minnesota physician december 2011

As we approach theend of year, we’llsoon be seeing the

inevitable end-of-the-year“Best of 2011” lists—fromthe frivolous to the pro-found. In health care, high-impact medical news in2011 ranged from food-borne illness to the aftermath of natural dis-asters; and from political concerns and newmodels of care to breakthrough drugs forvarious medical conditions.

For a Minnesota perspective on the pastyear in medical news, we asked physicians toanswer two questions for this feature:1. What was the “big story” or major trendfor your medical specialty/practice in 2011?2. What predictions do you have for yourmedical specialty/practice in 2012?

The physicians’ reflec-tions on 2011’s top stories runthe gamut from new medica-tions and treatments for spe-cific diseases to how newtechnology and paymentmodels are affecting theirpractices. Some see sweepingchanges ahead

due to health care and pay-ment reforms; others envisionprogress in improving patientcare and reducing morbidityand mortality from chronic,relentless diseases.

We thank all the physi-cians who participated in thisfeature for sharing their per-spectives with our readers.

TURNING THE PAGE to page 12 PRSRTSTDU.S.POSTAGE

PAIDDetriotLakes,MNPermitNo.2655

Volume XXV, No. 9

December 2011

HandoffcommunicationCreating a newprocess to improve care

By Sommer Alexander, MS, andMichael Aylward, MD

Consider the following twoscenarios:

• A 52-year-old woman with COPDcomes to the emergency depart-ment (ED) with cough and fever.She is diagnosed with pneumonia,and ceftriaxone and azithromycinare ordered. The ED physician callsthe inpatient physician. The EDnurse calls the inpatient nurse.The patient arrives on the floor,and it is not clear whether she everreceived the antibiotics. The inpa-tient nurse pages the residentadmitting for that night. The resi-dent says, “I've never heard of thatpatient, are you sure she’s comingto us?” And so on.

• The same patient comes into theED, a diagnosis of pneumonia ismade, and the patient is givenantibiotics. The physicians andnurses who were caring for her in

HANDOFF to page 22

The Independent Medical Business Newspaper

IN THIS ISSUE:Senior and long-term carePage 20

Turningthe page

Top stories of 2011,predictions for 2012

CAPSULES 4

MEDICUS 7

INTERVIEW 8

PROFESSIONAL UPDATE:DIABETESBending the curveon diabetes 30By Maggie Powers, PhD, RD,CDE; Teresa Pearson, MS, RN,CDE, FAADE; and Rita Mays,MS, RD, LN

ANESTHESIOLOGYPain control 32By John R. Mrachek, MD

DEPARTMENTS

SPECIAL FOCUS: SENIOR AND LONG-TERM CARE

C O N T E N T S DECEMBER 2011 Volume XXV, No. 9

DECEMBER 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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EDITOR Donna Ahrens [email protected]

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TheIndependentMedicalBusinessNewspaper

Turning the page 1Top stories of 2011,predictions for 2012

Handoff communication 1Creating a new process toimprove careBy Sommer Alexander, MS, andMichael Aylward, MD

FEATURES

www.mppub.com

Jennifer SorensenMinnesota HomeCareAssociation

Age-old injury,updated treatment 24By Edward G. Hames III, MD,PhD, and Charles R. Watts,MD, PhD

Awakenings 26By Laurel Baxter, MA, RN

Home care 28By Amy Nelson

Exp. Date

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MINNESOTA HEALTH CARE ROUNDTABLEMINNESOTA HEALTH CARE ROUNDTABLE

Background and focus:Medications treating chronicand/or life-threatening dis-eases are frequently newproducts, which are oftenmore expensive than genericor older, branded productsthat treat similar conditions.The term specialty pharma-cy has come to be associ-ated with these medications.Exponents claim the newtechnology improves qualityof life and lowers the costof care by reducing hospital-izations. Opponents claimthe higher per-dose costspread over larger popula-tions does not justify theexpense.

The cost of research, bothfailed and successful, is reflected in product pricing. Currentfederal guidelines allow generic equivalents marketplace accessbased on the patent date, not the release date, of a product. Thisconsiderably narrows the window in which costs of advances maybe recovered. A further complicating dynamic involves the payers.Physician reimbursement policies sometimes reward utilizinglower-cost “proven” products and cast those prescribing higher-cost products as “over-utilizers,” placing them in lower-tieredcategories of reimbursement and patient access.

Objectives: We will discuss the issues that guide the earlyadoption of new pharmaceutical therapies and how they relate tomedical devices. We will examine the role of pharmacy benefitmanagement in dealing with the costs of specialty pharmacy. Wewill explore whether it is penny-wise but pound-foolish to restrictaccess to new therapies and what level of communication withinthe industry is necessary to address these problems. With the babyboomers reaching retirement age, more people than ever will betaking prescription medications. As new products come down thedevelopment pipeline, costs and benefits will continue to esca-late. We will provide specific examples of how specialty phar-macy is at the forefront of the battle to control the cost of care.

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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 DECEMBER 2011

State, HennepinCounty to CreateACO ProjectHennepin County and theMinnesota Department ofHuman Services (DHS) arepartnering on a pilot account-able care organization (ACO)project to serve Medicaidenrollees in Hennepin County.

“Hennepin Health” will be ademonstration project servingadults without children whoearn less than $8,172 annuallyfor an individual or $11,040 fora married couple. The projectwill seek to improve outcomesby providing integrated medicaland behavioral health care, andsocial services, while reducingoverall costs.

“DHS is looking at newer,smarter ways of serving Minne-sotans,” says DHS Commiss-ioner Lucinda Jesson. “Weare excited to partner withHennepin County on this proj-ect [that] we think will deliverbetter results for people withhigher needs.”

County officials say theyhope to develop an ACO model

that could be replicated in otherparts of the county. ACOs havebeen in the spotlight recentlyas part of the federalAccountable Care Act, whichproposes using ACOs through-out the country as a way tobetter coordinate care andbring down costs. The Medicaidpopulation targeted by the pilotproject is considered a good testpopulation because it includesmany individuals with higher-than-average needs or complexissues that require coordinationof care.

The county is in a uniqueposition to develop the ACOconcept, Hennepin County offi-cials say, since county organiza-tions are already coordinatingcare. “The county has a cooper-ative network, which includes ahospital, a health care center, asystem of social workers andbehavioral health experts, anda managed care organization,”says Jennifer DeCubellis, thecounty’s area director forHuman Services and PublicHealth Department and directorof the project. “By blendingmedical, behavioral health,

and social services in a patient-centered care model—andmanaging the dollars—weshould reduce costs and theimpact on other systems suchas law enforcement, correc-tions, the courts, and commun-ity agencies.”

Questions RaisedAbout Best Age forCancer ScreeningsA new finding by University ofMinnesota surgeons is raisingquestions about the mostappropriate age for screeningfor rectal cancer.

The American CancerSociety currently recommendsthat Americans age 50 or olderbe screened for colorectal can-cer. But the U of M study, pub-lished in the journal Cancer,found a rise in rectal cancer inpeople age 40 and younger.

The U of M researchers,using the largest cancer data-base in the United States, foundthat signet cell histology, aunique type of cancer cell, wasalmost five times more preva-

lent in those under age 40 withrectal cancer than in olderpatients. “The prevalence ofsignet cell histology in patientsunder age 40 was statisticallysignificant at 4.63 percent ver-sus 0.78 percent in patients over40,” says lead investigatorPatrick Tawadros, MD, PhD.

“While rectal cancerremains fairly uncommon inpatients under 40, the risingtrend, combined with our novelfinding that signet cell histologyis found at a rate of almost onein 20 in this population, iscause for attention,” Tawadrossays. “Clinicians need to beaware of this condition andcarefully assess patients whopresent with any symptoms orsigns that may be suggestive ofrectal cancer.”

Tawadros adds that histeam will do further researchto see if a combination of ge-netic testing and other screen-ings might help in more effec-tively assessing a patient’s riskfor rectal cancer.

C A P S U L E S


Dayton Creates TwoTask Forces forHealth Care IssuesGov. Mark Dayton has createdtwo new task forces to leadhealth care reform efforts inMinnesota.

The governor says hisVision for Health Care Reformtask force will develop anaction plan for reforming howthe state delivers and pays forhealth care in Minnesota. He isalso establishing a task force tohelp set up health insuranceexchanges in the state.

“Minnesota historically hasled the nation and the world inthe quality of our health caresystems and the healthiness ofour residents,” Dayton says.“Minnesota also has been aleader in reforms that haveexpanded access to qualityhealth care for all Minnesotans.We must continue to innovate,and there is real urgency to ourmission. Health care costs arerising at an unsustainable rate,undermining the budgets ofMinnesota families, businesses,and our state and federal gov-ernment budgets. The statusquo is not good enough; weneed to find new ways to deliv-ering better quality health careat a lower price. The mission ofthis task force is to provide rec-ommendations about how wecan best accomplish this.”

Costs Reduced byAllina/HealthPartnersCollaborationA collaborative effort betweenAllina Hospitals and Clinicsand HealthPartners resulted inmore than $6 million in re-duced medical costs in its firstyear, according to the twoorganizations.

The Northwest MetroAlliance attempted to makehealth care delivery more effi-cient by enhancing connectionsbetween health care providers,integrating the electronic med-ical records used by bothorganizations, and providingbetter data to providers aboutperformance in comparison totheir peers.

Some specific strategiesused by the two groups in-cluded increasing the use ofgeneric drugs; reducing the rateof induced labor at Mercy Hos-pital; expanding urgent careservices so that emergencydepartment use was reduced;providing expanded supportfor high risk and complexpatients; and improving patientsatisfaction.

Officials say that as a resultof the collaboration, the med-ical cost growth rate for thefacilities involved dropped from8 percent to 3 percent.

“These results show thevalue of collaboration betweenhealth care organizations tocreate innovative models thatcan serve as an AccountableCare Organization, which aremodels of federal and statehealth care reform,” says PennyWheeler, chief clinical officerfor Allina Hospitals and Clinics.

Nursing Homes JoinProgram to ReduceRehospitalizationsNearly 50 Minnesota nursinghomes are joining an effort toreduce rehospitalizations. Thefacilities are working with theMinnesota Department ofHuman Services (DHS) toimplement a program called“Interventions to Reduce AcuteCare Transfers” (INTERACT).

The program has beenadopted by 49 of the 384 nurs-ing homes in Minnesota, andis based on a national modeldeveloped by geriatric careexperts in Georgia and Florida.The INTERACT program pro-vides a set of tools and prac-tices that help nursing homestaff make better observationsabout residents and changes intheir health status. The pro-gram helps nursing home staffcommunicate more clearly andaccurately with physicians andhospital personnel.

“The overall goal is toreduce the inappropriate use ofhospitals and also to create awork environment for staff inwhich they feel more empow-ered and more committed todoing a good job,” says RobertKane, MD, who leads the Univ-

CAPSULES to page 6

C A P S U L E S


ersity of Minnesota’s Center onAging and is the director of theMinnesota Area GeriatricEducation Center (MAGEC).

MAGEC is leading theeducation efforts with nursinghomes who implement theINTERACT program in Minne-sota. Staff members from par-ticipating facilities will undergoa one-year training program,and a mentor from MAGEC willalso work with participatingnursing homes to carry out theprogram.

Smoking BanCuts Cardiac Deaths,Study FindsA new report by Mayo Clinicresearchers shows that the inci-dence of heart attacks and sud-den cardiac deaths was cut byas much as 50 percent inOlmsted County after a smoke-free ordinance took effect.

The new report, presentedat an American Heart Associ-ation conference in Orlando,shows that during the 18

months before OlmstedCounty’s first smoke-free lawfor restaurants was passed in2002, the regional incidence ofheart attack was 212 cases per100,000 residents. In the 18months following a comprehen-sive smoke-free ordinance in2007, the report says the ratedropped to 103 cases per100,000 residents—a decreaseof about 45 percent. Addition-ally, the report found a 50 per-cent decrease in sudden cardiacarrest cases during that period.

“This study adds to theobservation that smoke-freeworkplace laws help reduce thechances of having a heart at-tack, but for the first time wereport these laws also reducethe chances of sudden cardiacdeath,” says Richard Hurt, MD,director of Mayo Clinic’sNicotine Dependence Center.“The study shows that everyone,especially people with knowncoronary artery disease, shouldavoid contact with secondhandsmoke.”

The study, supported by agrant from anti-tobacco groupClearWay Minnesota, also

found that the adult smokingrate dropped 23 percent afterthe smoking ban began.

MAPS ExpandsScope, Hires NewDirectorThe Minnesota Alliance forPatient Safety (MAPS) haslaunched a reorganization thatwill see the St. Paul-basedgroup expand its scope ofpatient-safety efforts after hir-ing a full-time director.

The group announced inNovember that it had hiredNancy Kielhofner, RN, mostrecently executive director ofquality, safety, and accreditationat Allina Hospitals and Clinics.Kielhofner, who served as MAPSculture workgroup co-chair dur-ing the past year, will now beexecutive director of MAPS.

Kielhofner notes thatMinnesota has been a leader inpatient safety and that theMAPS reorganization will allowthe group to expand on its earl-ier work. “The time has come toreally re-evaluate and raise the

bar even more for patient safetyin Minnesota,” she says. “Themission is to do a thoroughanalysis and assessment of theorganization’s current state,and talk to key safety and quali-ty leaders in health care acrossthe state, including not onlyhospitals but also nursinghomes, long term care, assistedliving, ambulatory clinics, andhospice.”

The expansion of patientsafety efforts is part of a move-ment in the industry to recog-nize the interconnectedness ofcare, Kielhofner says. “This is arecognition that patient safetyis not just focused on hospi-tals,” she says. “We’re reallyexpanding safety efforts acrossthe state in all areas of healthcare because the transitions ofhealth care are so important.”

As part of the restructuring,MAPS will be incorporated asa not-for-profit organization,Kielhofner says, and will beable to expand its membershipbase to a wider range of healthcare facilities and groups.

Capsules from page 5

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Ronald Petersen, MD, has been named chairman of the U.S.Department of Health and Human Services’ new Advisory Council onAlzheimer’s Research, Care and Services. Petersen currently directsthe Alzheimer’s Disease Research Center at the Mayo Clinic inRochester. He also is director of the Mayo Clinic’s Study of Aging. Aschairman of the advisory council, Petersen will lead a group of morethan 20 members from the public and private sectors who will meetquarterly to discuss the effectiveness of government programs that

target individuals who have Alzheimer’s andrelated dementias as well as their caregivers.

Vanessa Knoedler, MD, has joined MetroOBGYN, where she sees patients of all ages atclinic locations in St. Paul, Maplewood, andWoodbury. Board-eligible in obstetrics and gy-necology, Knoedler earned her medical degreeat New York Medical College in Valhalla, andcompleted her residency at Mercy Hospital andMedical Center in Chicago. Her special medical

interests include well-woman care, reproductive medicine, and min-imally invasive and robotic surgeries for conditions such as uterinefibroids. She is on the medical staff of St. John’s Hospital in Maple-wood, St. Joseph’s and United Hospitals in St. Paul, and WoodwindsHealth Campus in Woodbury.

Charles Fazio, MD, has been appointed chief medical officerof Gestalt Health, a Minneapolis-based deliverer of real-time healthcare information to partners within the health care community.Fazio most recently served as the chief medical officer and seniorvice president at Medica Health Plans inMinneapolis. Prior to working at Medica,Fazio practiced at a succession of clinics andmedical centers as a medical director, staffphysician, and emergency room physician.

Four physicians have recently joinedDuluth-based Essentia Health. Erik Wend-

land, DO, has joined theNephrology Departmentat Essentia Health-DuluthClinic. Wendland completed a residency atHennepin County Medical Center in Minnea-polis and a fellowship in nephrology at theUniversity of Connecticut in Farmington. Heattended Lake Erie College of Osteopathic inErie, Pa. Paul Tonkin,MD, has joined the Urol-

ogy Department at Essentia Health-DuluthClinic. Tonkin attended medical school at theUniversity of Minnesota Duluth (UMD), andcompleted his residency in urologic surgery atthe Medical College of Wisconsin in Milwau-kee. He received his medical degree from theUniversity of Minnesota and was in UMD’sRural Physician Associate Program. DavidJorde, MD, has joined Essentia Health’s Lakewalk Clinic as a family

medicine physician. Jorde received his medicaldegree from the University of Minnesota Med-ical School and completed his residency at theDuluth Family Practice Center. Before joiningEssentia, Jorde practiced in Grand Marais andon the Fond du Lac Reservation. JosephLevine, MD, has joined Essentia Health’s Can-cer Center in Duluth as a hematologist/oncolo-gist. Levine received his medical degree fromthe University of Minnesota Medical School

and is board-certified in internal medicine. He completed his inter-nal medicine residency at HCMC in Minneapolis and his fellowshipin hematology/oncology at the U of M.

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� What can you tell us about the mission and his-tory of the Minnesota HomeCare Association?

The mission of MHCA is to be the voice of homecare through advocacy, education, and networking.

The association has been around for 41 years.It was founded by a group of home care providersand has really grown in regard to the needs ofhome care, making sure that there are standards,and that providers have the resources they need tobe able to provide good quality care.

� Tell us a little bit about the different kinds oflicenses your members hold.

In Minnesota, we have four different classes oflicense. There is a class A, what is called a profes-sional home health license. The provider may pro-vide all home care services, such as nursing, physi-cal therapy, speech therapy, occupational therapy,nutrition services, social services, home health aidetasks, or the provision of medical supplies andequipment. These servicesmay be provided in a place ofresidence, including a resi-dential center, and housing-with-services establishments.

The class B, or para-professional agency license,allows the provider to per-form home care tasks andhome management tasks ina place of residence.

The class C licenses theindividual paraprofessional caregiver. We skip Dand E, and go to F. Under this license, a providercan provide home care services solely for a resi-dence of one or more registered housing-with-services establishments. The class F is the assistedliving component; services provided under thislicensure include nursing services, delegated nurs-ing services, or other services performed by unli-censed personnel.

Minnesota is very complex in regard to thenumber of licenses. There is discussion and workbeing done at the state level to revise the currentregulations to collapse all of these into maybe twodifferent types of state licensures.

� What are the kinds of health care servicesprovided by home care?

Skilled care is care for those who are in need ofmedical attention. Skilled services may includeRN oversight; medication management; physical,occupational, and speech-language therapy; car-diac and pulmonary care; wound care; homehealth aide; social services support; and infusiontherapy. There is also hospice and palliative carefor those with terminal illnesses. All of theserequire a physician’s order.

There are also other unskilled or companion-level-care services. These services may includecompanionship, certified nurses aides assisting

with activities of daily living, or even respite careand medication management, and do not requirea physician’s order.

� If a physician determines that a patient wouldbenefit from home care, then how is the homecare provider chosen?

It can be done by direct referral. Most of our agen-cies try to have a working relationship with physi-cian groups, offices, things like that, in regard toreferrals. They will actually go out and let thephysicians’ offices know who they are and whatservices they provide.

Some of the physicians’ offices are set up dif-ferently. They may have a medical social workerwho is available to assist with the referral process,or a discharge planner may assist with patientscoming out of the hospital. A lot of times it’s basedoff a list, or the client could be directed to call thehealth plan to find out who is in your network.

� Tell us about the “face-to-face” Medicare require-ments and their impact onhome care.

Face-to-face is a CMS federalrequirement for physicians tohave seen the patient andsigned off on home care 30days prior to implementationof services or within 60 daysof services starting. If thephysician does not sign off

on that plan of care for the home health agency,Medicare will not reimburse the home healthagency for any services rendered.

It’s one of those things that is very frustratingbecause the physicians really don’t understand,because it doesn’t affect them, other than they haveto schedule an extra appointment that a patientmay or may not necessarily need, and then they’refilling out another piece of paper.

The ramifications of the physician not signingthat piece of paper don’t impact the physician atall, but they impact the home care agency 100 per-cent. Home health agencies are relying on anaction of the physicians, but it’s out of their con-trol, so they spend a lot of time, resources, andback office staff getting that paperwork filled outand making sure that they’re seeing these patients.

� This sounds like it’s an administrative burden forthe physicians, and there’s some resistancethere. How do you deal with that?

A lot of our members have worked together to puttogether a template so that it’s easier for the physi-cian to read, see, and sign off. The home care agen-cies do a lot of hand-holding and calling and fax-ing. I think one agency faxed a form 14 timesbefore they could finally get it signed.

Other states are having bigger issues than we

Jennifer SorensenMinnesota HomeCare

Association

Jennifer Sorensen is theexecutive director of theMinnesota HomeCareAssociation (MHCA).The St. Paul-based

organization represents250 members, including

90 percent of allMedicare-certified

agencies in Minnesota.Sorensen co-chairs theStrategic Communica-tions Committee for theMinnesota Council onAging, is a member ofthe Reducing AvoidableReadmissions Effectively

(RARE) AdvisoryCommittee, and serves

on the PreparingCommittees LeadershipGroup of the Prepare

Minnesota forAlzheimer’s 2020

initiative.

Home care part of total package of health care


I N T E R V I E W

As an association,we would like to partnerbetter with physicians

on education andcollaboration.

are. We have a little better track record inMinnesota. What’s happening in other statesis then they have to write off the servicebecause they can’t get paid, and they end uphaving to discharge the patient. And thatdirectly impacts the patient.

As an association, we would like to part-ner better with physicians on education andcollaboration so that they fully understandthe scope of home care, and what home careagencies can do for them to keep rehospital-izations from mounting. Home care iswhere they’re going to be able to find thatimpact. If we can give the right amount ofservices at the right time, we can eliminatesome of those rehospitalizations.

� Are there areas where that collaborationis better?

I think you’ll see more of that maybe inrural areas—there are only a couple of homehealth providers, and there are only a hand-ful of physicians, so you see better collabo-ration. When you get into the larger metroareas, you see a lot of disconnect becausethere are so many people, it kind of gets lostin the shuffle.

� What’s an example of how home healthagencies communicate with physicians?

There are a few threads that relate back tothe rehospitalization issue. Medication man-agement is the number one rehospitalization

issue. Home health agencies will go into ahome, they’ll be monitoring the main med-ications and then look over to the night-stand and see a bottle of aspirin, a bottle ofTylenol, and of Advil. And as harmless asthey may seem, all these things impact theother regimen of medications. If the patientsays, “I’m still gonna take it because I’vebeen taking baby aspirin for years,” at leastwe can be a vehicle to let the physicianknow that, hey, this is happening, you mayjust want to be aware of this.

� What needs to be done to improve accessto home care?

Reduce the amount of back office adminis-trative components. Even physicians sufferfrom this; this is truly an industry-wideissue. You have to have double the staff inthe office just to get paid so you can be outsurveying your patients and your clients intheir homes or in their medical office. It’sreally kind of gotten out of control in termsof trying to put in safeguards for fraud andabuse and those types of things.

We just did a cosponsored event with agroup from the Netherlands that has madesome innovations in home care. One of thethings said at the table was, we keep pilingregulation upon regulation to try to fix anissue within the system. But what we don’tdo is go back and take the other regulationsoff to really realign it. So it’s almost like we

need to wipe the slate clean and start over.The other issue is the cost of care. As

the cost rises and people live longer, we haveissues with how to continue services asreimbursement gets cut. We keep gettingmore and more people needing more com-plex services, but the reimbursement ratesfor those services keep plummeting. Itmakes it very difficult for home health agen-cies and other specialties to stay alive. I’veheard some say, well, people just get intohome care because there’s a lot of money tobe made. I really find that to be untrue.

� What is the most important thing youwant doctors to know?

I want them to know that home health careaugments total care. It needs to be in play ina whole plan of care. If there are ever ques-tions about it, do not be afraid to call thehome health agency and ask, because theyare more than willing to educate and sharewith physicians. Especially if you’re dealingwith chronically ill folks that need care, it’sdefinitely a positive option for patientsbecause a lot of that monitoring and day-to-day care can be taken care of, and the physi-cians can know that they’re receiving goodcare at home.

At the end of the day, it’s about thepatient; it’s not about the physician or thehome health agency. It’s about, did we pro-vide the best care for this individual?


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References: 1. Jackson EK. Renin and angiotensin. In: Brunton LL, Lazo JS, Parker KL, eds. Goodman & Gilman’s The Pharmacological Basis of Therapeutics. 11th ed. New York, NY: McGraw-Hill Companies, Inc; 2006:789-822. 2. Data on fi le. Clinical study report 2327. Novartis Pharmaceuticals Corp. 3. Chrysant SG, Melino M, Karki S, Lee J, Heyrman R. The combination of olmesartan medoxomil and amlodipine besylate in controlling high blood pressure: COACH, a randomized, double-blind, placebo-controlled, 8-week factorial effi cacy and safety study. Clin Ther. 2008;30(4):587-604. 4. Alderman MH, Cohen HW, Sealey JE, Laragh JH. Plasma renin activity levels in hypertensive persons: their wide range and lack of suppression in diabetic and in most elderly patients. Am J Hypertens. 2004;17(1):1-7.

ACEI, angiotensin-converting enzyme inhibitor;ARB, angiotensin receptor blocker; BP, blood pressure; CO, cardiac output; PVR, peripheral vascular resistance; RAAS, renin-angiotensin-aldosterone system.

©2011 Novartis 6/11 XHV-1064621

For additional hypertension control,

– Renin triggers RAAS activation1

– Many untreated hypertensive patients, including those with diabetes, have an overactive RAAS4

– ACE inhibitors and ARBs only partially block the RAAS1

Not an actual health care professional.

DRAFT FCB HealthCareFile Name: R1029_Unbranded_Jrnl_Ad Location: PrePressClient: NOVARTISProduct: ALISKERINJob #: 2NOV-ALIS-R1029Live Area: 7"W x 10"H EACHSmall Trim: 8”W x 10.75”H EACHBleed: 17.25”W x 11.125”H Gutter: .5 EACH SIDE OF GUTTERColors: 4C

CAD RouterArt Director: Adam Nemser X2396Production: Barbara Grant X3946Traffi c Person: Stephanie Dalle Molle X3258Mac Operator: scDate: 7/11/11Time: 6pmRound: 25

SIGN-OFF Date Time OK Correx QueryStudio ManagerTraffi cVisual QCEditorCopywriterrCopy SupervisorrArt DirectorrArt SupervisorrAcct. ExecutiveAcct. ExecutiveProduction

COMMENTSRELEASES AS PDFX1A.7/1/11 • Mechanical • JV 7/6/11 • Update Hires -gh7/7/11 • Update Hires • sc7/11/11 • Update Hires • sc

S:14”

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T:16”

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B:11.25”

F:8”

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R1029_Unbranded_Jrnl_Ad.indd 1 7/11/11 5:55 PM

References: 1. Jackson EK. Renin and angiotensin. In: Brunton LL, Lazo JS, Parker KL, eds. Goodman & Gilman’s The Pharmacological Basis of Therapeutics. 11th ed. New York, NY: McGraw-Hill Companies, Inc; 2006:789-822. 2. Data on fi le. Clinical study report 2327. Novartis Pharmaceuticals Corp. 3. Chrysant SG, Melino M, Karki S, Lee J, Heyrman R. The combination of olmesartan medoxomil and amlodipine besylate in controlling high blood pressure: COACH, a randomized, double-blind, placebo-controlled, 8-week factorial effi cacy and safety study. Clin Ther. 2008;30(4):587-604. 4. Alderman MH, Cohen HW, Sealey JE, Laragh JH. Plasma renin activity levels in hypertensive persons: their wide range and lack of suppression in diabetic and in most elderly patients. Am J Hypertens. 2004;17(1):1-7.

ACEI, angiotensin-converting enzyme inhibitor;ARB, angiotensin receptor blocker; BP, blood pressure; CO, cardiac output; PVR, peripheral vascular resistance; RAAS, renin-angiotensin-aldosterone system.

©2011 Novartis 6/11 XHV-1064621

For additional hypertension control,

– Renin triggers RAAS activation1

– Many untreated hypertensive patients, including those with diabetes, have an overactive RAAS4

– ACE inhibitors and ARBs only partially block the RAAS1

Not an actual health care professional.

DRAFT FCB HealthCareFile Name: R1029_Unbranded_Jrnl_Ad Location: PrePressClient: NOVARTISProduct: ALISKERINJob #: 2NOV-ALIS-R1029Live Area: 7"W x 10"H EACHSmall Trim: 8”W x 10.75”H EACHBleed: 17.25”W x 11.125”H Gutter: .5 EACH SIDE OF GUTTERColors: 4C

CAD RouterArt Director: Adam Nemser X2396Production: Barbara Grant X3946Traffi c Person: Stephanie Dalle Molle X3258Mac Operator: scDate: 7/11/11Time: 6pmRound: 25

SIGN-OFF Date Time OK Correx QueryStudio ManagerTraffi cVisual QCEditorCopywriterrCopy SupervisorrArt DirectorrArt SupervisorrAcct. ExecutiveAcct. ExecutiveProduction

COMMENTSRELEASES AS PDFX1A.7/1/11 • Mechanical • JV 7/6/11 • Update Hires -gh7/7/11 • Update Hires • sc7/11/11 • Update Hires • sc

S:14”

S:10”T:16”

T:10.75”B:17.25”

B:11.25”

F:8”

FS:6.5”

F:8”

FS:6.5”

R1029_Unbranded_Jrnl_Ad.indd 1 7/11/11 5:55 PM

F E A T U R E

Charles Horowitz, MDMinneapolis Clinic of NeurologySpecialty: Neurology

2011 has been a major year of transition forthe neurologists at the Minneapolis Clinic ofNeurology, as we make the transition from papercharts to electronic health records (EHR). Thechange to EHR has affected us and our patientsin ways that are significant.

Neurology is a cognitive specialty. We are grounded in gettingthe full story from our patients, doing a thorough neurologic exam,and spending time to discuss our thoughts and plans. In the past,the orders, prescriptions, and letters to our referring doctors wereall paper-based and took a relatively short time to complete, and themajority of our visit was spent in direct care. We now find ourselvesspending a good portion of our time with patients reconciling theirelectronic medication list and waiting for e-prescribed medicationsto be accepted on our computer screen, scrolling through to clickon appropriate orders, and being sure to complete the mandatoryscreens to achieve “meaningful use.” Patients are learning to bepatient with this process. In our effort to maintain the same qualityof care and communication with our patients, the visits are longerand the after-clinic hours are much longer.

The transition to e-medicine is also changing how we physicallysee patients. In 2012 and beyond, we will see more examples oftelemedicine, and telestroke care is going to become increasinglyprevalent in Minnesota and the five-state area. This will potentiallyallow state-of-the-art stroke care to outstate areas.

Neurologic research continues to make amazing genetic discov-eries, but for the first time the editorials are focusing on cost-effec-tiveness of science discoveries and of clinical practices. We can lookforward to increasing dialogue and debate in these areas.

Ann Dillon, MDSharpe, Dillon, Cockson & Associates, PA, EdinaSpecialty: Internal medicine

One of the roles of a primary care internist isto consult with patients about their health carequestions. With a patient population that isgenerally well educated and computer savvy,this means spending a lot of time reviewingissues; possibly correcting advice from trainers,

neighbors, hairdressers, and Dr. Phil; and coordinating care withherbalists, chiropractors, and healers. 2011 seemed particularlyprone to these discussions, as many previous “givens” have beenundergoing re-evaluation. For example:Then: Pap smears yearlyNow: Pap smears every three yearsThen: PSA for prostate screeningNow: Don’t use PSAThen: Take your vitaminsNow: Possible excess mortality with vitaminsThen: Take your calciumNow: Possible excess coronary artery disease with calciumThen: Vitamin D—“Huh?”Now: Does Vitamin D cure heart disease, depression, and arthritis?

As we are one of the few remaining small, independent internalmedicine practices in the area, 2012 will hold many challenges.Electronic health records (EHR) will finally arrive in our practice,a major change that the doctors and staff both dread and anticipate.The financing of said EHR for a small group necessitates some lossof independence and a realignment of our business arrangementsafter 30 years. Consolidation of medical care into “coordinated caresystems” should become more of a reality and change how we prac-tice medicine. This may ultimately eliminate fee-for-service andintroduce bundling of charges that will unite doctors, hospitals, andsocial services in a new network to deliver health care.

Who says you can’t teach old dogs new tricks? Doctors in thenext few years will prove that adage wrong!

Paul Waytz, MDArthritis and Rheumatology Consultants, EdinaSpecialty: Rheumatology

Things occur slowly in rheumatology. Ratherthan experiencing highlights, rheumatologistsget excited more by encouragements or tenden-cies. Blockbusterism is foreign to rheumatology.Given those caveats, 2011 wasn’t too bad.

Though several medications have been usedoff-label to treat systemic lupus, Benlysta (belumimab), a mono-clonal antibody that inhibits certain B-cell activities, became thefirst lupus drug to gain FDA approval in more than 50 years. It isnot precisely clear who will most benefit from the use of Benlysta,which is given intravenously. Patients with severe renal or CNS dis-ease were not included in clinical trials; an endpoint was that peoplegenerally “did better.” Studies have been cited for various shortcom-ings, but the idea of a new drug for a disease with potentially seri-ous morbidity and mortality does offer promise.

2011 provided several studies showing very encouraging safetydata regarding anti-TNF (tumor necrosis factor) medications andrisk of malignancy. These medications have become a mainstay intreating rheumatoid arthritis, psoriatic arthritis, and ankylosingspondylitis. Since their introduction 13 years ago, a major concernhas been higher cancer rates, given TNF suppression—especially inadult RA, where the risk of cancer, especially lymphoma, is alreadyelevated. The studies found that aside from certain skin cancers,rates of cancer were not increased.


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In 2012, another biologic—the first one to be administeredorally—will become available for treating rheumatoid arthritis.More interestingly, perhaps, the extremely effective Enbrel, whichgenerated sales of over $3 billion in 2010, will be the first biologic tolose its patent. The FDA will likely determine the issue of “biosimi-lars” for biologics before this year ends. The pharmaceutical indus-try will need to address issues related to how similar somethinggeneric needs to be, the potential need for comparative clinical tri-als, the prolonged necessity to assess certain side effects, and whatto require for a biosimilar that might be more effective. And thenthere are the cost and coverage issues …

Nicholas J. Meyer, MDSt. Croix Orthopaedics, StillwaterSpecialty: Orthopedics

The latest development in my specialty of handsurgery has been the introduction of the long-awaited collagenase injection (Xiaflex) forDupuytren’s disease. This enzymatic injectablebreaks down the contracted fascia to relievecontracture in appropriate patients with

Dupuytren’s. It has taken more than 10 years to get the product tomarket and into the hands of doctors, and the $3,000 cost per injec-tion reflects that expensive and time-consuming process. So, is thishigh-tech, high-cost alternative “worth it,” when (a) surgery forDupuytren’s costs about the same (and is slightly more effective; and(b) needle aponeurotomy—a low-tech, low-cost, and essentiallyequally effective alternative—are also available? That’s a question wehave to ask. It’s imperative that our health care community continueto rein in health care costs while providing effective care.

Another big development in orthopedic surgery over 2010–2011has been in hip replacement surgery. Less invasive, more bone-spar-ing techniques have been developed and proven to be very effective.However, some of these prostheses showed early wear and looseningcharacteristics and had to be recalled. Fortunately, most of thesepatients do fine and don’t have any symptoms or need for furthersurgery.

Looking to 2012, the health care storm brewing on the horizonthreatens to become a deluge. Our unsustainable state of health—whether it’s Medicare, costs in general, obesity, or drug abuse—needs to be corrected proactively or it will consume our nation’sresources. Orthopedic surgery has been a target for those trying todecrease costs. Whether this is related to a perceived unfair reim-bursement policy for procedures, the cost of implants, or babyboomers needing total joint replacements, it seems that orthopedicsurgeons are coming under increasing attack from the public andothers in health care, and that orthopedic surgery in general willremain under scrutiny. Regardless, our goal in orthopedics remainsthe same: to improve our patients’ lives by restoring function andreducing pain.

Eric Brown, MDMinneapolis VA Medical CenterSpecialty: Psychiatry

Integration of psychiatric consultation into pri-mary care has been seen as a potential solutionto the difficulty of accessing care for manypatients with psychiatric illness. This idea isbecoming a reality, facilitated in part by themedical home movement. The change in role

from direct provider to consultant for certain cases will feelstrange to some psychiatrists, and will require developing a newcomfort level and skill set. I believe it is likely that this will becomean area of specialization for a certain cadre of psychiatrists. There

is no doubt, however, that there will still be a role for the tradi-tional model of care delivery for many, if not most, seriously illpatients.

A new effort by the National Institute of Mental Health, knownas the Research Domain Criteria (RDoC), has set an ambitious andexciting goal of reconceptualizing psychiatric diagnosis on a foun-dation of neural systems that underlie different domains of behav-ior, such as fear circuitry, working memory, or reward learning, forexample. There was a premature attempt to align the fifth versionof the Diagnostic and Statistical Manual of Mental Disorders(DSM-5), due to be published in 2013, with the findings of thiseffort, but this was significantly dialed back after justified accusa-tions of over-reaching. However, this commitment of federalresearch dollars should start to make our diagnostic system gradu-ally more reliable and valid for the future, and enhance our abilityto develop and choose better treatments for our patients.

Colleen Casey, MDCenter for Reproductive Medicine, MinneapolisSpecialty: Obstetrics and gynecology,reproductive endocrinology

It was the beginning of 2011, and I was sittingfor my reproductive endocrinology oral boards.There I sat, trying to recall all of the enzymesnecessary to convert cholesterol to estrogen, thework-up for Cushing’s disease, and ambiguous

genitalia. On the shuttle back to my hotel, it dawned on me howquickly the field of reproductive endocrinology has changed. Veryrarely will I diagnose and manage classic endocrine disorders orabnormalities of pubertal development, as my mentors (and boardexaminers) once did. Granted, I still see these patients, but more


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often than not they come seeking pregnancy. Increasingly, patientswant to store their eggs or sperm for future use for various reasons.Some are facing cancer therapy; others want to delay childbearing.For patients undergoing in vitro fertilization, there is an opportunityto cryopreserve excess embryos. For those ethically against freezingembryos, the choice to freeze oocytes prior to fertilization is analternative option.

Fertility preservation is an emerging field that offers bothmales and females an opportunity to delay childbearing for variousreasons. The technology of preserving cells in the frozen state(embryos, sperm, oocytes, ovarian and testicular tissue) continues toimprove, offering options for both male and female patients at riskfor loss of reproductive function. The problem for cells cooled belowfreezing is that intracellular water crystallizes to form ice and saltconcentrations rise, thus making cell survival impossible. The oocyteis particularly sensitive to freezing due to its large size and mem-brane composition. Advances in cryoprotectant composition andimproved freezing techniques, such as vitrification, offer protectionfor embryos and oocytes from freezing injury. Although theAmerican Society of Reproductive Medicine considers oocyte freez-ing for delayed childbearing experimental, small randomized trialshave shown that oocyte vitrification is an efficient method to pre-serve oocytes.

The field of reproductive endocrinology is revolutionizing ourlives, and these advances hold great promise for the future.

Luke Benedict, MDAllina Medical Clinic, HastingsSpecialty: Endocrinology

The big story in diabetes is the current assaulton established diabetes medications, so that thevariety of effective treatments seems to beincreasing and decreasing at the same time.

Take Avandia, for example. In the publicmind, this drug is now as reviled as Vioxx. What

was once thought to be a wonder drug has been pulled from themarket due a suspected (although never fully proven) increased riskof cardiovascular events.

Avandia isn’t the only diabetes drug under scrutiny. Its cousinActos, another thiazolidinedione drug, was linked in a recentEuropean study to an increased risk of bladder cancer. And drugs inthe GLP-1 analogue and DPP-IV inhibitor category (Byetta, Victoza,Januvia, Onglyza, Tradjenta) appear to increase the risk of pancre-atitis and, possibly, some malignancies.

Of course, what has really changed is patients’ knowledge of thebenefits and risks of the medications they are taking. A simpleGoogle search of “Avandia and heart attack” yields 1.5 millionresults; the top two direct you to law firms.

People are much less willing to continue to take a medicationthat has the faintest whiff of negative publicity (has anyone else hada patient stop taking alendronate in the last year because shethought her jaw would become necrotic?).

What is missing from all this is good science—a true risk/benefitanalysis of treatment. When patients voice concerns regarding theirmedications at clinic appointments, I simply review with them theknown benefits of the medication, and the known risks. Lettingpatients with osteoporosis know that the likelihood their alen-dronate will prevent a hip fracture is substantially higher than theirrisk of developing jaw osteonecrosis is usually reassurance enough.

The future of endocrinology, and of diabetes management inparticular, seems to be a circling back to the past. Time-proven med-ications—sulfonylureas, metformin, and insulin—may again be thepreferred mainstays of therapy.

Thaddeus Walczak, MDMINCEP Epilepsy Care, MinneapolisSpecialty: Neurology (epilepsy)

Most contemporary epilepsy treatment attemptsto continuously prevent seizures from startingup because it is usually impossible to predictwhen seizures will occur. The ideal epilepsytreatment would be activated only when aseizure starts and before the seizure causes

impairment. Such a treatment would prevent clinical manifestationof the seizure without continuously subjecting patient to side effectsof the treatment.

Class I trials of two novel therapies aiming to achieve this goalwere reported in the last year (Epilepsia(51), 2010; Neurology(77),2011). Both involved a new approach to treating seizures: directstimulation of brain. The SANTE (Superior Anterior Nucleus of theThalamus in Epilepsy) trial examined results of continuous stimula-tion of both anterior nuclei of the thalamus via depth electrodes ina group of patients with very severe epilepsy. In approximately40 percent of patients, the number of seizures was reduced by morethan 50 percent during the blinded portion of the trial. Perhapsmore interesting was a trial of the Responsive Neurostimulator(RNS). This device is a small processing unit implanted in the skulland attached to two or more electrodes placed directly on the areaof cerebral cortex known to cause seizures in that particular patient.The RNS device is programmed to detect seizures and deliver cur-rent to the seizure onset area immediately after seizure is detected.


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Unfortunately, bottom-line results were somewhat disappointing;approximately 35 percent of patients had seizures reduced by morethan 50 percent during the blinded portion of the trial.

While these results are no different than those achieved withmedications, I think the approach underlying both trials is likely tolead to significant breakthroughs in the next decade if not in 2012.It is increasingly reasonable to imagine a world in which implanteddevices play an important role in controlling seizures when medica-tions don’t work. But a lot more work needs to be done.

Timothy D. Henry, MDMinneapolis Heart InstituteSpecialty: Cardiology

The major advance in cardiology in 2011 has tobe the tremendous progress made in the avail-ability of percutaneous valve replacement, forboth aortic stenosis and mitral regurgitation.This effort has just culminated with the FDAapproving the first percutaneous valve for aortic

stenosis in the United States. This continues the shift towards lessinvasive therapy for cardiovascular disease, which also includes theadvantages of drug-eluting stenting for patients with left main coro-nary artery disease, compared to CABG (coronary artery bypassgraft) surgery.

Over the last decade we have experienced a major reduction inthe mortality for cardiovascular patients. For example, in Minnesotacardiac disease is no longer the No. 1 cause of death; and in particu-lar, deaths from heart attacks have decreased by more than 60 per-cent over the past 10 years. A consequence of this success is an olderpopulation with more complex disease. So the issue of percutaneousvalves is extremely important because we have an increasing popula-tion of patients 85 to 95 years old with severe aortic stenosis, livingat home. For these patients, open-heart surgery is frequently toohigh-risk, so the availability of a percutaneous valve procedure is amajor advance.

Since we have made such major progress in the mortality prob-lem, we are now working on quality-of-life issues. We are seeingincreasing complexity in patients who are living longer. I think thenext major advance will be stem-cell therapy for cardiovascular dis-ease. We’ve already made significant progress this year in cell ther-apy for patients with heart attack, refractory angina, heart failure,and peripheral arterial disease. In particular, we have strong evi-dence that stem-cell therapy works for patients who need to grownew blood vessels. Growing new heart muscle is a much greaterchallenge that will take more than a few years, but we’re moving inthat direction.

Nancy Hutchison, MDSister Kenny Rehabilitation Institute/Virginia PiperCancer Institute, MinneapolisSpecialty: Physical medicine and rehabilitation

The big story in my practice is the growth ofcancer rehabilitation as the key to cancer sur-vivorship. Research on cancer rehabilitation hasexploded in the last few years, and cancer sur-vivors are availing themselves of resources that

can minimize the impact of the morbidity from cancer treatment aswell as improve and enhance recovery.

Patients are better informed about treatment options now. Oncethey have a treatment plan for the cancer, they want to know how tomaintain function and minimize the side effects of treatment. Forexample, I now see patients before they start radiation for head andneck cancers, to get them started on throat, neck, and arm exercisesthat will help stave off the stiffness and weakness that can lead toaspiration and muscle contractures.

Cancer rehabilitation also has changed in the past year inresponse to evidence that early exercise, including weightlifting,and reduction of obesity reduce the risk of lymphedema. Sincemany breast cancer survivors have chest and arm pain, the CancerRehabilitation Clinic is the first step toward fixing the problemsthat prevent patients from taking advantage of these importantlifestyle changes.

Physical medicine and rehabilitation (PM&R) has alwaysfocused on function and on developing techniques to improve qual-ity of life and restore function. We’re now applying that focus onfunction to serve the need in cancer survivors.

We expect PM&R cancer rehabilitation to grow, and growthmeans more physiatrists will be needed to enter this area of speci-alty. Recommendations for optimal screening and early detection ofcancer-related morbidity will help oncology providers direct theirpatients to early rehabilitation care. The weakness and medicalfrailty induced by cancer treatment will not be viewed as “normal”anymore. Measuring and tracking outcomes from cancer rehabilita-tion will make the public aware of the cost-effectiveness and impor-tance of cancer rehabilitation as an integral part of cancer recovery.

Richard C. Lussky, MD, MPH, FAAPHennepin County Medical Center, NewbornIntensive Care Unit/Infant Apneaand Pulmonary ProgramSpecialty: Neonatal medicine

Newborn screening has evolved greatly since theintroduction of the Guthrie test for PKU testingin 1962. In 2011, the field of newborn screeningincorporated, for the first time, point-of-care

testing with the recommendation to screen each newborn infantwith pulse oximetry in the first 24 to 48 hours of life for critical con-


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genital heart disease (CCHD). Each year, 4,800 infants (11.6/10,000births) are born with CCHD and are at significant risk for disabilityor death if not diagnosed soon after birth. The most recent recom-mendations are at www.cdc.gov/ncbddd/pediatricgenetics/CCHDscreening.html and in the October issue of Pediatrics. Additionally,the Minnesota Department of Health’s Newborn Screening AdvisoryCommittee will soon provide a recommendation regarding a new-born pulse-oximetry screening algorithm.

In 2012, care of neonates will continue to improve, based on theawareness that in high-risk newborns there is the potential for life-long sequelae of multisystem organ injury, neurodevelopmentaldelays, and even death related to care provided in the first minutesto hour of life. The delivery room is becoming an extension of thenewborn ICU with the incorporation of sophisticated ICU technol-ogy and the ability to provide real-time audiovisual feedback to opti-mize collaboration and communication among multiple health dis-ciplines that are present for high-risk deliveries.

We also are seeing a shift from a focus primarily on survivaland life support-based interventions (as mortality rates have greatlydiminished) to a more prevention-oriented approach to support.This is based on an improved understanding of the multidimen-sional nature of premature birth and the subsequent diseaseprocesses affecting very immature organ systems and the interplayamong organ systems. An example is the multimodal approach topreventing neurological sequelae in high-risk populations of prema-turely born infants using prenatal betamethasone, inhaled nitricoxide, surfactant, indomethacin, and caffeine—all working on differ-ent pathways of the pathogenesis of brain injury in the prematurelyborn neonate.

Ronnell Hansen, MDMinneapolis VA Medical CenterSpecialty: Radiology

For radiology, issues of dose reduction and reim-bursement have been significant in 2011 andwill continue to take center stage in 2012.

The primary focus has been on health/safety,as concerns over imaging radiation are drivinginnovative efforts at dose reduction and accurate

reporting/tracking exposures over a patient’s lifetime. Various mod-els estimate relative risks of single/lifetime radiation exposure; how-ever, extrapolation to individual patient risk is challenging at best,with indeterminate predictive accuracy. The American College ofRadiology has coordinated with several professional organizations,simplifying the individual-patient approach by using ALARA (“aslow as reasonably achievable”) and diagnostic appropriateness prin-ciples: 1) protocols maximally lowering exposure while maintainingdiagnostic accuracy and 2) evidence-based computer-ordering sup-port gauging relevance to the clinical question. New software, vari-able x-ray energies, and super-fast scanning all contribute to signifi-cantly lower dose, often by 40 percent to 60 percent. Lower volumeof IV contrast is also often possible, reducing patient renal stressand risk of reactions. While attention particularly focuses on themost vulnerable (pediatric and chronic disease patients), globalefforts are directed to every patient.

As in all of medicine, reimbursement reduction is complexand onerous to sustainability of practice and access for patients.Medicare funding for imaging has been cut seven times in six years,$5 billion since 2007 (spending is now at 2004 levels). Imaginggrowth is now low, at 2 percent. The Obama Administration hasrecommended an additional $1.3 billion in imaging cuts; many inpolicy agree this may damage patient access to care and threaten


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the sustainability of private practice.Radiology is in consensus with all of medicine that we must

reduce costs and that imaging is vital to that solution. Of great con-cern, however, is that proposed new reductions will disproportion-ately affect multiple trauma, stroke, and cancer patients, who oftenrequire multiple scans interpreted by different subspecialty radiolo-gists to survive serious illness/injury. As patient advocates, we mustall stay tuned to unintended consequences of reform.

Richard L. Lindstrom, MDMinnesota Eye Consultants, MinneapolisSpecialty: Ophthalmology

While we live in a period of transformation andturmoil in American medicine, the future isbright for the ophthalmologist who positions thepractice properly. The 78 million baby boomerswill demand access to the best care availableand choice of who delivers it. Ophthalmologists

can provide primary eye-care services through the most complex ter-tiary surgical care, although the overall number of ophthalmologistsin the U.S. is shrinking.

The successful practice in the future will use an integrated eye-care delivery model. Ophthalmic surgeons will practice collegiallyand provide well-coordinated care along with medical ophthalmolo-gist and optometry business partners. Each of these practitionerswill be supported by technicians and assistants, all of whom shouldbe focused on providing easy access for patients and synchronizingservices among all care-team members. The practice will functionmost effectively when focused on a single line of business: eye-careservices. The magic is in the integrated eye-care delivery systemmodel, not the scale.

The big story in ophthalmology in 2011 was the introductionof Femtosecond laser-assisted cataract surgery. Today’s cataractpatients are generally able to choose their refractive outcome witha variety of intraocular lenses now available. Some of these lensescan correct astigmatism and provide for reading or multifocal capa-bilities. Although the Femtosecond laser-assisted cataract surgery isvery new technology, the hope is that it will provide more precisionand predictability to meet patients’ desired refractive outcomeswhen used in conjunction with certain types of intraocular lenses.As cataract and refractive surgery are becoming more integrated,the future thriving ophthalmologist will need to successfully acquireand blend both surgical skills.

Anne M. Murray, MD, MScHennepin County Medical Center, Geriatrics DivisionSpecialty: Geriatrics

This summer, after 10 years of preliminary workand publications, I was very fortunate to receivea five-year grant from the National Institute onAging for a study that will measure stroke andcognitive impairment in chronic kidney disease(CKD) patients: the BRain IN Kidney disease

(BRINK) Study. The grant has transformed my career. It has enabledme to form an outstanding interdisciplinary team of collaboratorsfrom the University of Minnesota Medical School, VeteransAdministration Medical Center (VAMC), and Mayo Clinic. We willexplore why patients with moderate CKD (GFR <45) have four timesthe risk of stroke and twice the risk of dementia compared topatients without CKD. We will obtain brain MRIs and laboratorytests to measure the roles of stroke, white matter disease, inflamma-tion, and dialysis initiation on cognitive decline.


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My goal is to use this study as a springboard for ancillary stud-ies and to give Hennepin County Medical Center (HCMC) and theUniversity of Minnesota Medical School trainees an opportunity todevelop their own research careers. The study will be conducted atthe Berman Center and the Chronic Disease Research Group atHCMC, the VAMC, and the Mayo Clinic in Rochester.

The view to the future in geriatrics is less promising. There is aremarkable lack of “story” for academic geriatrics at the U of MMedical School, from the meager geriatrics and dementia medicalschool curriculum, to the absence of a geriatrics research institute,to unwillingness to support a division of geriatrics. As the healtheconomics of the aging population confronts every health sector andthe need for clinicians and researchers with geriatrics trainingexplodes, the university persists instead in making investments instem cell research, regenerative medicine, and medical devices. It ishurting us all. An endowed chair in geriatrics and a division of geri-atrics could begin to build what has been sorely missing for the past10 years.

Robert Ganz, MDMinnesota Gastroenterology, PA, BloomingtonSpecialty: Gastroenterology

The field of GI continues to evolve quickly. TheAmerican Gastroenterological Association (AGA)recently published a new guideline on the diag-nosis and treatment of Barrett’s esophagus, withseveral notable changes. The new guideline(Gastroenterology, March 2011) calls for screen-

ing for Barrett’s esophagus in patients with multiple risk factors,including the general population of white males over age 50, andpatients with chronic GERD, hiatal hernia, elevated BMI, or intra-abdominal distribution of fat. Also importantly, the guidelineincludes new recommendations for Barrett’s patients with high-

grade dysplasia; for Barrett’s patients with confirmed low-gradedysplasia; and for patients with nondysplastic Barrett’s esophagus(metaplasia only). The guideline notes limitations of scientificknowledge and uncertainty in several areas of Barrett’s, andemphasizes that in areas of uncertainty, decision-making shouldbe shared between physicians and patients depending on the nethealth benefit.

In the area of hepatology, there have been significant recentadvances in the treatment of hepatitis C viral infection (HCV). Thestandard therapy for hepatitis C until very recently was a combina-tion of pegylated interferon-alpha and ribavirin. However, this regi-men was suboptimal, with a sustained virologic response (SVR) ofonly approximately 40 percent for HCV genotype 1, even after 48weeks of therapy. The responses are even lower for black patients orand those for high viral loads or advanced fibrosis. This year hasseen a major advance in HBV therapy with the approval of tela-previr (Incivek) and boceprevir (Victrelis), two new, direct-actingantiviral agents specifically targeted to inhibit proteases necessaryfor viral survival. Addition of these drugs to standard interferontherapy has resulted in dramatic improvements in SVR in boththose naïve to treatment and nonresponders to prior treatment.Several additional direct-acting anti-HCV agents, as well as noveltherapies directed at different HCV targets, are under development.These new therapies are revolutionizing the therapy of type C viralhepatitis.


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Victoza® (liraglutide [rDNA origin] injection)Rx OnlyBRIEF SUMMARY. Please consult package insert for full prescribing information.

WARNING: RISK OF THYROID C-CELL TUMORS: Liraglutide causes dose-dependent and treat-ment-duration-dependent thyroid C-cell tumors at clinically relevant exposures in both genders of rats and mice. It is unknown whether Victoza® causes thyroid C-cell tumors, including medullary thyroid carcinoma (MTC), in humans, as human relevance could not be ruled out by clinical or nonclinical studies. Victoza® is contraindicated in patients with a personal or family history of MTC and in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). Based on the findings in rodents, monitoring with serum calcitonin or thyroid ultrasound was performed during clinical trials, but this may have increased the number of unnecessary thyroid surgeries. It is unknown whether monitoring with serum calcitonin or thyroid ultrasound will mitigate human risk of thyroid C-cell tumors. Patients should be counseled regarding the risk and symptoms of thyroid tumors [see Contraindications and Warnings and Precautions].

INDICATIONS AND USAGE: Victoza® is indicated as an adjunct to diet and exercise to improve gly-cemic control in adults with type 2 diabetes mellitus. Important Limitations of Use: Because of the uncertain relevance of the rodent thyroid C-cell tumor findings to humans, prescribe Victoza® only to patients for whom the potential benefits are considered to outweigh the potential risk. Victoza® is not recommended as first-line therapy for patients who have inadequate glycemic control on diet and exercise. In clinical trials of Victoza®, there were more cases of pancreatitis with Victoza® than with comparators. Victoza® has not been studied sufficiently in patients with a history of pancreatitis to determine whether these patients are at increased risk for pancreatitis while using Victoza®. Use with caution in patients with a history of pancreatitis. Victoza® is not a substitute for insulin. Victoza® should not be used in patients with type 1 diabetes mellitus or for the treatment of diabetic ketoacidosis, as it would not be effective in these settings. The concurrent use of Victoza® and insulin has not been studied.CONTRAINDICATIONS: Victoza® is contraindicated in patients with a personal or family history of medullary thyroid carcinoma (MTC) or in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2).WARNINGS AND PRECAUTIONS: Risk of Thyroid C-cell Tumors: Liraglutide causes dose-dependent and treatment-duration-dependent thyroid C-cell tumors (adenomas and/or carcinomas) at clinically relevant exposures in both genders of rats and mice. Malignant thyroid C-cell carcinomas were detected in rats and mice. A statistically significant increase in cancer was observed in rats receiv-ing liraglutide at 8-times clinical exposure compared to controls. It is unknown whether Victoza® will cause thyroid C-cell tumors, including medullary thyroid carcinoma (MTC), in humans, as the human relevance of liraglutide-induced rodent thyroid C-cell tumors could not be determined by clinical or nonclinical studies [see Boxed Warning, Contraindications]. In the clinical trials, there have been 4 reported cases of thyroid C-cell hyperplasia among Victoza®-treated patients and 1 case in a compara-tor-treated patient (1.3 vs. 0.6 cases per 1000 patient-years). One additional case of thyroid C-cell hyperplasia in a Victoza®-treated patient and 1 case of MTC in a comparator-treated patient have sub-sequently been reported. This comparator-treated patient with MTC had pre-treatment serum calcitonin concentrations >1000 ng/L suggesting pre-existing disease. All of these cases were diagnosed after thyroidectomy, which was prompted by abnormal results on routine, protocol-specified measurements of serum calcitonin. Four of the five liraglutide-treated patients had elevated calcitonin concentrations at baseline and throughout the trial. One liraglutide and one non-liraglutide-treated patient developed elevated calcitonin concentrations while on treatment. Calcitonin, a biological marker of MTC, was measured throughout the clinical development program. The serum calcitonin assay used in the Victoza® clinical trials had a lower limit of quantification (LLOQ) of 0.7 ng/L and the upper limit of the reference range was 5.0 ng/L for women and 8.4 ng/L for men. At Weeks 26 and 52 in the clinical trials, adjusted mean serum calcitonin concentrations were higher in Victoza®-treated patients compared to placebo-treated patients but not compared to patients receiving active comparator. At these timepoints, the adjusted mean serum calcitonin values (~ 1.0 ng/L) were just above the LLOQ with between-group differences in adjusted mean serum calcitonin values of approximately 0.1 ng/L or less. Among patients with pre-treatment serum calcitonin below the upper limit of the reference range, shifts to above the upper limit of the reference range which persisted in subsequent measurements occurred most fre-quently among patients treated with Victoza® 1.8 mg/day. In trials with on-treatment serum calcitonin measurements out to 5-6 months, 1.9% of patients treated with Victoza® 1.8 mg/day developed new and persistent calcitonin elevations above the upper limit of the reference range compared to 0.8-1.1% of patients treated with control medication or the 0.6 and 1.2 mg doses of Victoza®. In trials with on-treatment serum calcitonin measurements out to 12 months, 1.3% of patients treated with Victoza® 1.8 mg/day had new and persistent elevations of calcitonin from below or within the reference range to above the upper limit of the reference range, compared to 0.6%, 0% and 1.0% of patients treated with Victoza® 1.2 mg, placebo and active control, respectively. Otherwise, Victoza® did not produce consis-tent dose-dependent or time-dependent increases in serum calcitonin. Patients with MTC usually have calcitonin values >50 ng/L. In Victoza® clinical trials, among patients with pre-treatment serum calci-tonin <50 ng/L, one Victoza®-treated patient and no comparator-treated patients developed serum calcitonin >50 ng/L. The Victoza®-treated patient who developed serum calcitonin >50 ng/L had an elevated pre-treatment serum calcitonin of 10.7 ng/L that increased to 30.7 ng/L at Week 12 and 53.5 ng/L at the end of the 6-month trial. Follow-up serum calcitonin was 22.3 ng/L more than 2.5 years after the last dose of Victoza®. The largest increase in serum calcitonin in a comparator-treated patient was seen with glimepiride in a patient whose serum calcitonin increased from 19.3 ng/L at baseline to 44.8 ng/L at Week 65 and 38.1 ng/L at Week 104. Among patients who began with serum calcitonin <20 ng/L, calcitonin elevations to >20 ng/L occurred in 0.7% of Victoza®-treated patients, 0.3% of placebo-treated patients, and 0.5% of active-comparator-treated patients, with an incidence of 1.1% among patients treated with 1.8 mg/day of Victoza®. The clinical significance of these findings is unknown. Counsel patients regarding the risk for MTC and the symptoms of thyroid tumors (e.g. a mass in the neck, dysphagia, dyspnea or persistent hoarseness). It is unknown whether monitoring with serum calcitonin or thyroid ultrasound will mitigate the potential risk of MTC, and such monitoring may increase the risk of unnecessary procedures, due to low test specificity for serum calcitonin and a high background incidence of thyroid disease. Patients with thyroid nodules noted on physical examination or neck imaging obtained for other reasons should be referred to an endocrinologist for further evalua-tion. Although routine monitoring of serum calcitonin is of uncertain value in patients treated with Victoza®, if serum calcitonin is measured and found to be elevated, the patient should be referred to an endocrinologist for further evaluation. Pancreatitis: In clinical trials of Victoza®, there were 7 cases of pancreatitis among Victoza®-treated patients and 1 case among comparator-treated patients (2.2 vs. 0.6 cases per 1000 patient-years). Five cases with Victoza® were reported as acute pancreatitis and two cases with Victoza® were reported as chronic pancreatitis. In one case in a Victoza®-treated patient,

pancreatitis, with necrosis, was observed and led to death; however clinical causality could not be established. One additional case of pancreatitis has subsequently been reported in a Victoza®-treated patient. Some patients had other risk factors for pancreatitis, such as a history of cholelithiasis or alcohol abuse. There are no conclusive data establishing a risk of pancreatitis with Victoza® treatment. After initiation of Victoza®, and after dose increases, observe patients carefully for signs and symptoms of pancreatitis (including persistent severe abdominal pain, sometimes radiating to the back and which may or may not be accompanied by vomiting). If pancreatitis is suspected, Victoza® and other poten-tially suspect medications should be discontinued promptly, confirmatory tests should be performed and appropriate management should be initiated. If pancreatitis is confirmed, Victoza® should not be restarted. Use with caution in patients with a history of pancreatitis. Use with Medications Known to Cause Hypoglycemia: Patients receiving Victoza® in combination with an insulin secretagogue (e.g., sulfonylurea) may have an increased risk of hypoglycemia. In the clinical trials of at least 26 weeks duration, hypoglycemia requiring the assistance of another person for treatment occurred in 7 Victoza®-treated patients and in two comparator-treated patients. Six of these 7 patients treated with Victoza® were also taking a sulfonylurea. The risk of hypoglycemia may be lowered by a reduction in the dose of sulfonylurea or other insulin secretagogues [see Adverse Reactions]. Renal Impairment: Victoza® has not been found to be directly nephrotoxic in animal studies or clinical trials. There have been postmarketing reports of acute renal failure and worsening of chronic renal failure, which may sometimes require hemodialysis in Victoza®-treated patients [see Adverse Reactions]. Some of these events were reported in patients without known underlying renal disease. A majority of the reported events occurred in patients who had experienced nausea, vomiting, diarrhea, or dehydration [see Adverse Reactions]. Some of the reported events occurred in patients receiving one or more medica-tions known to affect renal function or hydration status. Altered renal function has been reversed in many of the reported cases with supportive treatment and discontinuation of potentially causative agents, including Victoza®. Use caution when initiating or escalating doses of Victoza® in patients with renal impairment. Macrovascular Outcomes: There have been no clinical studies establishing con-clusive evidence of macrovascular risk reduction with Victoza® or any other antidiabetic drug.ADVERSE REACTIONS: Clinical Trials Experience: Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice. The safety of Victoza® was evaluated in a 52-week monotherapy trial and in five 26-week, add-on combination therapy trials. In the monotherapy trial, patients were treated with Victoza® 1.2 mg daily, Victoza® 1.8 mg daily, or glimepiride 8 mg daily. In the add-on to metformin trial, patients were treated with Victoza® 0.6 mg, Victoza® 1.2 mg, Victoza® 1.8 mg, placebo, or glimepiride 4 mg. In the add-on to glimepiride trial, patients were treated with Victoza® 0.6 mg, Victoza® 1.2 mg, Victoza® 1.8 mg, placebo, or rosiglitazone 4 mg. In the add-on to metformin + glimepiride trial, patients were treated with Victoza® 1.8 mg, placebo, or insulin glargine. In the add-on to metformin + rosiglitazone trial, patients were treated with Victoza® 1.2 mg, Victoza® 1.8 mg or placebo. Withdrawals: The incidence of withdrawal due to adverse events was 7.8% for Victoza®-treated patients and 3.4% for comparator-treated patients in the five controlled trials of 26 weeks duration or longer. This difference was driven by withdrawals due to gastrointestinal adverse reactions, which occurred in 5.0% of Victoza®-treated patients and 0.5% of comparator-treated patients. The most common adverse reactions leading to withdrawal for Victoza®-treated patients were nausea (2.8% versus 0% for comparator) and vomiting (1.5% versus 0.1% for comparator). Withdrawal due to gastrointestinal adverse events mainly occurred during the first 2-3 months of the trials. Tables 1, 2 and 3 summarize the adverse events reported in ≥5% of Victoza®-treated patients in the six controlled trials of 26 weeks duration or longer.Table 1: Adverse events reported in ≥5% of Victoza®-treated patients or ≥5% of glimepiride-treated patients: 52-week monotherapy trial

All Victoza® N = 497 Glimepiride N = 248Adverse Event Term (%) (%)Nausea 28.4 8.5Diarrhea 17.1 8.9Vomiting 10.9 3.6Constipation 9.9 4.8Upper Respiratory Tract Infection 9.5 5.6Headache 9.1 9.3Influenza 7.4 3.6Urinary Tract Infection 6.0 4.0Dizziness 5.8 5.2Sinusitis 5.6 6.0Nasopharyngitis 5.2 5.2Back Pain 5.0 4.4Hypertension 3.0 6.0

Table 2: Adverse events reported in ≥5% of Victoza®-treated patients and occurring more frequently with Victoza® compared to placebo: 26-week combination therapy trials

Add-on to Metformin TrialAll Victoza® +

Metformin N = 724Placebo +

Metformin N = 121Glimepiride +

Metformin N = 242Adverse Event Term (%) (%) (%)Nausea 15.2 4.1 3.3Diarrhea 10.9 4.1 3.7Headache 9.0 6.6 9.5Vomiting 6.5 0.8 0.4

Add-on to Glimepiride TrialAll Victoza® +

Glimepiride N = 695Placebo + Glimepiride

N = 114Rosiglitazone +

Glimepiride N = 231Adverse Event Term (%) (%) (%)Nausea 7.5 1.8 2.6Diarrhea 7.2 1.8 2.2

the ED speak directly and as ateam to the nurses and physi-cians who will be caring for heron the floor. By the time thepatient arrives on the floor, thenurse, resident physician, andattending physician are all onthe same page with regard toher treatment plan and course.

The transfer of informationand responsibility for the careof a patient is called a handoff.It can be a spontaneous after-thought, as in the first scenario,or a carefully choreographedcommunication, as in the sec-ond. Intuitively, clear communi-cation around patient careseems to be the correct path;however, the evidence for this isonly beginning to be uncovered,and the cultural awareness ofthis in health care settings isnot realized.

According to the JointCommission, communicationerrors are the leading cause ofsentinel events in hospitals. Aspatients move through thehealth care system, they are par-ticularly vulnerable to communi-cation errors at the time of tran-

sitions. Nearly every type oftransition of care—outpatient toinpatient, between physicians,between teams, between nurses,between departments, and frominpatient back to outpatient—has been implicated in the litera-ture as a critical safety risk. Inmost cases, handoffs have devel-oped organically out of necessi-ty, and have not been intention-ally designed to address theneeds of the providers involvedor of the specific care situationspatients find themselves in.

Studies of residents, nurses,and emergency departmentstaffs have all shown a subjec-tive sense that patients wereharmed or potentially harmedbecause of a poor handoffprocess. However, there is not aprescriptive method availablecurrently for how to solve therisks posed to patients due tohandoffs. Most articles on thissubject point to deficiencies intechnology and human factorsas the core issues leading tothese negative outcomes. It’sclear that technology, in theform of a reliable, consistentelectronic medical record,

needs to be leveraged to supportthese processes. However, likenearly every aspect of medicine,a technological solution does notsuffice.

Studying “real-world”handoffs vs. staff perceptions

Two years ago the Joint Com-mission created the Center forTransforming Healthcare, anambitious attempt to create bestpractices and disseminate themby working with the JointCommission’s member hospitals.The center chose to use theSix Sigma DMAIC (“Define–Measure–Analyze–Improve–Control”) quality improvementmethodology to identify andcorrect deficiencies in the healthcare system.

University of MinnesotaMedical Center Fairview/Univer-sity of Minnesota AmplatzChildren’s Hospital (UMMC/UMACH) was invited to joinnine other health care systemsand the Center for TransformingHealthcare to collaborate indeveloping solutions to poorhandoffs and provide recom-mendations to other institutionsnationwide. In 2009, representa-tives from the 10 hospital sys-tems met regularly to wrestlewith the problems and solutionssurrounding handoffs.

The collaborative foundhandoff communication to bewidely variable and minimallydefined at all institutions. Thegroup quickly realized that forall the literature showing thathandoffs were a problem, therewas scant evidence on how toactually fix them, or what, if any,best practices existed for hand-offs. The best practices dis-cussed in the literature werelargely expert opinion or hadbeen “harvested” from data fromhigh-reliability organizationssuch as the aviation industry ornuclear power plants. The JointCommission group decided tolook at several metrics pertain-ing to handoffs, ranging fromwhat components were present(and how much they mattered)to how satisfied people werewith the process.

UMMC/UMACH focused onphysician and nurse handoffcommunication from the emer-gency department to two inpa-tient care units: one adult and

one pediatric. UMMC createdfocus groups of residents, physi-cians, nurses, care coordinators,and other members of the healthcare team to discuss the currentstate of handoffs. But trying tomap out the handoff processbetween the emergency depart-ment and inpatient services pre-sented a stumbling block. Itturned out that there was no sin-gle process for communicatingabout a patient moving from theemergency department to theinpatient floor. Instead, therewere many, poorly definedprocesses that often dependedon the individual physicians andnurses.

This presented a problem:Six Sigma DMAIC is a solidquality improvement methodo-logy for improving an existingprocess, but there was noexisting process on which toimprove. Since the chosenmethodology presumed an exist-ing process, we chose to followthe collaborative’s timeline butto use quality improvementmethodologies (e.g., Six SigmaDMADV [Define–Measure–Analyze–Design–Verify] andInnovation tools).

In-situ simulation—video-taped simulations of handoffsfollowed by a debriefing sessionwith those involved—was usedto gather our most critical infor-mation on how handoffs hap-pened in a real-world setting.The in-situ simulations showedclearly that successful handoffswere characterized by active lis-tening, dynamic skepticism, situ-ational awareness, and a shared“mental model” of the patient.In other words, the peopleinvolved in handoffs are ateam—and the attributes of asuccessful handoff are the sameas the attributes of successfulteamwork. These factors, cou-pled with standardized clinicalcontent, formed the foundationfor our handoff improvements.

Our research gave us amodel for understanding hand-offs and a process for changingthem. We spoke of handoffs inthe language of teamwork, alanguage that many of the emer-gency room and floor staff hadalready been trained in andunderstood. We showed the in-situ simulation videos in manyforums, from resident morning


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Handoff from cover

reports to nursing staff meet-ings. Several common themesran through all of the scenariosof poor handoffs: gaps in infor-mation, lack of active listening,time wasted by different mem-bers of the health care team say-ing the same thing, and a lack ofalignment between the ED andthe inpatient care teams.

A new model

The UMMC/UMACH groupused the results of the focusgroup meetings and debriefings,in combination with theresearch literature and in-situsimulations, to identify core ele-ments of effective patient carehandoffs.

The intervention thatemerged was a scheduled con-ference call among nursing andphysician team members caringfor a patient. Specifically, theemergency room resident, andattending physician, and nurseare conferenced in with theinpatient attending physician,resident, and nurse. The patientplacement manager is also onthe call, to facilitate communica-tion and help to quickly get a

bed assigned and the patienttransported. On the conferencecalls, the emergency room andinpatient service jointly review ahigh-level checklist that theyjointly developed. The checklistis standardized to ensure thatinformation is communicated inan expected order and is com-plete, regardless of what individ-ual staff members are involvedin the handoff.

Beginning Dec. 14, 2010, thenew handoff process, using thechecklist and an interdiscipli-nary handoff via conference call,was rolled out for all pediatricunits admitting patients throughthe emergency department.

Results

Results of the implementationshow that using the new hand-off process improved standardi-zation of clinical content ofhandoffs by 90 percent. The

new handoff process reducedthe number of handoffs fromfour to one while decreasing thetime for the handoff by 50 per-cent. Extrapolating the timesavings to all pediatrics emer-gency department admissions,we can predict a reduction ofapproximately 2,100 hours ofclinical work spent on handoffsannually.

The presence of the inter-disciplinary members on theconference call has presentedlogistical challenges. Manage-ment of this change in processis critical because clinicians arenot used to scheduling a timefor ED-to-inpatient handoffs;handoffs are usually occurringwhen staff can fit it in betweenother clinical tasks.

In addition, physicians arenot accustomed to conductinghandoffs with nursing staffpresent in the conversation.

Training about the process andinformation about the benefitsto the patient are critical.

Though adverse events arelow in number, we are monitor-ing our impact on them. Ourfollow-up on staff perceptionsof patient safety and teamworkhas indicated that staff viewthis process as facilitating thepatient experiencing improvedcontinuity of care, and that stafffrom the ED and inpatient unitsfeel more aligned. Perseverancein change management strate-gies such as employee sensingsessions, one-on-one meetingswith leadership, and communi-cation of progress were and con-tinue to be critical to sustainingthis project’s impact.

Sommer Alexander, MS, is Lean SixSigma Black Belt at University ofMinnesota Medical Center, Fairview.Michael Aylward, MD, is assistantprofessor of medicine and pediatrics atthe University of Minnesota MedicalSchool, Minneapolis.


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According to the Joint Commission,communication errors are the leadingcause of sentinel events in hospitals.

The horrible martyrdomso brutally inflicted onPierrette by two imbecile

tyrants—… led, medically speak-ing, to her being subjected byMonsieur Martener, withBianchon’s approval, to theterrible operation of trepanning.… the calumniated Pierrettelanguished in suffering from themost terrible pains known tomedical science.”

—Honoré de Balzac(1799–1850 A.D.), “Pierrette”

According to Centers forDisease Control and Prevention(CDC) data for 2007, accidentaltrauma is the fifth-leading causeof death in all age groups andthe ninth-leading cause of death

in individuals 65 years of ageor older. The top three causesof injury are accidental fall,motor vehicle accident, andunspecified.

Although heart disease,stroke, and cancer rank higherwith regard to cause of death,accidental trauma is the leadingcause of injury in the elderly,with accidental falls being byfar the most prevalent etiology.The total cost of care (medicaland loss of work) in 2005 forelderly individuals sustainingaccidental injury with an associ-ated traumatic brain injury wasapproximately $1.4 billion. Thisdoes not fully account for theemotional costs to the individ-

ual and family due to the lossof function, independence, andcognitive decline.

Though the opening quota-tion from Balzac is perhaps thebest-known literary example,the surgical treatment ofintracranial disease (trephina-tion) with survival of the patientdates back to Mesolithic times.There is fossil evidence of itswidespread use in WesternEurope and Asia, with healedcranial bones dating to 3000 to2000 B.C. Although many ofthese procedures are hypothe-sized to have been done as partof a religious ritual, there is noconvincing evidence to disprovethat they may have been uti-lized to treat missile injuries tothe head and skull fractures.

The first medical treatiseon the treatment of head injurythat classified the types ofinjury amenable to trephinationwas written by Hippocrates ofKos (460 to 377 B.C.) and isconsidered the historical foun-dation of modern neurosurgery.With the decline and fall of theRoman Empire, little develop-ment occurred in the surgical

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Over the next 25 years,

the number of Minne-

sotans over age 65 will

double—from 600,000 to

1.2 million. This shift

will require increasing

attention by health care

providers to meeting the

needs of the aging popu-

lation. This month’s spe-

cial focus looks at three

types of care for seniors:

medical treatment for

head injuries from falls;

a pilot project aimed at

reducing unnecessary

medications in nursing

homes; and home care

options to help seniors

stay in their homes

longer.

S P E C I A L F O C U S : S E N I O R A N D L O N G - T E R M C A R E

To learn more call 651.842.6780www.sttheresemn.org

Palliative Senior Care with the Comforts of Home

Now Open!(Immediate availability)

Palliative care is designed to improve the quality of life at the time when an individual’s disease is not responsive to curative treatment.

rivate care suites and baths in a beautiful 8-bedroom home

-hour nursing supportastoral care programming for

Catholic and non-Catholic residents and their families

herapeutic whirlpool tubuiet and serene location close to

St. Odilia Catholic School and ChurchOngoing bereavement support for

family after the death of a loved one

Saint Therese at St. Odilia features...

sciences. Modern surgicaltreatment of traumatic braininjury is only 130 years old, atmost, with the most dramaticchanges in diagnosis and treat-ment occurring within the last40 years with the advent ofmodern medical imaging (CTand MRI).

In modern neurosurgicalpractice, the role of opening theskull via a craniotomy (trephi-nation) or bur hole is to relievepressure on the brain andrestore a state of normal brainphysiology and metabolism.With the exception of decom-pressive craniectomies (removalof part of the skull) done fortreatment of severe cerebraledema, this usually involves theremoval of a mass lesion.

Types of hematomas

Traumatic mass lesions mayoccur from a variety of sources.

Epidural hematomas occurdue to a hemorrhage betweenthe skull and lining of the brain(dura) and are usually associat-ed with a skull fracture. Theextent of the hemorrhagiccollection is usually confinedby the suture lines of the skull.The presentation is usuallyacute and requires rapid eval-uation and potential surgicalintervention.

Intraparenchymal hema-tomas (contusions) are due toinjury of the small perforatingcapillaries within the brain.They may present either acutelyor in a delayed fashion withinthe first 24 to 96 hours ofinjury. Although surgical treat-ment may be required, they areoften treated with intensivemedical support of the patient.They are considered to be anindication of severe underlyinginjury to the brain parenchyma.

Subdural hematomas(SDHs) are due to a hemor-rhage between the brain andthe dura. They are usuallycaused by a tear in a bridgingvein that runs between the sur-face of the brain and a duralvenous sinus but may also becaused by arterial injury. Theextent of hemorrhage is notconfined by the sutures lines ofthe skull. The presentation maybe either acute, requiring emer-gent surgical evacuation, or

insidious over a period of weeksto months. SDHs developingbetween three days and threeweeks after head injury aretermed “subacute”; those thatare manifest later than threeweeks after injury are definedas “chronic.”

The discussion below cen-ters on chronic subduralhematomas in elderly patients.

Etiology of chronic SDH

The incidence of chronic SDHsin the elderly is 7.4 per 100,000people per year. Between 25 per-cent and 50 percent of thesepatients will have no history ofhead injury, and in those with ahistory of trauma, the injury isoften mild. A significant propor-tion of patients are predisposedto SDHs because of chronicalcoholism, epilepsy, or coagu-lopathies (often related toCoumadin or antiplatelet agents,e.g., ASA and/or clopidogrel).

Small amounts of hemor-rhage into the subdural spaceor larger hematomas in patientswith underlying brain atrophymay fail to produce symptomswithin a week to 10 days. Theinitial hematoma is covered byan outer membrane beneath thedura. By three to four weeks, aninner membrane forms betweenthe hematoma and the pial sur-face of the brain, completelyenclosing the hematoma.During this period the

hematoma liquifies andbecomes progressively morehypodense on CT scans. In thenext weeks, in some patientsthe hematoma graduallyenlarges, and in other patientsthere is a gradual re-absorptionof the liquefied blood.

An etiology of chronic SDHenlargement within the capsulehas been postulated. The albu-min/gamma globulin and totalprotein concentrations withinthe hematoma are much higherthan in the serum, resulting in

a higher osmotic pressure with-in the hematoma. The higherosmotic pressure will drawwater out of the serum into thehematoma via diffusion, thusenlarging the mass. A chronicSDH may also enlarge fromrecurrent smaller hemorrhagesinto its surrounding mem-branes. It is likely that a combi-nation of the two mechanismsis at work in most large, ex-panding chronic SDHs. Thereis considerable CT evidence thatsome hematomas regress in sizeand do not need surgical treat-ment. It is likely there is a bal-ance between hematoma pro-duction and re-absorption. Ifre-absorption exceeds produc-tion, the hematoma will shrink,and when production exceedsre-absorption, the hematomawill enlarge.

Diagnosis and treatmentof chronic SDH

The symptoms and signs ofchronic SDH are extremelyvariable and are not necessarilypathognomonic. In elderlypatients the insidious onset of


BRAIN INJURY to page 38

Create a plan to stay at home for yourself, your aging parents, your partner or a friend.Get step-by-step help to find out how to stay in your home longer and find services near home.

To get started visit www.longtermcarechoices.minnesotahelp.info

Need help to planfor aging at home?

Who uses the navigator tool?People who are thinking aboutstaying in their home while theyget older. People who are trying tofigure out how to handle yard work,groceries, help for an older parent, orassisting their partner and friends.

What areas does it assist with?

Who can I call for assistance?Senior LinkAge Line® at 1-800-333-2433Monday–Friday 8 a.m. to 4:30 p.m.

Home maintenanceSafetyHousing options

MedicationsCaregiver supports

FIGURE 1. A 76-year-old male witha three-month history of cognitivedecline, increasing agitation, andworsening gait instability after sus-taining a fall three months prior topresentation. (A) CT of the headdemonstrating bilateral chronic sub-dural hematomas of mixed densitywith significant cerebral and ven-tricular compression. (B) CT of thehead at two months post-bilateralbur hole drainage, demonstratingalmost complete resolution of thesubdural hematomas and restora-tion of normal ventricular volume.The patient experienced a near-complete resolution of symptoms.


You’re the physician oncall for the weekend. At 9p.m. on Saturday, you get

a call from a nurse at a localnursing home saying they’vetried everything to calm an agi-tated resident. They’re askingyou to order something. This isstill a very familiar scenario,even though the long-term careprofession in Minnesota hasmade progress in decreasing theuse of unnecessary drugs.

To change the way antipsy-chotic drugs are used in nursinghomes, Ecumen (a provider ofsenior housing and services inMinnesota) is going further,implementing a comprehensiveprogram called Awakenings. Thegoal is to awaken Alzheimer’sand dementia patients to afuller, richer life by decreasingtheir dependence on unneces-sary medications. Physicians arekey partners in this work.

How Awakenings began

Awakenings was piloted at anEcumen nursing home in TwoHarbors, Minnesota in 2009.Based on those remarkableresults and thanks to a $3.8 mil-

lion, three-year state grant, theinitiative is expanding to 15other Ecumen nursing homes inMinnesota. We hope that whatwe learn from this expansionwill provide Alzheimer’s “bestpractice” guidance to physiciansand care centers in Minnesotaand across the country. Earlierthis year, a New York Times blogdiscussed the promise of thisinitiative (Paula Span, “Clearingthe Fog in Nursing Homes,”New York Times, Feb. 15, 2011).

The Two Harbors pilotdemonstrated that residentswith Alzheimer’s could enjoy abetter quality of life if behavioraland environmental interven-tions, rather than antipsychoticdrugs, were tried first. Thesedrugs not only can rob residentsof their personalities and energy;in some cases they actuallyworsen cognitive functioning

among elderly dementiapatients, and can speed theirdecline—making strokes, pneu-monia, or serious adverse drugeffects more likely.

Despite the fact that antipsy-chotic drugs carry a Food andDrug Administration black-boxwarning that elderly patientswho use them have an increasedrisk of death, their use has sky-rocketed in recent years. Medi-caid spends more on antipsy-chotics than any other class ofdrugs—including antibiotics,AIDS drugs, or medications totreat high blood pressure.

As nursing home residentsin Two Harbors were weaned offantipsychotics, staff membersengaged more with them, takingthem on walks, and playinggames and exercising with them.Certified nursing assistantsassumed a more important role.A variety of therapies using vali-dation, reminiscence, music,aroma, and pets were employedto improve residents’ physicaland cognitive functions.

Within six months, the useof antipsychotics was eliminatedamong all residents, and antide-pressant use decreased by 30 to50 percent. Before the pilot proj-ect, the home was quiet; severalresidents preferred to stay inbed, and others had a far-off,vacant look. Today, residents areengaged in meaningful activitiesand relationships, and relation-ship-based care has become thenormal routine for the entirehome. Indeed, the Awakeningsapproach has far-reachingeffects in reducing unnecessarypsychotropic medications orother potentially unnecessarymedication for any nursinghome resident.

Key strategies for change

This shift toward nonpharma-ceutical interventions involvesevery staff member. Awakeningstakes a holistic, individualizedapproach to Alzheimer’s care toget to the root cause of behav-ioral issues. Collaborative teams

—“circles of care”—are builtaround each resident, involvingfamily, case workers, and theright doctors and nurses. A teamevaluates the situation of eachresident to find the right mix ofcare to help ensure best qualityof life. Again, the focus of carebecomes human relationshipsrather than solely drugs.

One of the first steps inintroducing Awakenings isrecruiting project leads andrehabilitation nursing staff.Rehabilitation nursing is a keyelement of success, along withenhanced, personalized activi-ties. Residents are less likely toget agitated when their individ-ual preferences are met.

These staff members, whoare trained in several areas,including assessment for delir-ium and alternative care planinterventions, share this learningwith all team members. Theteam considers the underlyingcauses of agitation before callingthe physician. Training is alsoprovided for administrators anddirectors of nursing in each carecenter, teaching them to ask“why” when they hear about aresident’s behavioral symptoms.

Physicians are an importantpart of Awakenings care teams.Attending physicians and med-ical directors are invited to meetwith a physician certified in psy-chiatry and neurology to sharethe latest knowledge about theuse of psychotropic medications.Physicians are encouraged toconsider underlying causes ofagitation prior to ordering treat-ment with medication.

Family members are alsokey members of the team. Theyare directly involved with resi-dent activities and help sharetheir relative’s life story, whichis part of assessment and alter-native care planning, includingspiritual care. It’s crucial thatstaff understand as much abouteach resident’s needs and prefer-ences as possible in order forrelationship-based care to suc-ceed.

Teams also work with phar-macy consultants in creatingindividual care plans. Thisallows the pharmacist to under-stand more about a residentthan can be gained by readingclinical records. If deemed bene-ficial by the attending physician,

AwakeningsTransforming Alzheimer’s care in Minnesota

By Laurel Baxter, MA, RN

Read usonlinewherever you are!

www.mppub.com


the team has access to otherhealth care professionals such aspsychiatrists, behavioral psy-chologists, and clinical experts.

Case studies

The stories of Marjorie andLouise (names have beenchanged) show the real-lifeeffects this program can have.

Marjorie’s team discoveredthat some of her behavioralproblems were caused by herfear of incontinence. Antipsy-chotic drugs had failed to stopthe behaviors. So her care teamwent beyond medications to getto the core of her anxiety andhelp restore her personality.Using talk therapy and interven-tions, engaging family members,building her self-confidence,stopping antipsychotic medica-tions, and re-introducing exer-cise into her life have made anenormous difference. She’s eat-ing and sleeping again, whichhas led to a new, healthy state ofcalm. Marjorie is awake and liv-ing, and her family shares thehappiness she can still convey.

Louise was taking too manytumbles—tripping over her own

feet, swaying and losing her bal-ance, or simply running into fur-niture in her nursing home. Hercare team scrutinized her med-ications and decided to discon-tinue her antipsychotic and anti-anxiety medications. As thosetwo medications were phasedout, she became steadier on herfeet and felt more confident.Louise began engaging more inthe community around her, help-ing set tables and clearing clut-ter from the nurse’s station. Herhusband noticed she was moreawake and responsive duringhis visits. She was even able toresume attending regular churchservices with him. Alzheimer’sdisease will continue to claimmore and more of Louise’s abili-ties, but for now, her family hasa more alert Louise to enjoy andcherish.

Measuring outcomes

Hard data support the positiveeffects of the Awakenings pro-gram. At the end of the three-year Awakenings initiative grant,we will have measured severaloutcomes with an “at-risk” com-ponent that will result in a rate

decrease from the MinnesotaDepartment of Human Servicesif outcomes goals are not met.

First, on average, we intendthat the collaborative of 15 nurs-ing homes will achieve a 20 per-cent improvement over thebaseline in the Minnesotarisk-adjusted quality indicator“prevalence of antipsychoticswithout a diagnosis of psycho-sis.” (That translates to a 10 per-cent decrease the first year and5 percent decreases in each sub-sequent year.) Since Awakeningswas introduced in late 2010, thecollaborative has improved 62percent over that baseline.

Second, we also anticipatea 6 percent improvement rateover baseline in the MinnesotaDepartment of Human Services(DHS) Quality of Life Surveyin two domains: MeaningfulActivities and Relationships.The DHS Quality of Life surveysstarted in October 2011 andresults will be forthcoming.

Both the scale and innova-tion of Awakenings make itunique. We are retooling theentire approach to care, replac-ing a fragmented approach often

found in health care today witha holistic, integrated approachcentered on the individual. Theprogram builds on practicesthat have been proven throughresearch, applying them in thereal world of long-term care. Inthe process, we are radicallychanging the culture of medica-tion use in nursing homes.

A relationship-careapproach like Awakenings canbring many of the estimated27,000 Minnesota nursing homeresidents who are on antipsy-chotic drugs increased empow-erment, vitality, joy, and dignity.Physicians will have backupfrom a team of professionalswho provide accurate assess-ments to help assure properdiagnosis, documentation, andprescribing of psychotropic andother medications. More infor-mation about Awakenings,including a list of the Ecumennursing homes now using thisapproach, is available atecumen.org/aging-resources.

Laurel Baxter, MA, RN, is theAwakenings project manager at Ecumen,based in Shoreview, Minn.


Boynton Health Service

Welcome to Boynton Health ServicePsychiatrist

(612) 624-1444

and 174055

A Diverse and Vital Health Service


As health care reformbecomes a reality,momentum is building

toward keeping patients in theirhomes whenever possible. Homecare helps to achieve health carereform mandates—such asreducing re-hospitalizationrates—by allowing care recipi-ents to avoid expensive institu-tional alternatives like hospitalsand nursing homes. Physicianswill be integral to the success ofthese efforts. Patient-preferredand cost-effective, home care isbecoming an integral part of thehealth care continuum, as itbridges the clinic-based modeland the actual world patientslive in.

For all ages andmultiple conditions

The primary population creatingthe demand for home care isseniors. As 78 million babyboomers in the United Statesapproach retirement age, ournation’s demographics are shift-ing significantly. Seniors willsoon constitute 20 percent of thepopulation. It’s estimated that bythe year 2020, 12 million older

Americans will need long-termcare.

A recent consumer surveyconducted by AARP showed thathome care is the preferred carechoice for 95 percent of seniorsand retiring baby boomers. Bothgroups are interested in stayingout of what is commonly knownas the “broken hip revolvingdoor” of hospitals, rehab cen-ters, and short-term nursinghome placements.

In addition to seniors, homecare serves people of all ageswho are recovering from healthchallenges, disabled, chronicallyill, or in need of end-of-life care.Their ongoing needs may bemedical, nursing, therapeutic, orassistance with the basic activi-ties of daily living.

Two growing service nichesin home care are pediatric care(including premature babies)

and young disabled adults.Home care is now a viableoption for children who wouldhave been institutionalized orhospitalized long-term, or whowould not have survived at allin years past.

John McNamara, MD, med-ical director of Children’s HomeCare & Hospice Program atChildren’s Hospitals and Clinicsof Minnesota, has said, “Wehave sent over 400 childrenhome with trachs and vents andfind home care to be a very goodalternative with fewer infectionsand low readmission rates. Evenchildren with acute illnesseshave been successfully cared forat home.”

Recent advances in medicaltechnology have increased thepopulation of patients nowtreated at home. Chronic patientneeds being handled by homecare nurses include tracheo-tomies, ventilators, gastrostomytubes, IV therapies, and manycardiac conditions. Cancer andtransplant patients are also ableto recuperate at home.

Recent advances in medicaltechnology have increasedthe population of patients nowtreated at home. Common homemedical interventions include:infusion therapies with centraland peripheral lines, lab draws,parenteral and enteral nutrition,sleep diagnostic testing, respira-tory assistive devices such asventilators, CPAP, oxygen moni-toring, CO

2monitoring, and air-

way clearance equipment andtechniques.

Additional technologies thatimprove home care include tele-health service management,electronic medical records, anda variety of assistive technolo-gies such as home sensors. Anurse using telehealth equip-ment, for instance, can poten-tially make up to 15 visits a dayrather than the standard five.

Comparing costs

Home care is from five to 20times less expensive than care in

an inpatient facility. A 2009study published by AvalereHealth estimated that earlyhome care use was associatedwith a $1.71 billion reduction inMedicare post-hospitalizationspending over a one-year period.

Medical professionals andtheir patients (and patients’families) can leverage home careto maximize care capacitieswhile minimizing costs. In 2009,national charges by Medicarewere $135 per home care visit,$622 per day for skilled nursingfacilities, and $6,200 per day forinpatient hospital care. Thenumbers speak for themselves.

The physician’s role

Family practice physicians,gerontologists, and medicalspecialists—for example, inorthopedics and cardiology—can benefit from understandinghow home care fits into theevolving health care paradigm.Points to consider:• Increasingly skilled privateduty nurses, along with caremanagers, regularly meet com-plex medical needs in homesettings. Physicians sign off onall such nurse activities. Pa-tient care plans are recertifiedat a minimum every 60 days.

• Cost savings, familiar sur-roundings, and communitysupport services make homecare a viable option for manycare recipients.

• Proactively discussing dis-charge planning, includinghome care, at the time of apatient’s hospital admissioncan be helpful.

• Because hospitals haveincreased incentives to preventre-hospitalizations, morephone follow-up by hospitalsand doctors to home careplacements is becoming com-monplace.

• Open communication on thepart of physicians is key,including telling home careprofessionals what is needed tohelp physicians provide opti-mal care. Speak to and meethome care providers at leaston an annual basis.

• Physicians can refer patientsto nonprofit resources, listedin the sidebar, to learn moreabout home care.

Home carePatient-preferred and cost-effective

By Amy Nelson

9533 0611 ©2011 ALLINA HEALTH SYSTEM. ®A REGISTERED TRADEMARK OF ALLINA HEALTH SYSTEM

Allina Hospitals & Clinics inMinnesota/Western Wisconsin

AllergyDermatology

Hospitalist

Hospitalist

Allina offers a competitive bene�ts and salary package.For more information, please contact:

Kaitlin Osborn, Allina Physician Recruitment Toll-free: 1-800-248-4921 | Fax: 612-262-4163

Email: [email protected] Website: allina.com/jobs

EOE

Allina Hospitals & Clinics is known for its clinical quality, and an award-winning EMR. At Allina, physician leadership and involvement drive our success.The Clinic and Community Division features the Allina Medical Clinic, Aspen Medical Group, and Quello Clinics, as well as Home and Community Services. Our clinics, as well as our 11 hospitals, are located in the Twin Cities metro area, throughout Minnesota, and in western Wisconsin.Full- or part-time urban, suburban, and rural openings are available inthe following specialties:


Types of home care

Home care ranges from a one-hour weekly visit to 24-hour live-in care. It provides a one-on-onefocus, which is difficult toobtain in hospitals or groupfacilities. Home care alsorespects cultural differences andethnic diversities by assigningstaff members not only by skillsets but also by language (fromSpanish to Somali to sign) andbehavioral criteria, such as notsmoking or not consuming pork.In hospital settings, there is nochoice as to who provides thepatient care. Home care allowsthe patient to select the serviceprovider upfront and providescare in a controlled setting.

The checklist of questionsabove is designed to help physi-cians, patients, and familiesmatch the needs of the patientto home care provider skill sets.

There are five basic homecare service options:1. Personal care assistants pro-

vide assistance with activitiesof daily living such as dress-ing, bathing, feeding, gettingto doctor appointments, etc.They are not licensed by thestate. This type of care typi-cally is paid for by MedicalAssistance, Minnesota’sMedicaid program.

2. Private duty care—basicallyprivate-pay care—providesassistance with nonmedicalneeds such as shopping,cooking, transportation, andcompanionship and involveshousehold managementservices but no hands-onmedical care. Some long-termcare policies will cover suchhome care, but reimburse-ment terms and exclusioncriteria vary.

3. Licensed home care agenciesemploy a variety of homehealth care professionals,including skilled nurses, ther-

apists, and home health aides.This type of care typically ispaid for by private insurance,Medicare, and Medicaid.

4. Medicare-certified skilledhome care typically is pro-vided on an acute, intermit-tent basis, i.e., following anillness, injury, or change indisease status. Such servicesare physician-driven andreimbursement is contingenton the individual demonstrat-ing progressive improvementwhile being homebound.

5. Extended-hour nursing offershigh-level, one-on-one care,from four to 24 hours a dayfor patients with medicallycomplex needs. Not all homecare agencies offer this type ofcare. This is an intensive levelof care provided for at-homepatients requiring trachs,G-tubes, IV, and ventilation.

Who pays for home care?

Funding for home care isincreasing. Many insurancecompanies now cover extended-hour nursing and care visits. Atracheotomy patient, for exam-ple, can be approved for 24-hour-a-day care for one monthand then be weaned into familycare. Managed care companiessuch as Medica, HealthPartners,UCare, and Blue Cross and BlueShield have come to understandthat home care is safe, efficient,and cost-effective.

Payment options for homecare include self-pay, Medicare,Medicaid, Veterans Administra-tion, community organizations,commercial health insurancecompanies, managed care organ-izations, CHAMPUS (militaryhealth plan), and workers’ com-pensation.

Bringing it home

Home care is a critical compo-nent of collaborative care that is

rapidly moving from the periph-ery to the mainstream of patientcare. The types of care nowbeing handled at home are dras-tically different from care mod-els even 10 years ago, and theywill continue to evolve as tech-nologies advance. Home iswhere families want their loved

ones to be, and home care sup-ports the best quality of life forpatients.

Amy Nelson is founder, president, andCEO of Accurate Home Care, a provider ofhome care services in the Upper Midwest.AHC serves a wide range of medically com-plex pediatric and adult clients.


Finding the right match ofpatient needs, home care services

Matching patients’ needs with home care providers’ skill sets is a primaryconsideration for physicians, patients, and families. These qualifier ques-tions can help determine the optimal home care provider for any particu-lar situation:1. What process do you use to match employees with clients?2. What type of training is given to your staff members?3. Does your agency have licensed social workers on staff to address the

emotional needs of clients and families?4. How closely do your supervisors evaluate the quality of care provided?5. How are problems addressed and resolved?6. How do you manage scheduling? Is care available around the clock if

needed?7. What are the credentials of your employees who will be in the home?

Can they provide individual references?8. What procedures are in places in case of an emergency, such as a

power failure or inclement weather?9. Are all of your caregivers licensed in their fields?10. Can you provide references, including doctors, hospital discharge

planners, and clients?11. How do you handle expenses and billing? Has your company ever

been accused of fraud?12. Will I receive a written care plan before service begins?

Nonprofit resources for home care

• MN HomeCare Association: www.mnhomecare.org• Senior LinkAge Line: 800-333-2433• Metropolitan Area Agency on Aging:www.tcaging.org/findinghelp/sll.html

• PACER Center (advocacy group for children with disabilities):www.pacer.org

• Disease management groups such as the Muscular DystrophyAssociation (www.mda.org/), ALS Association (www.alsa.org/),Brain Injury Association of Minnesota (www.braininjurymn.org/),Autism Society of Minnesota (www.ausm.org/)

• National Association for Home Care and Hospice: www.nahc.org

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

The American DiabetesAssociation’s (ADA) slo-gan is “Stop Diabetes.” If

this is really possible, why isthe prevalence of diabetesincreasing at epidemic propor-tions? The number of peoplewith diabetes in the UnitedStates increased by 17 millionpeople from 1958 to 2010,according to the U.S. Depart-ment of Health and HumanServices; more than 8 percentof the American population hastype 2 diabetes now, and one inthree children born after 2000will develop diabetes unlessstrong preventive steps aretaken. Furthermore, due to theinsidious nature of the disease,by the time the diagnosis ismade, many people have hadthe disease for anywhere fromnine to 12 years, resulting inthe presence of complicationsin as many as 39 percent ofthose with newly diagnoseddiabetes. And we know thatthose who are at risk for dia-betes are at similar risk for car-diovascular disease and periph-eral vascular disease as thosewho have diabetes.

The Minnesota Departmentof Health (MDH) reports thatevery year 20,000 Minnesotansare newly diagnosed with dia-betes. Our goal is to bend thecurve on the rising incidence ofdiabetes.

There are a number of rea-sons to work hard at preventingdiabetes. One important reasonis the cost of having diabetes,including the cost of health care

visits and tests, diabetes med-ications, and supplies.

Additionally, people withdiabetes often have more healthproblems than those withoutdiabetes. Other health problemsassociated with the disease

increase the cost of health care,as they may require moreexpensive tests, medications,and hospitalizations. In Minne-sota, diabetes costs almost $3billion a year—about $12,000for every person with diabetes.According to the ADA, healthcare costs for people with dia-betes are three to four timeshigher than the costs for peoplewithout diabetes.

There are also emotionalcosts associated with diabetes.In fact, 20 percent of Minne-sotans who have diabetes alsohave depression, which cannegatively influence diabetesmanagement and self-carebehaviors.

Health professionals whocare for people with diabetesunderstand the harm and costsof diabetes. At the same timethey may be frustrated that theyhave little time to spend on dia-betes care when patients pres-ent with multiple health issues.Identifying people at risk ofdeveloping diabetes—i.e., thosewith prediabetes—and knowingwhat resources are availablecan help physicians work withpatients before the most seriouscomplications of the diseasedevelop.

Warning signs of type 2diabetes and prediabetes

There is strong evidence thattype 2 diabetes can be pre-vented or delayed. The warningsigns of diabetes listed in thepatient handout on p. 31 helpidentify which adults and chil-dren are at risk.

In Minnesota, the mostfrequent risk factor is beingoverweight.

More than 1 million peoplein Minnesota have prediabetes,but only 20 percent know theyhave it. That means 80 percentdo not know that they havethis health problem, are notaddressing it, and are atincreased risk of developingtype 2 diabetes. Table 1 lists thelatest criteria for diagnosingdiabetes and prediabetes.

Evidence forpreventing diabetes

The National Institutes ofHealth-sponsored DiabetesPrevention Program (DPP)was stopped early because theresults in one of the treatmentgroups were so dramatic that itwould be irresponsible if thesuccessful intervention was notoffered to all study participants.The intervention that decreasedparticipants’ risk of developingtype 2 diabetes by 58 percentwas a 16-session lifestyle educa-tion/support program. The pri-mary goals were for partici-pants to:• lose 5 to 7 percent of current

body weight—about 10pounds

• moderately exercise for a totalof 30 minutes a day, five daysa week

Some people think this iseasy, but for most people it isnot easy. Structured programsthat guide and support individ-uals have proven to be veryhelpful.

Patients’ perspectives

A 2009 ADA survey showed thatpeople at high risk of develop-ing diabetes report they followa poor diet (67 percent), main-tain an unhealthy weight (62percent), and avoid doctors’visits (50 percent). Admittedly,changing unhealthy behaviors isnot easy for many people, yetresearch shows that change can

Bending the curveon diabetesPhysician engagementcan improve outcomes

By Maggie Powers, PhD, RD, CDE; Teresa Pearson, MS, RN,CDE, FAADE; and Rita Mays, MS, RD, LN


Live in the relaxed lake country of Mille Lacs and practice medicine where you will make a difference.

We’re looking for a Family Physician to join us atMille Lacs Health System in Onamia, Minnesota.

Loan forgiveness options may be available.

Contact: Fern Gershone: [email protected] Dr. Tom Bracken: [email protected]

7 FAMILY PHYSICIANS • 8 PAs • 1 GENERAL SURGEON • CRITICAL ACCESS HOSPITAL

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More than 1 million people inMinnesota have prediabetes,

but only 20 percent know they have it.

occur when knowledge and bar-riers are addressed. In the 2009survey, more than half of theresponders mistakenly statedthat “eating too much sugar” isa risk factor for diabetes. Ontheir own, patients may try to

eliminate sugar yet end up con-suming more calories becausethey consume more high-fatfoods. Others may mistakenlyreplace sugary soda pop withfruit juice, unaware that regularjuice is very high in sugar, and

thus achieve no reduction insugar, carbohydrate, or caloricintake.

If losing body weight waseasy, two-thirds of the Americanpopulation would not be over-weight or obese. Providingaccurate information and sup-port can help patients develophealthier eating and activitypatterns that can reduce theirrisk—and physicians do notneed to do all of this them-selves.

Minnesota action

The Minnesota Diabetes Plan2015 focuses on stemming thetide of the diabetes epidemicand improving diabetes care.

The plan encompasses expand-ing and easing access to care,education, and food, andincreasing accountability forcare coordination, referringpatients to appropriate re-sources, supporting diabetesself-management skills in pre-vention of type 2 diabetes, andmaking effective diabetes pre-vention programs (DPPs) avail-able statewide.

Minnesota has been aleader in piloting preventionprograms. The state is nowfacilitating access to these pro-grams while also actively sup-porting additional programs so


DIABETES to page 36

Patient handout: Warning signs of type 2 diabetes

Do you have any of these warning signs of diabetes? If you do, talkto your doctor about how you can prevent or delay getting diabetes.• I have a close family relative (mother, father, brother, or sister) withdiabetes.

• I am not very physically active. I exercise fewer than three times aweek.

• I have high blood pressure or blood pressure equal to or greaterthan 140/90 mmHg.

• I have low HDL cholesterol (the good cholesterol)—less than35 mg/dL.

• I have high triglyceride levels (fat in the blood)—more than250 mg/dL.

• I have an A1c (a special blood sugar test) equal to or greater than5.7 percent.

• I have had heart disease/problems.• I am very overweight.• I have acanthosisnigricans (a skin reaction that darkens the skinaround the neck and under the arms).

• I am a woman and have had gestational diabetes or a babyweighing more than 9 pounds.

• I am a woman, and have PCOS (polycystic ovary syndrome).• I am part of an ethnic group that has a higher number of peoplewith diabetes—Latino, Hispanic, African American, AsianAmerican, American Indian, Pacific Islander.

TABLE 1. ADA diagnostic criteria forprediabetes and diabetes

Normal Prediabetes DiabetesA1c ≤5.6 5.7–6.4 ≥6.5Fasting plasmaglucose (mg/dL) <100 100–125 ≥1262 hr 75 gmOGTT (mg/dL) <140 140–199 ≥200Random plasmaglucose (mg/dL) <140 N/A >200 and classic

diabetes symptoms

Confirm diagnosis of diabetes on a subsequent day unless there isevidence of unequivocal hyperglycemia.

www.mankato-clinic.com

Urgent CareMankato Clinic is looking for exceptional Physicians,Physician Assistants and Nurse Practitioners to workin our busy Urgent Care Department. Customer serviceskills and the very best patient care are essential for theseprofessionals who are the first point of contact for somepatients.You will work with a team of highly skilled supportstaff in an efficient, fast-paced environment.

There are full-time and casual shift opportunities available.Hours are weekdays 8 a.m.–8 p.m., Saturdays 8 a.m.–5 p.m., andSundays noon–5 p.m. Care is provided in three locations, two full-serviceurgent care/occupational medicine facilities and one express serviceclinic located in Mankato’s shopping mall.

Providers in full-time positions will enjoy an excellent benefits packageincluding generous CME expense and time-off allowances; 401(k) profitsharing plan; EAP; employee discounts and more.

Apply online at www.mankato-clinic.com, or contact Dennis Davito,Director of Provider Services at [email protected];Phone: 507-389-8654; Fax: 507-625-4353; Mankato Clinic, 1230 E. MainSt., Mankato, MN 56001. Mankato Clinic is an Affirmative Action/EqualOpportunity employer.

A N E S T H E S I O L O G Y

James was surprised whenhis anesthesiologist wantedto talk about developing a

plan for controlling the pain hemay have on Thursday—thethird day after his upcomingsurgery. “I thought he just tookcare of me in surgery, kept measleep, and woke me at the end,”James said. In fact, there ismuch more to this specialty andmuch more to what anesthesiol-ogists can do for patients.

The role of the anesthesiolo-gist has expanded over the pasttwo decades. Before that, it wascommon practice for the anes-thesiologist to be responsible forthe patient in the immediateperioperative period. Typically,he or she met the patient justprior to inducing anesthesia andthen transferred postoperativecare to a nurse in the postanes-thesia care unit (PACU). It wasup to the surgeon or other physi-cians to deal with pain controlbeyond the immediate postoper-ative period. Now, though, thereis a new paradigm within thespecialty of anesthesiology.Today’s anesthesiologists areinvolved with all aspects of care

and they are the central figure inthe continuum of surgical care.

No longer is our responsibil-ity limited to the care of patientsexclusively during surgery. It isclear that what we do onMonday makes a difference onFriday. As perioperative physi-cians, we have a unique view ofhealth care in the perioperativeperiod—before, during, andafter surgery. We are perfectlypositioned to coordinate allaspects of surgical care. We canoffer so much to patients, ourphysician colleagues, our hospi-tals, and to health care as awhole. Our involvement mayinclude making sure a patient’shypertension is addressed post-operatively, or that patients whoappear to have sleep apneareceive proper follow-up diagno-sis and care. One of our primary

responsibilities is to assureappropriate pain control beyondthe immediate postoperativeperiod.

Most patients who are hav-ing surgery are primarily con-cerned about anesthesia or pain.Many studies have demonstratedthat poor postoperative paincontrol leads to poor outcomes,low patient satisfaction, andincreased costs. We feel that youcannot have excellent surgicalcare without having excellentpostoperative pain control. As aresult of the paradigm shift inanesthesia care, NorthwestAnesthesia PA, which providesall anesthesia services at AbbottNorthwestern Hospital and theOrthopedic Institute SurgeryCenter, has developed a compre-hensive sophisticated Acute PainService (APS) to address postop-erative and acute pain.

The philosophy of the APSis simple: Provide superior post-operative pain control while min-imizing the side effects related tosuch an effort. The APS uses avariety of mechanisms, skills,and techniques to control pain,including peripheral nerveblocks, multimodal preemptiveanalgesia, neuraxial blocks, andketamine infusions. These non-narcotic mechanisms for con-trolling pain avoid many of theuntoward side effects of narcoticmedication, including nausea,vomiting, constipation, itching,sedation, respiratory depression,and potential addiction.

Orthopedic patients

Many orthopedic surgical proce-dures are associated withintense postoperative pain. Wehave developed multiple tech-niques for controlling postopera-tive pain. We tailor these tech-niques to both the surgical pro-cedure and the patient’s needs.We use specific nerve blocks forevery orthopedic surgical proce-dure performed. For example,we use a continuous interscalenenerve block for complex shoul-

der procedures such as rotatorcuff repair and joint replace-ment. This nearly painless pro-cedure involves placing a cath-eter to deliver local anesthetic tothe nerves that provide feeling tothe shoulder. We use ultrasoundguidance to place the nerveblock for patient comfort and toconfirm catheter placement. Thecatheter is then connected to adisposable infusion pump thatallows a continuous infusion oflocal anesthetic for excellentpain control.

Total knee arthroplasty(TKA) is widely considered themost painful elective orthopedicprocedure performed. Conse-quently, we place multiple nerveblocks for TKA including contin-uous femoral nerve blocks. As aresult of implementing the APSpain protocol for TKAs, we haveimproved our patient satisfac-tion and clinical outcomes, re-duced length of stay, decreasedthe percent of patients dis-charged to a skilled nursingfacility, and reduced our costs.

We do these procedures pre-operatively as part of our pre-emptive analgesia. This tech-nique provides superior paincontrol and significantly reducesthe need for IV narcotics. As aresult, we can conduct our non-joint replacement shoulder sur-gery on an outpatient basis. Ourpatients are able to recover athome, avoiding unnecessaryhospitalization or the need forconvalescence in a hotel recov-ery unit. Superior postoperativepain control improves patientoutcomes and satisfaction,increases safety, reduces use ofhealth care resources, andincreases inpatient capacity.This is a rare win-win-win-winsituation: It is better for thepatient, the physician, the hospi-tal, and the payer—exactly theresult that everyone is hoping toachieve with health care reform.

Patient satisfaction

We continually survey ourpatients to measure their levelof satisfaction and to makeimprovements to our program.Our patient satisfaction datahave guided many of our clinicaldecisions as we improve andexpand the APS program. The

Pain controlGood news for patients

By John P. Mrachek, MD


family room |

Marshfield Clinic continues to redefine health care through our innovative technology and practices, but it doesn’t end there. We’re also redefining what it means to be a physician practicing with us. Our setting in the heart of Wisconsin makes it possible for you to explore all of the lifestyle options that come with living in an environment rich in natural wonders and short on congestion. We have openings for BC/BE physicians in:

• Dermatology • Family Practice • IM • Neurosurgery • Orthopaedic Surgery• Pediatrics (general and subspecialty) • PM&R • Pulmonary Critical Care • Urology

(please contact us if you don’t see your speciality listed)

Marshfield Clinic is one of the largest physician-directed private group practices in the United States employing more than 800 physicians and over 6000 support personnel in 54 locations throughout northern, western and central Wisconsin. As one of the most respected and recognized names in health care delivery, Marshfield Clinic combines world class services with a solid commitment to quality of life for both patients and staff, which makes Marshfield Clinic and Wisconsin a very attrac-tive place to get your career on the right path.

To hear more about the numerous physician practice opportunities we have available and the very competitive compensation package we offer, please contact: Physician Recruitment, Marshfield Clinic, 1000 N. Oak Ave., Marshfield, WI 54449. Phone: 800-782-8581, ext. 15770; Fax #: 715-221-5779; E-mail: [email protected]; Website: www.marshfieldclinic.org/recruit; Facebook: www.facebook.com/marshfieldclinicphysrec

PAIN CONTROL to page 34


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 Northwoods 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

Yup.

Stillwater Medical Group is an 90+ provider multi-specialty group practice affiliated with Lakeview Hospital. For more than 50 years we have been providing comprehensive healthcare services in the St. Croix Valley, just east of the Twin Cities metro area.

Internal and Family Medicine Physician Opportunities:Stillwater Medical Group has exciting new Internal and Family Medicine Physician opportunities at our NEW Mahtomedi, MN clinic opening Fall 2012! Additional opportunities also available in Stillwater, MN.

Mahtomedi, MN? (Ma-toe-me-dye)So what if you can’t pronounce it? We can help with that. Mahtomedi is located in Washington County, on the east shore of White Bear Lake. Residents appreciate the community’s small town charm, lakeside flavor, and close proximity to the Twin Cities Metropolitan Area. In addition, the Mahtomedi School District and other area colleges offer excellence in education.

For further information please contact:Patti Lewis, Director Human Resources1500 Curve Crest Blvd, Stillwater MN(651) 275-3304, [email protected]

Internal Medicine?

Family Medicine?

Internal and Family Medicine Opportunities

NEW clinic inMahtomedi, MN?

We’ll make it all better.

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

Sioux Falls VA Health Care System“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 Health Care System.

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

• Orthopedic Surgeon

• Emergency Department Physician

• Chief of Primary Care andSpecialty Medicine

results demonstrate high patientsatisfaction. For example, whenwe asked our first 200 patientswhether they would they opt fora continuous peripheral nerveblock if they needed the surgicalprocedure again, 100 percent ofpatients answered “yes.” Whenpatients were asked if, based ontheir experience with the APS,they would recommend ourhospital to a relative or friend,again, 100 percent of patientssaid they would recommend ourhospital. And finally, 99 percentof patients said they were eitherextremely satisfied or highlysatisfied with their postoperativepain control.

Preventing chronic pain

Chronic pain is a devastatingcondition suffered by thousandsof people throughout the UnitedStates. Conservative studiesshow that one in four adults inthe U.S. report chronic pain and50 percent of cancer patientshave chronic pain, causingpatients and family memberssignificant suffering. A 2003

study estimated the cost ofchronic pain in the U.S. at$61.2 billion annually.

Chronic pain often arisesfrom acute pain episodes causedby a fracture or a surgical proce-dure. Pain from a surgical pro-cedure, though often intense,should be transient and shouldresolve with time. Unfortunately,in some patients that acuteepisode is prolonged, leading tochronic pain lasting months, oreven years. Could early, compre-hensive pain control diminish oreven eliminate some chronicpain syndromes?

Significant scientific andclinical evidence demonstratesthat excellent postoperative paincontrol leads to a decrease inthe incidence of chronic pain.

This should be important topatients, physicians, and payerswhen considering options forsurgery. It is an important ele-ment that is often overlooked,but may have as significant animpact as any other componentof perioperative care. Patientsand their physicians shouldconsider postoperative paincontrol when choosing a facilityfor surgery.

Are we preventing cancerfrom recurring?

Choosing regional anesthesiaand analgesia for surgical pro-cedures has obvious benefits,including deceased side effectsfrom narcotics, decreased inci-dence of nausea and vomiting,improved pain control, earlierphysical therapy, and betterlong-term outcomes. But couldthese procedures also preventcancer recurrence?

Abbott Northwestern’s APSoffers comprehensive, coordina-ted, multimodal postoperativepain control. This includes theuse of paravertebral nerveblocks for breast surgery. In thisprocedure, we inject local anes-thetic near the nerve roots of thenerves that give feeling to thechest. Additionally, we place asmall catheter to continue toinfuse local anesthetic so thatwe can provide extended painrelief. Paravertebral nerve blocksallow us to create a band ofnumbness covering the surgicalsite, minimizing the need fordeep general anesthesia and nar-cotic pain medicine. It providesa better experience for thepatient while avoiding sideeffects such as nausea, vomiting,sedation, and sleep disruption.So, could these techniques alsoprevent certain cancers fromrecurring? Two recent studieshave suggested support for thisprovocative theory.

Surgical resection—i.e.,lumpectomy and mastectomy—

remains the best treatment forbreast cancer. However, residualdisease is a real possibility.Metastatic spread of these resid-ual cells is affected by many fac-tors, especially the body’s natu-ral ability to kill tumor cells viathe immune system and develop-ment of new blood vessels at thesite of disease. We know thatvolatile anesthetics, interactionbetween the nervous and endo-crine systems in response to thestress of surgery, and opioidsadversely affect these factors.

One study looked at therecurrence of breast cancer aftersurgical resection over a 36-month period (Exadaktylos, E.K.et. al., Anesthesiology, Oct.2006). Fifty patients had surgerywith paravertebral nerve anes-thesia and analgesia combinedwith general anesthesia, and 79patients had general anesthesiawith morphine for postoperativepain relief. Recurrence andmetastasis-free survival was 94percent versus 82 percent at 24months, respectively, and 94 per-cent versus 77 percent at 36months in the patients receivingparavertebral- and general anes-thesia. These results are com-pelling, and have prompted alarger study to confirm thesefindings.

Another study looked at therecurrence of prostate cancerfollowing prostatectomy. It, too,showed a decreased incidence ofdisease recurring following theuse of regional analgesia insteadof narcotics. Again, these resultswarrant a larger trial, but theinitial results are compellingand exciting.

It is clear that high-quality,comprehensive, postoperativepain control is a critical compo-nent of high-quality health care.The availability of such careshould be an expectation ofevery patient requiring surgery.As James attests, “This paincontrol was great; I felt great,and I got back to living my lifequicker.”

John P. Mrachek, MD, a physicianwith Northwest Anesthesia PA, isdirector of acute pain service at AbbottNorthwestern Hospital.


No longer is the anesthesiologist’sresponsibility limited to the care ofpatients exclusively during surgery:

It is clear that what we do onMonday makes a difference on Friday.

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:

• ENT

• Family Medicine

• General Surgery• Geriatrician/

OutpatientInternal Medicine

• Hospitalist

• Infectious Disease• Internal Medicine• OB/GYN

• Oncology

• OrthopedicSurgery

• 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

Pain control from page 32


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].

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

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]

all Minnesotans have easyaccess to diabetes preventionservices. The Diabetes Programat the MDH provides a currentlisting of group diabetes preven-tion programs in Minnesota,including contacts, dates, loca-tions, and costs of participation(go to www.icanpreventdiabetes.org/groups.html).

Three 16-week DPP pro-grams currently are offered inMinnesota:• Lifestyle Balance for

American Indians (offeredthrough the Indian HealthBoard in Minneapolis andtribal communities)

• I CAN Prevent Diabetes(offered throughout the statewith coordination by MDH)

• Y-DPP (offered by the metro-area, Willmar, and AlexandriaYMCAs)

The I CAN Prevent Diabetesprogram has demonstrated thatpeople who attend 80 percent ormore of the 16-week session aremore successful than those thatdon’t. The average weight lossfor people who attend 13 or

more sessions has been 6 per-cent but only 4 percent for thoseattending 12 or fewer sessions.

Other prevention programsare available in Minnesota andmay be offered by registereddietitians, diabetes educationprograms, or communitygroups. Although the effective-ness of these programs maybe untested or less vigorouslytested, many have been suc-cessful.

Action steps for physicians

Behavior change is a long-termprocess and physician engage-ment in setting expectations,making a referral, providingsupport and monitoring atten-dance, process and outcomes iskey to success. Here are stepsphysicians and their staffs cantake to help patients with predi-abetes or diabetes achieve

desired outcomes.1. Identify patients who have

risk factors for diabetesand/or pre-diabetes.

2. Set clear expectations forpatients with prediabetesbased on the DPP recommen-dations to:a. lose 5 to 7 percent of body

weight andb. be active 30 minutes, five

days a week.3. Provide patients with

resources to make healthylifestyle choices to reach theirgoals and help patientsaddress barriers.a. Ask patients what would

most help them be suc-cessful; what support/resources previouslyresulted in behaviorchange.

b. Refer patients to a regis-tered dietitian for medicalnutrition therapy or toattend a group DPPlifestyle intervention pro-gram. If these resourcesare not available in yourclinic or community, con-sider collaborating withothers to make neededresources available.

c. Offer encouragement!4. Establish a system to check

in with patients betweenphysician visits.

5. Celebrate successes, largeand small.

Maggie Powers, PhD, RD, CDE, isa research scientist at the InternationalDiabetes Center at Park Nicollet,Minneapolis. Teresa Pearson, MS, RN,CDE, FAADE, is a health care and clini-cal consultant with Halleland HabichtConsulting, LLC, Minneapolis. RitaMays, MS, RD, LN, is a diabetesprevention planner at the MinnesotaDepartment of Health.


Diabetes from page 31 The intervention that decreasedparticipants’ risk of developing type 2diabetes by 58 percent was a 16-sessionlifestyle education/support program.

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

Our award winning patient care and uncommon medical special-ties set us apart from other regional health care groups. LakeRegion’s physicians and their families also enjoy an unmatchedquality of professional and personal life.

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

Practice Well.Live Well.

Lake Region Healthcare is an Equal Opportunity Employer. EOE

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

For more information contactBarb Miller, Physician [email protected] • (218) 736-8227

www.lrhc.org

• Dermatologist• Family Medicine• General Surgery

• Hospitalist• Internal Medicine• Pediatrics 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 ...


Connecting your business to your market

Connecting your business to your market

By Robert Sweet, MD“I have prostate cancer

… and I want a robotic

prostatectomy ” This is

a common presenting“chief complaint” heard

nowadays in urologists’

offices across the state

and across the country

If you perform robotic prostatectomy, it

can be a plus in marketing your practice

If you don’t, you either try to convince your

patient that robotic prostatectomy isn’t all

it’s cracked up to be, or you refer him to

someone who does itTo date, removing the prostate with the

aid of a robot is the most common current

application of robotic surgery Approx-

imately 90,000 radical prostatectomies

are done annually in the United Sta

and, according to Intuitiv

of Sunnyvale Calmanuf

figure, given the rela-tively recent adoption

of the robot for use in

clinical applicationsThe rapid growth in

this field promisesto permanently alter

the way surgical proce-

dures—especially mini-

mally invasive surgeries—are performed

and taughtThe current state-of-the-art

The da Vinci robot and its

progeny, the da Vinci S HD

surgical system, were releas d

in 1999 and 2006Essentiall

Volume XXI, No.7October 2007


B edside manner may be

viewed as a “soft” skill these

days, and advances in medi-

cine continue to heighten the

emphasis on clinical and technical

expertise But as medicine shifts its

focus to become more patient cen-

tered, patient experience is fast gain-

ing ground as a key measure of qual-

ity In 2004, for example, the U S

Medical Licensing Examination

added a national skills test on per-

sonal interaction and communica-

tion that medical students must pass

to be eligible for licensure And this

year, the National Committee for

Quality Assurance (NCQA) added

“shared decision-making” as one of

seven measures to assess patient

experienceShared decision-making involves

systematic interaction with patients

to arrive at an informed decision,

based on their values and prefer-

DECISION-MAKING to page 12

Talk it outShared decision-making improves

the patient experienceBy Marcus Thygeson, MD,

and Karen Kraemer, RN, CMC

Lending ahandRobotic surgerymakes inroads into the

OR and beyond

Special Focus: Rur lP

Volume XXI, No.8November 2007


Bringing a new medical deviceto market was a lot easierin the good old days It wessentially a t

Bringing a newmedical deviceto marketThe challengesof picking a winnerBy Curt Miller

in Minnesota Physician

612-728-8600

Advertise

www.olmstedmedicalcenter.org

Opportunitiesavailable in the

following specialty:

Family MedicineRochester

Northwest Clinic

Family MedicineSt. Charles Clinic

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

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

Urgent Care

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

For consideration, apply online at healthpartners.jobs and follow the Search Physician Careers link toview our Urgent Care opportunities.For more information, pleasecontact [email protected] or call Diane at: 952-883-5453; toll-free:1-800-472-4695 x3. EOE

©

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

symptoms may be interpretedas dementia. In other patientsthe onset of a motor, speech, orsensory deficit may be confusedwith a cerebrovascular accident,transient ischemic attack, orbrain tumor.

The diagnostic procedureof choice for evaluation of achronic SDH is the CT scanwithout contrast. In the firstweek after injury, a chronicSDH appears hyperdense in re-lation to the brain. In the nexttwo weeks, most hematomaswill appear isodense. Afterthree weeks, the vast majoritywill appear hypodense andassume a lenticular appearance.Nevertheless, because recurrentbleeding frequently occurs fromthe vascularized hematomamembranes, chronic SDH canappear as an admixture ofhypo- and hyperdense material.

Close monitoring ofpatients with serial CT scansallows determination of chronicSDH reabsorbtion or enlarge-ment. Operative treatment ofchronic SDH has been achievedwith the use of craniotomy or

bur holes. Bur hole removal iseffective if multiple membranesappear absent and the hema-toma appears hypodense on CT(see Fig. 1). The presence ofmultiple membranes and mixeddensity hematomas with acuteand chronic componentsrequires craniotomy.

The frequent use of post-opCT scans to follow the postoper-ative progress of patients withchronic SDH demonstrates thatresidual hematoma is quitecommon regardless of operativetechnique used. Generally, thesmall residual hematoma willgradually reabsorb over a per-iod of weeks to months. Truere-accumulation of the hema-toma is reported to occur asoften as 35 percent in someseries and probably results fromre-bleeding of vascular mem-branes. Infectious complica-

tions include subdural empye-ma, brain abscess, and meningi-tis. These complications areuncommon and occur in lessthan 1 percent of patients.Seizures are reported in 10 per-cent to 12 percent of cases andappear to be related to the sizeof the hematoma and underly-ing brain shifts. The morbidityfollowing treatment of a chron-ic SDH is less than 8 percent inmost large series and about 75percent of patients resume nor-mal functioning. Outcome cor-relates most closely with thepatient’s neurological state atthe time of treatment.

Toward improvedclinical outcomes

Much has changed since theaccurate literary description ofbrain trauma by Honoré deBalzac in the early 19th century.

The advent of modern medicalscience and imaging, especiallywithin the last 40 years, hasallowed for the early diagnosisand aggressive treatment oftraumatic brain injuries withimproved clinical outcomes.

Given the increasing sizeof the aging population and thehigh personal and societalexpectations of maintaining arelatively high degree of physi-cal functionality, the evaluationand treatment of traumaticbrain injuries will continue toplay an important role. Physi-cians should have a high indexof suspicion in those elderlypatients presenting with anunexplained neurological orcognitive decline, even in theabsence of a history of per-ceived significant trauma.

Edward G. Hames III, MD, PhD, andCharles R. Watts, MD, PhD, practicewith the Spine and Brain Clinic atFairview Southdale Hospital and areemployed by University of MinnesotaPhysicians through the Department ofNeurosurgery at the University ofMinnesota.


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26th Annual Family Medicine Today March 8-9, 2012

30th Annual OB/Gyn Update April 12-13, 2012

The Mind of a Child: Psychiatric Challenges for Today’s Youth April 19, 2012

Psychiatry Update: Selected Topics for the Non-Psychiatrist April 20, 2012

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Fundamental Critical Care Support July 19-20, 2012

30th Annual Strategies in Primary Care Medicine September 20-21, 2012

Optimizing Mechanical Ventilation October 26-28, 2012

13th Annual Women’s Health Conference November 2012

continuing medical education

Brain Injury from page 25 The advent of modern medical science andimaging has allowed for the early diagnosisand aggressive treatment of traumatic braininjuries with improved clinical outcomes.

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