an EO/AA Employer. Employment contingent upon passing a

criminal background check.

Two BC/BE Orthopaedic Surgeonswanted to join four orthopaedic sur-geons at Sanford Bemidji OrthopaedicsClinic in Bemidji, Minnesota. Part ofan 85-physician, multi-specialty grouppractice and 118 bed acute care hospi-tal. 1:6 call anticipated. Competitivecompensation/benefits package, paidmalpractice, relocation assistance andmore. Sanford Health of NorthernMinnesota has 1,450+employees andis part of Sanford Health system basedin Fargo, ND and Sioux Falls, SD.

Bemidji, Minnesota, located in north-western Minnesota, is a beautifulresort community offering exceptionalschools, a state university, and year-round cultural activity as well as greataccess to the outdoors for year-roundrecreation activity. To learn moreabout this excellent practiceopportunity contact:

Kathie Lee,Director Physician PlacementPhone: 701-280-4887Fax: 701-280-4136Email: [email protected]

AA/EOE

OrthopaedicSurgery

OpportunityLive in Beautiful

MinnesotaResort Community

www.olmstedmedicalcenter.org

Olmsted Medical Center,a 150-clinician multi-specialty

clinic with 10 outlyingbranch clinics and a 61 bed

hospital, continues to experiencesignificant growth.

Olmsted Medical Centerprovides an excellent opportunityto practice quality medicine in a

family oriented atmosphere.

The Rochester communityprovides numerous cultural,educational, and recreational

opportunities.

Olmsted Medical Centeroffers a competitive salary

and comprehensivebenefit package.

Send CV to:

OlmstedMedical Center

Administration/Clinician Recruitment

1650 4th Street SE

Rochester, MN 55904

email: [email protected]

Phone: 507.529.6610

Fax: 507.529.6622

EOE

Opportunities availablein the following specialty:

Family MedicineRochester Northwest ClinicRochester Southeast Clinic

St.Charles Clinic

Internal MedicineSoutheast Clinic

Occupational MedicineSoutheast Clinic

DermatologySoutheast Clinic

Minneapolis VA Medical CenterMedical Director of Community-Based

Outpatient Clinics

The Minneapolis VA Medical Center (MVAMC), affiliated withthe University of Minnesota, is seeking a dynamic leader for theposition of Medical Director of the Community-Based OutpatientClinics (CBOCs).The Director supervises the clinical operationsand providers of 10 clinics throughout Minnesota andWisconsin,and oversees the development of several new clinics in bothmetropolitan and rural settings.We seek a physician with experi-ence in ambulatory medicine and administration who will pro-vide leadership and clinical duties for the CBOCs.The CBOCsprovide primary care, and mental health care onsite and throughtelemedicine to more than 20,000 veterans.This position wouldinclude an academic appointment at the University of Minnesota.Applicants must be board-certified in Internal Medicine andexperience working inVA facilities is preferred.Competitivesalary, possible recruitment incentive, and benefits with perform-ance pay.

Interested candidates should contact Don Rainwater,413-584-4040, ext. 2907, or [email protected].

Equal Opportunity Employer

tained by simple clinical obser-vations—pulse and blood pres-sure, urine output, warmth ofskin, and mental state. Arbitraryassays of measured surgicalblood loss or level of anemia areinferior to the readily observedclinical parameters.

Our efforts at North Memor-ial to improve transfusion prac-tices in surgical care were notinitially accepted enthusiastical-ly by surgeons and anesthesiolo-gists. Not surprising! As a non-clinician pathologist, farremoved from the surgical envi-ronment, I had no direct patientcare responsibility. What I wasproposing was to alter physicianbehavior. Besides, surgeons didnot see a problem; they simplyordered replacement transfu-sions with scant consideration,just as they were trained to do.And their patients did just fine.Blood bank logistics and costcontainment were not theirproblem.

I was fortunate to gain theattention of some key and influ-ential physicians who workedsolely at North Memorial. They

were willing to modify theirbehavior in transfusion philoso-phy. As soon as they overtly lim-ited their transfusion usage andnoted that their patients didwell, they were convinced.

Results of a peer review study

Over the years, during which Iwas invited to present our trans-fusion program at several TwinCities and outstate hospitals, itbecame apparent to me that wewere accomplishing somethingdifferent; our transfusion prac-tices were clearly superior. Thisimpression was reinforced byseveral physicians at North whoalso worked at other hospitals,where emphasis on reducingtransfusions was rare.

All of the above observationswere based only on impressionsor hearsay. What I desired wasto collect hard data and publishour results. Unfortunately, mytime was occupied by an activepathology practice and a grow-ing responsibility for educationof medical students at theUniversity. Purely by coinci-dence, I was handed a copy of areport on the quality of surgical

practices in Minnesota by a localpeer review organization, theFoundation for Health CareEvaluation (in 1997, the organi-zation merged with the HealthOutcomes Institute to becomethe quality improvement organi-zation Stratis Health). Thisrequired Medicare study in-cluded data on blood transfu-sions. The study involved fivelarge community hospitals, fourin the Twin Cities and one out-state. The case content of thestudy were five commonly per-formed operations, all of whichfrequently involve transfusions.More than 500 cases were stud-ied, the majority derived fromNorth Memorial. The dataassembled were numbers oftransfusions, surgical bloodloss, and blood hemoglobinpreoperatively and on the day ofdischarge.

Results confirmed thatNorth administered much lessblood for the five proceduresthan did the other four institu-tions. North transfused only 7percent of cases; the other fourranged from 40 to 80 percent.Despite using much less blood

replacement, the patient out-comes at North were compara-ble to the others. The sole differ-ence was the number of bloodtransfusions administered.

Advantages of improvedtransfusion practices

Several advantages can be real-ized from the improved transfu-sion practices. Better patientcare can be achieved becauseblood transfusions may createwell-described adverse effects.Although we did not know abouthepatitis C virus and its abilityto cause chronic hepatitis at thetime, we now know that we mayhave prevented hundreds ofcases. In addition, using lessblood could improve the logis-tics of the blood supply.

Finally, fewer transfusionscould save a lot of health caredollars. Currently a single bloodtransfusion costs approximately$500. Our program both savedmoney and enhanced patientcare. The knowledge is available.Let’s use it.

Seymour Handler, MD, is a retiredpathologist who lives in Edina.


Transfusions from page 32

Crookston, MN, a strong community of8,000, is located along the Red Lake Riverin the heart of the fertile Red River Valley.Altru Clinic—Crookston is a well-established,collegial medical group with 3 FamilyPractice Physicians, 3 Internists and 4Mid-Level Providers. We have an ongoingpartnership with RiverView Hospital inCrookston that is a 25-bed, critical-accesshospital connected to our clinic. Call is 1:10.

Roseau, MN, which is just 20 minutes frombeautiful Lake of the Woods, is a FamilyPractice clinic consisting of 6 Family PracticePhysicians and 3 Mid-Level Providers.The town of Roseau has over 2,500 residents.LifeCare Medical Center is a 25-bed, critical-access hospital just adjacent to our clinic.Our friendly community is safe andwelcoming. Call is 1:7.

Altru is a physician-led, not-for-profitintegrated health system that serves a referralpopulation of more than 225,000. More than180 physicians representing 44 specialtiesserve this population base. Altru HealthSystem provides competitive compensation,reviewed annually with specialty-specificindustry data, along with an extensivebenefits package including generous pensionand profit-sharing plans.

Contact:

Kerri Hjelmstad, Physician RecruiterAltru Health SystemPO Box 6003Grand Forks, ND 58201-60031-800-437-5373 Fax: [email protected]

Family Medicine w/ OB Opportunitiesin 2 Wonderful Rural Locations

Altru Health System is seeking Family Practitioners to join our existingand thriving practices in Crookston,MN and Roseau,MN.

www.altru.org


EOEAn equal opportunity employer and provider

Signing bonus

insurance

Wadena, MN 56482Tri-County

Health CareHealth CareTri-County

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Growing multi-specialty group practicein Northern Minnesota is looking fora BC/BE Family Practice Physician,Internal Medicine Physician,Emergency Room Physician,OB/GYN Physician, Urologist as well asan Orthopaedic Surgeon. Join an existinggroup practice and take over existingpractices from departing physicians. GrandItasca Clinic & Hospital in Grand Rapids,Minnesota has recently opened a new stateof the art clinic & hospital. Excellent salaryguarantee with outstanding incomepotential, full benefits and sign-on bonus.Community located in the beautifulnorthern Minnesota lakes area.

Contact: Gail Anderson(218) [email protected].

h e a l t h p a r t n e r s . c o m

Urgent CareMinneapolis /St. Paul

We have part-time and on-call positions available at a variety ofTwin Cities’ metro area HealthPartners Clinics. Evening and weekend shifts are currently available. We are seeking BC/BE full-range family medicine and internal medicine-pediatric(Med-Peds) physicians. We offer a competitive salary and paidmalpractice.

For consideration, apply online at healthpartners.jobs and followthe Search Physician Careers link to view our Urgent Careopportunities. For more information, please contact [email protected] or call Diane at: 952-883-5453; toll-free: 1-800-472-4695 x3. EOE

Family PracticeUrgent Care

NEW POSITIONS:

Dynamic, independent 3 location, single-specialtypractice in northwest Minneapolis suburbs is seekingadditional associates for its Rogers site and has Full Time/Part Time shifts in the Crystal and Rogers Urgent Care.

• Partnership opportunity after 2 years

• Competitive salary with incentives

• Excellent benefits, 401k/employer paid pension

• Practice at one site/one hospital

• Physician-owned

Please contact or fax CV to:Joel Sagedahl, M.D.

1495 Highway 101 North, Plymouth, MN 55447763-504-6600 • Fax 763-504-6622

Visit our website at www.NWFPC.com

safe procedure, and it is mini-mally painful.

Imaging or CSF biomarkersalso provide evidence of neuro-degeneration due to AD.Hippocampal atrophy is a com-mon feature at autopsy in peo-ple with AD. With the availabil-ity of the coronal imaging ca-pability of MR, hippocampalatrophy was indeed found inpatients with AD dementia.Unfortunately, there is consider-able overlap of simple measure-ments of hippocampal atrophybetween AD dementia patientsand others (either cognitivelynormal or with other demen-tias). There are visual ratingscales for hippocampal atrophy,as well as quantitative softwareapplications that might be moreaccurate. In addition, there hasbeen increased interest in quan-titative measurements of otherbrain regions that characteristi-cally undergo atrophy in AD.These might prove to be morediscriminating. For now, logisti-cal and computational limita-tions will keep quantitative

cortical volumetric measure-ment techniques in the researchlaboratory.

PET scanning with thetracer fluorine-18 (F-18) fluo-rodeoxyglucose (FDG), calledFDG-PET, measures brainmetabolism. In AD dementiapatients, FDG-PET shows anapparently unique pattern ofhypometabolism in the lateralparietal, lateral temporal, andposterior cingulate cortices.Although approved by Medicarefor the differential diagnosis ofAD versus frontotemporaldegenerations, it does not offermuch additional value in diag-nosis. Carefully done studies inindividuals with MCI revealedthat those MCI patients whohad the “AD pattern” ofhypometabolism had a greatlyincreased risk for subsequently

developing dementia. But, likehippocampal atrophy, absenceof the “AD pattern” on FDG-PET does not rule out the possi-bility that the cognitive disorderis due to AD.

In addition to structuralMR and FDG-PET imaging,there is a CSF biomarker ofneuronal injury: the micro-tubule-associated protein tau.Although tau protein is an inte-gral component of the histologi-cal hallmark of AD pathology(i.e., the neurofibrillary tangle),elevations in CSF tau occurwith any brain disease thatcauses death of neurons. In thesetting of abnormally low levelsof CSF β-amyloid, elevated CSFtau is a sensitive biomarker forAD pathophysiology. In prac-tice, the commercial assay forCSF AD biomarkers includes

both β-amyloid and tau meas-urements.

From research to clinic?

The revised guidelines forAlzheimer’s state that “presently,the use of biomarkers toenhance certainty of AD patho-physiological process may beuseful in three circumstances:investigational studies, clinicaltrials, and as optional clinicaltools for use where availableand when deemed appropriateby the clinician.”

Though additional researchneeds to be done to validate theapplication of biomarkers, theyhold promise for improved, ear-lier, and more definitive diagno-sis of Alzheimer’s disease, espe-cially in asymptomatic individu-als. Introduction of therapiesfor preventing or delaying theappearance of cognitive deficitsfrom AD pathophysiology willrequire biomarkers to identifythose at risk.

David S. Knopman MD, is a professorin the Department of Neurology, MayoClinic, Rochester, and is an investigator inMayo Clinic Alzheimer Research Center.


Alzheimer’s from page 19 Biomarkers hold promise for improved,earlier, and more definitive diagnosis of

Alzheimer’s disease, especially inasymptomatic individuals.

CardiologyDermatologyENTEmergency MedicineFamily MedicineGastroenterologyHospitalistsInternal MedicineNeurologyOccupational MedicineOncologyOrthopedic SurgeryPediatric SpecialtiesPsychiatryPulmonology (Sleep)RheumatologyUrology

Come home.Where organizational strength lies in the diversity of peoplewho call SANFORD HEALTH – home.

Sanford Health – Fargo Regionis redefining health care. Servingnorthwestern Minnesota andeastern North Dakota,we offerinnovative technology, support ofa multi-specialty organization, anddependable colleagues.

Excellent practice opportunitiesexist in family-oriented communitiesthat offer year-round outdooractivities, cultural events, andsuperior education districts thatwill allow you to balance yourwork & life.

Our employment model featurescompetitive salaries, a comprehensivebenefits package, paid malpracticeinsurance, and a generous relocationallowance.Contact:

Jean KellerPhysician RecruiterPhone: (701) [email protected]

• Internal Medicine• Pediatrics

• Family Medicine

• General Surgery

Lake Region Healthcare is located in a magnificent, rural, andfamily-friendly setting in Minnesota lakes country where weaim to be the state’s preeminent regional health care partner.

Our award winning patient care and uncommon medical specialties set us apart from other regional health caregroups. Lake Region’s physicians and their families also enjoy an unmatched quality of professional and personal life.

Current opportunities including competitive salary and benefit packages available for BE/BC physicians are:

Practice Well.Live Well.

712 Cascade St. S.Fergus Falls, MN736-8000 | (800) 439-6424

For more information contact

Barb Miller, Physician [email protected] • (218) 736-8227

Lake Region Healthcare is an Equal Opportunity Employer. EOE

• Internal Medicine • Family Medicine • Urology

• Pediatrics • General Surgery • Psychiatrist


In the heart of the Cuyuna Lakes region of Minnesota, the medical campus in Crosby includes Central Lakes Medical Clinic, a 30-physician multispecialty group and Cuyuna Regional Medical Center, a critical access hospital offering superb new facilities with the latest medical technologies.Outdoor activities abound, and with the Twin Cities metropolitan area just a short drive away, you can experience the perfect balance of recreational and cultural activities.

Enhance your professional life in anenvironment that provides exciting practice opportunities in a beautiful Northwood’s setting.The Cuyuna Lakes region welcomes you.

CENTRALLAKES

MEDICAL CLINICP.A.

Contact: Todd Bymark, [email protected](866) 270-0043 / (218) 546-4322 | www.cuyunamed.org

We invite you to explore our opportunities in:

• Family Medicine • Internal Medicine• Emergency Room Medical Director

The perfect match ofcareer and lifestyle.

Affiliated Community Medical Centers is a physician ownedmulti-specialty group with 11 affiliate sites located in westernand southwestern Minnesota. ACMC is the perfect match forhealthcare providers who are looking for an exceptional prac-tice opportunity and a high quality of life.Current opportuni-ties available for BE/BC physicians in the following specialties:

• Family Medicine

• General Surgery• Geriatrician/OutpatientInternal Medicine

• Hospitalist

• Infectious Disease

• Internal Medicine• Oncology

• OrthopedicSurgery

• Pain Management

• Psychiatry

• Pediatrics

• Pulmonary/Critical Care

• RadiationOncology

• Rheumatology

For additional information, please contact:

Kari Bredberg, Physician [email protected], 320-231-6366

Julayne Mayer, Physician [email protected], 320-231-5052

www.acmc.com

Physicians:• Let us do your scheduling& credentialing

• Paid Malpractice• Physician Friendly• Choose where andwhen you want to work

• Competitve Rates• Courteous Staff

Clients:• Prevent loss of revenue• BC/BE physicians• Competitive rates• Quality coverage• Malpractice coveragepaid by us

P-763-682-5906/[email protected]

www.whitesellmedstaff.com

Look for thefriendly doctorin a MN based

physician staffingservice ...

is ‘send it to the doctor’ and weneed people to work up to thetop of their license.”

Discussion

We found that physiciansreported increased satisfactionwith their practice after imple-mentation of the medical home.Using qualitative data, we wereable to understand key factorsthat contributed to their satis-faction, such as the teamapproach to patient care andthe addition of chronic diseasenurses to assist with medicallycomplex patients. Physiciansdescribed being able to providehigher quality care for patientsand more often work at the topof their skill level for medicaldecision-making.

Studies of physician satis-faction suggest that conditionssuch as pace, work control,and organizational factors arehighly associated with physi-cian satisfaction. One studyfound that 26.5 percent of pri-mary care physicians reportedburnout, and this burnout was

associated with high stress,decreased satisfaction, andintent to leave the practice.With fewer physicians enteringgeneral internal medicine,increasing satisfaction for prac-ticing internists is important inpreventing burnout and attract-ing more physicians to primarycare. This study adds to thebody of work seeking to under-stand physician perceptions ofpractice redesign and, in partic-ular, the medical home modelof care and key componentshelpful to physicians.

Our most meaningful find-ing was that doctors embracedthe small, dedicated teamapproach to chronic diseasemanagement. They felt itimproved care for patients byproviding resources for educa-tion, access, and care coordina-tion not previously provided.They enjoyed the enhancedrelationships with staff that ateam approach offered, yet didnot describe losing the closerelationship with the patientthat is so important in primarycare. A critical component ofthe team approach was clearly

defined roles for team mem-bers, enabling all members towork at the top of their skilllevel. In the current environ-ment where many primary carephysicians feel overwhelmedwith their workload, it is notsurprising that physicians wel-comed a role-defined, team-based approach to the mostmedically complex patients.

Physical proximity of staffwas repeatedly mentioned askey to team functioning. Themedical home model facilitatedfrequent, informal, face-to-facecommunication among teammembers about patient care.Physicians who were part ofteams in close proximity feltmore connected with theirteams than those in teams moregeographically divided.

Limitations. Our findingsare based on comments from14 physicians at a single site,which limits the ability to gen-eralize. Because the medicalhome intervention was phasedin over years, the potential forrecall bias exists.

A critical component

Physician perceptions of themedical home in their depart-ment were universally favor-able. Key elements were theadded resource of chronic dis-ease nurses and a teamapproach to caring for medi-cally complex patients, allowingphysicians to more often workat the top of their skill level.During a time when primarycare is struggling, improvingthe satisfaction of practicingphysicians is important forretention in and recruitment tothe field. It may in fact be acritical component in improv-ing the U.S. health system.

Mary Sue Beran, MD, MPH;Elizabeth A. Kind, MS, RN; andCheryl E. Craft, RN, are investigatorswith the Park Nicollet Institute in St. LouisPark. Jinnet B. Fowles, PhD, wassenior vice president for research at thePark Nicollet Institute and is currently inthe U.S. Peace Corps in the South Pacificisland of Tonga. This study was fundedby a grant from the Park Nicollet Foun-dation. The authors acknowledge theskilled help of Jennifer O’Connell, BS,senior research assistant, in transcribingeach of the taped interviews.

Medical homes from page 11


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