Minnesota Physician April 2019 by Minnesota Physician Publishing

MINNESOTA

APRIL 2019

PHYSICIAN

THE INDEPENDENT MEDICAL BUSINESS JOURNAL

Volume XXXIII, No. 1

Health care legal partnerships A team-based approach BY KATHRYN FREEMAN, MD, AND MEGHAN SCULLY, JD

Social determinants of health Customizing patient care

alter, a patient with uncontrolled diabetes, walks into your exam room. You have been working with Walter over the past 12 months to get his blood sugars and A1C under control. Walter has been homeless for the past three years and without a safe place to store his insulin. Each visit you check his lab values and review his medications, titrating up on his insulin. You refer him to diabetes education. You provide information and handouts on lifestyle changes, including healthy diet and exercise. Yet, despite regular visits, appropriate medications, and a strong patient-provider relationship, there has been little change in Walter’s health. Why? Without stable housing, he has no place to store his medication and insulin. As his provider, it can feel beyond your control; the barriers to Walter’s health are outside of your area of expertise. Social determinants of health—including access to nutritious and healthy food; a safe and habitable shelter; relationships that are safe and free from Health care legal partnerships to page 124

BY KATHLEEN A. CULHANE-PERA, MD, MA, AND CHRIS SINGER, MAN, RN, CPHQ

ur work in health care is only part of what contributes to overall health. Social Determinants of Health (SDoH)—people’s education, employment, finances, legal status, literacy skills, English fluency, transportation, housing, and, most importantly, their neighborhood—can be just as important. SDoH factors contribute to health disparities in Minnesota; our communities with high SDoH burdens experience higher rates of disease and disabilities. Social inequities also contribute to disparate medical quality scores; those of us who see patients with high SDoH burdens have lower scores. The challenge is to identify these issues in our patients and determine how to respond as individual physicians and as members of health care institutions to promote health. Social determinants of health to page 104

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APRIL 2019 MINNESOTA PHYSICIAN

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ND 52 SESSION

APRIL 2019

Volume XXXIII, Number 1

COVER FEATURES Social determinants of health

Health care legal partnerships

By Kathleen A. Culhane-Pera, MD, MA, and Chris Singer, MAN, RN, CPHQ

By Kathryn Freeman, MD, and Meghan Scully, JD

Customizing patient care

A team-based approach

DEPARTMENTS CAPSULES

MEDICUS

INTERVIEW

NEUROLOGY Obstructive sleep apnea

Examining the adverse consequences By Tacjana K.E. Friday, MD

Shaping our health and well-being John R. Finnegan Jr., PhD University of Minnesota School of Public Health

PEDIATRICS Parenteral nutrition

PAIN MANAGEMENT 16 Dialing down opioid use

By Lisa Tollefson, PharmD; Sarah Keyes, RN, BSN; and Maria Mahady, RD, LD

Helping youth thrive at home

Alternative treatments By David Schultz, MD

The Gallery, Hilton Minneapolis | 1001 Marquette Avenue South

A look at new FDA-approved devices

BACKGROUND AND FOCUS:

By Thomas Samuelson, MD, and David Hardten, MD, FACS

PROFESSIONAL UPDATE: GASTROENTEROLOGY Heartburn 18 Individualizing diagnosis and treatment By Kourtney Kemp, MD, FACS

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ART DIRECTOR

As health care costs constantly rise, containment strategies involve care teams. Many individuals are now part of every physician-patient encounter. Some are hands-on with the patient, some the patient never sees. New entities become part of care teams offering services from chronic care management, to behavioral health screening, to care coordination, to coding, charting and much more. With goals of lowering costs, increasing reimbursement, and improving outcomes, clinics can customize teams to individual patient needs. Keeping up with this rapidly evolving landscape can exceed the capacity of many medical groups. OBJECTIVES:

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Improving interoperability

Thursday, November 14, 2019, 1â&#x20AC;&#x201C;4 p.m.

OPHTHALMOLOGY 20 Advances in treating eye disease

EDITOR

CLINICAL AND NON-CLINICAL CARE TEAMS

Mike Starnes, mstarnes@mppub.com

Richard Ericson, rericson@mppub.com Scotty Town, stown@mppub.com

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ACCOUNT EXECUTIVE ______________________________ Shawn Boyd, sboyd@mppub.com

Minnesota Physician is published once a month by Minnesota Physician Publishing, Inc. Our address is 2812 East 26th Street, Minneapolis, MN 55406; email mpp@mppub.com; phone 612.728.8600; fax 612.728.8601. We welcome the submission of manuscripts and letters for possible publication. All views and opinions expressed by authors of published articles are solely those of the authors and do not necessarily represent or express the views of Minnesota Physician Publishing, Inc. or this publication. The contents herein are believed accurate but are not intended to replace medical, legal, tax, business, or other professional advice and counsel. No part of the publication may be reprinted or reproduced without written permission of the publisher. Annual subscriptions (12 copies) are $48.00/ Individual copies are $5.00.

We will examine the diversity of care teams and how they interact. We will explore benefits that could result from improved coordination of these care teams. We will identify the barriers to this improved communication, such as incompatible EHRs and data privacy issues, and ways around them. We will provide examples of successful integration of clinical and non-clinical care teams and a road map for adopting and scaling these models for all elements of our health care delivery system.

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Northfield City Council Approves Clinic and Birth Center Expansion Plans Northfield Hospitals and Clinics is moving forward with expansions on both its Northfield Clinic and Birth Center in 2019. The Northfield Clinic has outgrown its current space, as it continues to gain new providers and more patients. It needs room for growing services, such as family medicine, pediatrics, internal medicine, and specialty care, as well as new services. The expansion will add exam rooms and space for providers joining the practice, using a design that supports its care team model. The Birth Center welcomes about 550 babies per year, and needs more space to accommodate more births simultaneously. The expansion project will increase its capacity to allow for 750 births per year, and add an operating room specifically for C-sections.

The two projects will cost about $13 million total. The Northfield City Council approved the expansion plans in early March, and now the Northfield Hospitals and Clinics board is moving forward to prepare an RFP for architect and construction services. They plan to begin construction in the spring.

Summit Orthopedics’ Surgery Center First to Earn Distinction for Spinal Fusion Summit Orthopedics’ Eagan Surgery Center has become the first surgery center in the nation to earn The Joint Commission’s Certificate of Distinction for the Management of Spinal Fusion. To earn the certification, medical facilities must meet a robust and challenging list of requirements in areas including program management, clinic care, patient self-management, clinical information management, and

performance measures. Since the spinal fusion certification was introduced two and a half years ago, 12 facilities have earned it. All of them are hospitals. Nicholas Wills, MD, a spine surgeon at Summit Orthopedics, said that despite earning its Certificate for Distinction for spinal fusions, the surgery center focuses first on conservative, nonsurgical treatments for its patients, pursuing surgery only when all other treatment options have been exhausted. He noted that just 15 percent of Summit Orthopedics’ spine patients are treated with surgery. “For those patients who do undergo spinal fusion surgery at Summit, we have a standardized approach to every aspect of their care, and our entire staff adheres to that protocol,” said David Strothman, MD, a spine surgeon at Summit Orthopedics. “In this way, we minimize the risks associated with the complexity of spinal fusions. Based on our outcomes, I would say that our approach is working very, very well.”

According to Strothman, who developed Summit Orthopedics’ spinal fusion protocols, since the Eagan location opened in March 2017, of the more than 150 spinal fusions that have been performed, the incidence of infection was zero.

Report Shows Hospital Pricing Rising Faster Than Economy An analysis of hospital prices from National Nurses United and Minnesota Nurses Association (MNA) shows that Minnesota hospitals are charging an average of 212 percent more than it costs them to provide care for patients. They note that the cost for care includes not only direct labor and supplies, but also administrative and general costs, such as maintenance and housekeeping. Sources for the report, called Minnesota’s Most and Least Expensive Hospitals, include 2016-2017 Medicare

V Autism and Obstructive sleep apnea are now approved conditions V

HAVE YOU REGISTERED WITH THE MINNESOTA MEDICAL CANNABIS PROGRAM? Registration can be done online; there is no fee and it takes only a few minutes. Visit the registry website: mn.gov/medicalcannabis Your account will provide access to medical cannabis purchasing information from patients you certify. Once you are registered, you will be able to certify patients with a variety of conditions, including: • Cancer, Glaucoma, Tourette Syndrome, HIV/AIDS, and ALS

• Inflammatory bowel disease, including Crohn’s disease

• Seizures, including those characteristic of Epilepsy

• Terminal illness, with a probable life expectancy of less than one year

• Severe and persistent muscle spasms, including those characteristic of MS

• Intractable Pain

• Obstructive sleep apnea

• Autism

• Post-Traumatic Stress Disorder

Cannabis Patient Centers are now open to approved patients in Minneapolis, Eagan, Rochester, St. Cloud, Moorhead, Bloomington, Hibbing, and St. Paul.

OFFICE OF MEDICAL CANNABIS (651) 201-5598: Metro (844) 879-3381: Non-metro P.O. Box 64882, St. Paul, MN 55164-0882 health.cannabis@state.mn.us

Many patients have reported improvement in their health status from medical cannabis — some describing dramatic improvements. Smoking cannabis is not allowed under the program. Visit our website for educational resources about cannabinoids and the endocannabinoid system and for scientific literature on the efficacy of medical cannabis in treating certain conditions.

See our website for a detailed first year report. mn.gov/medicalcannabis

APRIL 2019 MINNESOTA PHYSICIAN

CAPSULES

Cost Reports for each of the 111 hospitals included in the report, as well as data collected by the Bureau of Labor Statistics, the Center for Medicare and Medicaid Services, and the American Hospital Association. Medicare Cost Reports provide data on hospital charges and costs for a variety of services, and the charges are often referred to as charge master prices—most patients won’t pay the base charge master price, but it sets a starting point for negotiations between the hospital and insurance companies over reimbursement rates. These prices impact the cost of care, as those higher rates are often passed from the insurance company on to the patients, according to MNA. The cost-to-charge ratio (CCR) is a way to measure the relationship between hospital costs and charge master prices. If charges are higher than the costs, the CCR will be higher than 100 percent, and if the charges are lower than costs, the CCR will be below 100 percent. The average CCR in 2016 for Minnesota hospitals was 212 percent. The lowest CCR at a hospital was 108 percent and the highest was 383 percent. Notable takeaways from the report include that hospitals with higher CCRs are mostly located in larger metro areas; providers with high CCRs tend to be part of larger health care systems; and high CCR hospitals had a higher ratio of excess revenue over expenses (profit) than those with lower CCRs. In addition, Minnesota hospitals’ profit margins have steadily risen over the past 20 years, with little deviation from the trend, and hospital spending as a percentage of health expenditures has increased over the past 20 years from 27.7 percent to 33.8 percent. MNA notes that unless something changes, this trend will only continue.

patients undergoing cancer care. Digital medicine technology is used to help patients manage medications for a variety of diseases, including diabetes and hypertension, but it has not been used for cancer until now. “When we give people chemotherapy in the clinic with an intravenous drug, we’re able to assess the dose and timing and make sure they’re well enough to continue getting the treatment,” said Edward Greeno, MD, oncologist/hematologist and professor in the University of Minnesota Medical School’s department of medicine. “But when you send them home with a bottle of pills, you don’t know when they’re taking them or if they’re well enough to take them.” According to Greeno, the technology could significantly improve cancer care because the timing and dosage of chemotherapy is critical. He and other physicians at the Masonic Cancer Clinic have begun prescribing pills embedded with small, ingestible sensors. The sensors, designed by Proteus Digital Health, are the size of a grain of sand and can track information including heart rate, activity level, and sleep cycle. Once a patient ingests the pill, it sends the data to a small patch on the patient’s abdomen, which then connects to a mobile app that both the patient and their physician can access. The technology will allow physicians to ensure patients are taking their medications as prescribed. They also can automatically tell how many pills a patient has left in their prescription, which helps them better manage refills. In addition, according to the researchers, it can give a sense of comfort to some patients, helping them take a more active role in managing their medication.

Digital Pills Allow Physicians Mayo Clinic Begins to Monitor Patients with Expansion to La Crosse Cancer at Home The University of Minnesota and Cancer Center Fairview Health Services are now the first in the world to use digital medicines to allow doctors to monitor

Mayo Clinic has received a philanthropic gift of $5 million to support the renovation and expansion of the

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CAPSULES

Mayo Clinic Health System Cancer Center in La Crosse, Wisconsin. Stephen and Barbara Slaggie of Marco Island, Florida, and Winona, Minnesota, gave the gift in recognition of their long, 70-plus-year relationship with Mayo Clinic. Mayo Clinic plans to name the cancer center in honor of the Slaggie family. Naming details will be shared at the expansion opening later in 2019. The expansion project is already underway at the cancer center, and construction is scheduled to be completed this year. It will add 3,900 square feet of space and enlarge the pharmacy area. It will also add nine exam rooms and nine treatment chairs for medical oncology, as well as improve the workflow efficiency of the space. The center opened in September 2004, and since then, the number of patients it serves has doubled. The expansion will allow Mayo Clinic to meet the current patient demand and allow for future growth.

Adverse Health Events Continued to Increase in 2018 The number of reportable adverse events at Minnesota hospitals, ambulatory surgical centers, and community behavioral health hospitals has reached a new high after slowly increasing for five years, according to the 15th annual public report from the Minnesota Department of Health (MDH). The reporting system tracks 29 serious events, such as wrong-site surgeries, severe pressure ulcers, falls, and serious medication errors. Between October 2017 and October 2018, there were 384 events out of 5 million patient days. MDH notes that though the number of events increased again, they remain very rare with a frequency far below 1 percent of hospitalizations, and that number has remained steady over the past 15 years of reporting. The report shows that the increase in adverse health events

during this period was largely driven by a rise in pressure ulcers, retained foreign objects, and the loss or damage of irreplaceable biological specimens. “This system has given us a much deeper understanding of how and why adverse events occur, and it has helped create a culture of learning and improvement across Minnesota. But despite earnest collaboration and effort, in the last few years of reporting, the number of reported events has plateaued in several categories and increased in others,” said Jan Malcolm, Minnesota commissioner of health. “It is clear there is still more to do to keep patients safe every time they receive care. We look forward to working with our partners this year to ensure this system can continue to improve, evolve, and get results.” Of the reports during this period, 31 percent resulted in serious injury (118 events) and 2 percent (11 events) led to the death of a patient. In the past, falls, severe ulcers, medication

errors, and product/device malfunction were the most common causes of serious patient injury or patient death, and that pattern continued in 2018. Five of the 11 deaths were associated with falls, three with the death of a neonate, two with medication errors, and one as the result of a suicide. There were 33 reported cases of retained foreign objects during the reporting period—while there has been a decrease over 10 years, the number of these events has increased each year for the past four years, highlighting it as an area to focus on improvement. The number of wrong-site procedures fell by a third during the reporting period, due to hospitals and surgical centers focusing intensely on preventing those in 2018. And the number of reported pressure ulcers increased in 2018, from the previously reported 120 to 147, continuing the upward trend that has been shown for the past six years in this category.

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APRIL 2019 MINNESOTA PHYSICIAN

MEDICUS

Mark Rosenberg, MD, vice dean for education and academic affairs at the University of Minnesota Medical School, has been named the new president of the American Society of Nephrology (ASN). ASN includes 20,000 health professionals across 131 countries and is the largest organization committed to treating and understanding kidney diseases. Rosenberg is also a professor in the department of medicine in the medical school and serves on the ASN council. Before coming to the University of Minnesota in fall 2012, Rosenberg served as chief of medicine and director of the primary and specialty medicine service line at the Minneapolis VA Health Care System. He earned his medical degree at the University of Manitoba, Winnipeg, Canada.

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Peter Nalin, MD, has been appointed the new head of the Department of Family Medicine and Biobehavioral Health at the University of Minnesota Medical School, Duluth Campus. He will also serve in the newly created role of associate dean for rural medicine. Nalin’s responsibilities will include the oversight of outreach, research, and clinical teaching activities at the school, which serves a primary role in the state by training physicians to provide care in rural and Native American communities. Previously, Nalin served as executive associate dean for educational affairs and an associate professor in clinical family medicine at Indiana University School of Medicine. He has an extensive career in medical education, which began as a rural medicine education preceptor in upstate New York, and at Indiana University where he led the Bloomington Medical Education Center. Nalin earned his medical degree at the University of Vermont College of Medicine. He will step into his new position on June 30.

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Kimberly Tjaden, MD, a family physician with St. Cloud Medical Group, has received the 2019 Family Physician of the Year award from the Minnesota Academy of Family Physicians for representing the highest ideals of the specialty of family medicine, including caring, comprehensive medical service, community involvement, and serving as a role model. She was selected from 30 nominees, and a group of five finalists. Tjaden has served with CentraCare Health for nearly 20 years. She has an interest in public health and has been recognized for her work on health disparities between urban and rural women in Minnesota. She has also served as chair of the Minnesota Medical Association’s Committee on Public Health. Tjaden earned her medical degree at University of Nebraska College of Medicine and completed a residency and internship at Bishop Clarkson Memorial Hospital in Omaha.

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MINNESOTA PHYSICIAN APRIL 2019

INTERVIEW

Shaping our health and well-being John R. Finnegan Jr., PhD University of Minnesota School of Public Health What do you want people to think when they hear the term “public health”?

difficult if you’re poor; it’s harder if you’re poor and a person of color; and even harder if you’re poor, a person of color, and an immigrant.”

Public health is about the forces and factors that combine to shape the health and well-being of population groups. Core to public health is disease prevention and health promotion, and the partnerships it takes to make these efforts effective. Just a few examples of the variety of public health work from our school: We’ve developed apps for just-in-time interventions to stop HIV transmission; we help keep farm children safe from injuries; and we design and run some of the largest clinical trials in the world in infectious and communicable diseases. Public health has a full dance card!

What are the biggest challenges facing the field of public health?

Let me single out three: aging populations, climate change, and the need for further federal investment in U.S. public health. Today, 8.5 percent of people in the world are 65 and older; by 2050, that will likely reach 17 percent. This means a greater burden of chronic disease, rising health and long-term care costs, strains on health infrastructures, and an even more urgent need for prevention and health promotion at younger ages.

What are some of the common misperceptions people have about the field?

And second, some think public health efforts lead to “a nanny state,” though most public health professionals, including our school’s graduates (master’s and doctorates), work in the private sector. Regardless of that fact, public health relies on education, technology, and community partners to disseminate what it learns through evidence-based research that explores what is hurting or helping our collective health. What can you tell us about gun violence as a public health issue?

Some 100 people die every single day from guns in the U.S., and suicide accounts for 63 percent of those deaths. What’s more, a 2018 study in Health Affairs found that U.S. children ages 15–19 were 82 times more likely to die from gun homicides than those in our peer nations. We look at the problem through multiple interventions. I know that some people are deeply afraid that preventing gun violence means taking away people’s guns, but

APRIL 2019 MINNESOTA PHYSICIAN

“...”health’s focus on Public the population contrasts with medicine’s focus on the individual. that’s not a public health approach. For us, it’s about realistic, achievable ways to reduce the carnage.

As for federal funding, we’re not spending enough as a nation on prevention and health promotion. Some 90 percent of our nation’s health dollars go to health care, a system which many studies have shown is the most expensive and least efficient on the planet. We need a rebalancing!

How can public health initiatives address social disparities in health care?

What could the media do to heighten awareness of public health issues?

“...”

First, a lot of people think of public health in medical terms, such as treating patients. There is a strong complementary connection between medicine and public health, to be sure, but the focus and the tools are different. Public health’s focus on the population contrasts with medicine’s focus on the individual, for example.

Climate change exacerbates a host of public health concerns, such as the emergence and reemergence of infectious diseases, respiratory illness, water pollution, and excessive heat affecting aging adults and other vulnerable populations.

One approach we take is to shine a light on health care disparities, then follow up whenever possible with solutions that often lie in public policy and system changes. Two examples: Associate professor Katy Kozhimannil, PhD, found that birth doulas improve birth outcomes for low-income women, among whom women of color and American Indians are overrepresented. Her research had direct impact on the 2013 passage of Minnesota’s “Doula Bill” that permitted Medicaid coverage of services provided by a certified doula. SPH’s Upper Midwest Agricultural Safety and Health Center is addressing the well-being of immigrant farm workers. Co-director professor Jeff Bender, DVM, says, “Accessing health care is

The media can play a positive role to further public health, especially through advertising and television programming. The recent Merck ad (www. tinyurl.com/mp-merck) for HPV vaccine is extremely effective. On the other hand, with the explosion of social media there is potential for negative impact. Witness the anti-vaccine movement that promotes the falsehood that childhood vaccines cause autism. I also believe that scientists and journalists need to communicate research better to the public. Recently you were awarded one of 11 research grants nationally to improve the interface between public health research and physicians in clinical practice. What can you tell us about this project?

The grant supports a collaboration among SPH,

Mayo Clinic, and Hennepin Healthcare. With a $4 million, five-year award, we’ll train researchers in a game-changing approach to health care and health care research called learning health systems (LHS). In LHS, researchers embed in a health care system, bringing continuous and real-time learning into the relationship between researchers and clinicians to improve the quality of patient care. Fairview Health Services, Minneapolis VA Health Care System, Children’s Minnesota, Ebenezer, Essentia Health, and HealthPartners will partner with the program (Minnesota Learning Health System Mentored Career Development Program) to train the scholars, offering diverse patient populations and dynamic learning laboratories. What concerns do over-consolidation in health care pose to public health?

Like it or not, consolidation is the rule today and the question is whether or not it will reduce costs and keep quality high. Many experts believe that this trend is actually raising health care costs, shifting costs to consumers, but not improving patient care. We know that the consolidation of certain services leaves many in rural areas with reduced

access to health care. A recent study from our school (www.tinyurl.com/mp-SPH-study) found that rural U.S. counties that lost hospital-based obstetric services and were not adjacent to urban areas had significant increases in out-of-hospital births, births in a hospital without an obstetric unit, and preterm births in the first year. What can you tell us about the role of public health in shaping health care legislation?

Public health research provides data and evidence for health care legislation and helps guide policy decisions. Health policy and management are major parts of many schools of public health, like ours, and our research shapes the design of public programs, such as Medicare and Medicaid. For public health to be truly effective, though, we need legislators to pay more attention to research. We also need to make our findings easier to understand and apply. Our school did a study with the University of Minnesota Medical School and found that only 41 percent of all formal legislative discussions on childhood obesityrelated bills in Minnesota from 2007–2011 cited some form of research-based evidence.

What can physicians do to become more involved with a public health agenda?

Physicians are our best partners when it comes to protecting people from disease and fostering good health and well-being. We have physician-researchers on our faculty as well as physician-students who seek an MPH or PhD. Often they discover public health after they have spent many hours treating people with chronic diseases that could have been prevented. Those of us in public health and primary care have an important opportunity to form strong partnerships with communities to promote disease prevention and a culture of health. A good example of this is the Practical Playbook (www.tinyurl.com/mp-playbook). John R. Finnegan Jr., PhD, has been dean and professor at the University of Minnesota School of Public Health since 2005. With a doctorate in journalism and training in mass communication, he developed public health campaigns and a research and education program in health communication. He serves on several health-related local, national, and international boards.

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MINNESOTA PHYSICIAN APRIL 2019

3Social determinants of health from Cover

Working with these underserved populations led us to seek additional information and develop a focused response. In 2016, we began to Struggling with these issues at Minnesota Community Care (previously develop a data system that provided direction to more effectively known as West Side Community Health Services), we have taken some steps impact the communities served and to identify strategies in specific to quantify, explore, understand, and respond to SDoH. clinical indicators and health systems that could overcome the barriers that facilitated inequitable health care. Through About our clinic the Disparities Leadership Program at Harvard As a Federally Qualified Health Center (FQHC) University, we decided to expand our identification with 17 locations in Ramsey County, Minnesota and understanding of SDoH that may be affecting Community Care (MCC) provides comprehensive our quality metrics and contributing to our health We are looking for new, primary health care services to a population that disparities and health inequities. We adopted the innovative ways to partner disproportionately shoulders the burden of health Kotter Model for Leading Change as a blueprint with other organizational and disparities in our community. In 2017, of 36,338 for change and to translate understanding of societal advocacy groups. patients, 98 percent had incomes below 200 percent disparities into realistic solutions. Dr. John Kotter of the federal poverty level, 71 percent were women observed organizations execute their strategies for and children, 42 percent were medically uninsured, over 40 years, extracted the success factors, and and over 56 percent did not speak English as a developed them into a methodology. (See www. first language. In addition, 86 percent were from tinyurl.com/mp-kotter.) communities of color, predominantly Hispanic/Latino, Black/African The Kotter Model shows eight steps toward leading change: American, and Asian (mostly Hmong). MCC services are available to all; patients with incomes less than 300 percent of poverty level are offered a • Create a sense of urgency. sliding fee program. No one is turned away for lack of insurance or inability • Build a guiding coalition. to pay for services. Anecdotally, we know that many of our patients struggle • Form a strategic vision and initiatives. with SDoH issues, but other than race/ethnicity, preferred language, and • Enlist a volunteer army. country of origin (often known collectively as RELO), we had not collected specific data to quantify these issues. • Enable action by removing barriers. • Generate short-term wins. • Sustain acceleration. • Institute change. This model challenged us throughout the improvement project, from assessing varying accomplishments—or lack of progress—and as we completed the project. While we initially assessed that the system resided at “generate short-term wins,” the team later determined that, in some aspects, the first step of “creating a sense of urgency” had not yet been created. The Kotter Model was instrumental in guiding our progress toward a deeper level of cultural assessment and uncovering system barriers that critically impacted the communities we served.

Preparing for PRAPARE With the system now ready for change, the first goal we set included developing a sophisticated data infrastructure to identify social determinant disparities with the hope that we could target our services to identified special populations. Prior to this goal, we had used a data structure that produced system-level data to support reportable measures, such as diabetes, asthma, and cancer screenings. This system did not include the infrastructure to include disparity reporting, including race, ethnicity, language, and country of origin (RELO), and SDoH data with insecurities such as food, housing, transportation, legal services, safety of household, and neighborhood. In an alignment of timing, the National Association of Community Health Centers (NACHC) began dissemination of the PRAPARE (Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences) tool. The tool consists of a set of national core measures as

APRIL 2019 MINNESOTA PHYSICIAN

well as a set of measures for community priorities. It was informed by research, the experience of existing social risk assessments, and stakeholder engagement. Core measures include personal information about education, employment, income, literacy skills, and safety; insecurities in housing, utilities, food, and transportation; and factors such as social integration and stress. (See www.tinyurl.com/mp-prapare.) We customized the PRAPARE tool based on patient engagement and stakeholder assessment and created an adjusted tool to collect the measures. Data collection began in June of 2017, focusing on adult populations as a pilot project and then expanding to all family practice sites. Because the PRAPARE tool has not yet been validated in pediatric populations, we continue to focus on adults.

with transportation challenges (60 percent versus 70 percent). There are no differences in rates for housing, education, and social integration.

Follow-up action steps What do these results mean, and what do they signify?

We Minnesota physicians continue our dedication to improving health of Minnesotans.

Results The results to date quantify the extent of SDoH for 3,756 adults who have completed the form. Most of the adults who completed the form were middle-aged women with a range of ethnicities/races, education, and insurance. About 10 to 18 percent of respondents reported having insecurities in housing, utilities, food, clothing, childcare, and phone service. About 9 to 18 percent had difficulties accessing needed medical, mental health, and dental care. Many respondents reported low levels of contact with people whom they care about and are close to: 41 percent said they interacted with others just one to three times per week, while 48 percent said their contacts occurred less than weekly. When asked about stress, 55 percent reported they were somewhat stressed, and 22 percent had a lot of stress. To explore how these SDoH factors may affect quality of care, we are examining how these issues are related to our quality metrics, and, therefore, may be affecting our quality measures. [Note: MCC reports to the federal government using the Uniform Data System (UDS), and to Minnesota’s Statewide Quality Reporting and Measurement System (SQRMS) through MN Community Measurement.]

Data on two fronts For this article, we examine one preventive health service measure (cervical cancer screening) and one chronic disease measure (A1C as a measure of control for diabetes mellitus).

These results are limited in several ways. One, these results do not represent our entire population. While MCC serves over 36,000 people, only 10 percent have completed a PRAPARE questionnaire so far. Two, these descriptive statistics are not analytical statistical assessments. They are the beginning descriptions that afford us additional insights into SDoH for our patients. Three, they represent slices of people’s lives, and do not measure other aspects of health, health status, and the many other factors that impact their ability to achieve healthy outcomes.

Despite these limitations, the PRAPARE data lay the foundation for ongoing clinical improvements. Understanding the SDoH connections more clearly than we did before we collected the data, we are designing internal quality improvement efforts to align our clinical care with identified disparities, deficiencies, and gaps, in order to improve clinical and operational outcomes. And we are looking for new, innovative Social determinants of health to page 144

ENGAN ASSOCIATES

Creating Healing Environments for 40 Years

Our overall cervical cancer screening rate is 55.2 percent, which is the percentage of women 23 to 64 years of age who have had pap smear in the previous three years. The highest rates are in Hispanic White women (65 percent), younger women (57 percent <40 years of age), and those who are uninsured on our discount program (54 percent). The lowest rates are in women who report a lot of stress versus no stress (48 percent versus 59 percent); in women who connect with people they care about less than weekly versus more than three times a week (53 percent versus 61 percent); and in women who report unstable housing versus stable housing (35 percent versus 56 percent). There are no differences in rates for education and literacy. Our overall diabetes control rate is 29.1 percent, which is the percentage of adults with diabetes mellitus type 1 or 2, 20 to 75 years of age, who have had an A1C <9 percent in the past year. The highest rates are adults >60 years of age (70 percent), women (64 percent), and non-Hispanic Whites (64.9 percent), with about equal rates of insured and uninsured. The lower rates are in people with a lot of stress (62 percent versus 79 percent) and

“We wouldn’t hesitate to work with Engan Associates again.” (Matt Reinertson, Heartland Orthopedic Specialists)

3Health care legal partnerships from Cover

about malpractice or litigation; others may worry about patient privacy and protection of information.) But the goal of a health care legal partnership is violence; and opportunities to pursue education, employment, and a community to serve clinic patients. For example, one Bethesda patient was referred to the in which we feel safe—are increasingly being recognized as significant factors onsite attorney because she had received a termination notice from public contributing to one’s overall health. To better housing. The termination was based on the patient’s address the social and economic conditions affecting failure to follow the management’s housekeeping their patients’ health, physicians at Bethesda Family expectations. However, because of complications Medicine Clinic, a primary care residency clinic in during her pregnancy and the subsequent birth, this St. Paul, are turning to an attorney. single mother of three young children was physically There are over 15 health care unable to do so. With the help of the mother’s An attorney in the house legal partnerships across provider at Bethesda, the onsite attorney was able to Bethesda has partnered with Southern Minnesota the state of Minnesota. demonstrate that her health condition was directly Regional Legal Services (SMRLS), a local legal aid linked to the reason for the termination, and was provider, to form a health care legal partnership able to save the patient’s affordable housing. The (sometimes referred to as a medical legal attorney also helped the family obtain services to partnership) with the goal of addressing patients’ ensure that the mother remained lease-compliant social determinants of health through legal while she continued to heal from her recent childbirth. The attorney’s work, in intervention. Founded in 1909, SMRLS attorneys provide free legal services consultation with the mother’s provider, helped the mother save her housing, to help low-income individuals and families secure and protect their basic allowed her to heal from a difficult pregnancy and birth, and protected the needs, and to maintain freedom from hunger, homelessness, sickness, and health needs of her young children and newborn baby. abuse. Since July of 2017, a full-time SMRLS attorney has been providing The health care legal partnership attorney has the ability to address legal services to Bethesda’s patients. Embedded within the clinic, the attorney many social and economic problems that are beyond a physician’s expertise. functions as a member of the care team. Just like a clinical pharmacist, the Through representation in eviction proceedings, the attorney can help attorney can be called in to meet in-person with a patient. prevent a family from becoming homeless. This means that the family can At first, the idea of an attorney onsite at a medical clinic may seem live in a safe place, attend school regularly, and attend regular preventive both puzzling and daunting. (Many physicians may jump to concerns visits. The attorney can also help an elderly patient appeal a wrongful reduction in food support. This means that the patient is able to access healthy food, maintain strength, and avoid a disastrous fall at home. Or when the attorney helps a patient fleeing an abusive partner obtain an order of protection, a young woman can sleep soundly at night, attend regular psychotherapy visits, and decrease her number of psychiatric medications. These are just a few examples. The attorney is also available to help children with learning disabilities receive the services they need to succeed in school, or to help refugees apply for citizenship.

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Impact on health outcomes and cost Partnerships like the one between Bethesda and SMRLS have been shown to improve patient health outcomes, reduce cost, decrease hospital admissions, and improve provider satisfaction. One study through the University of Arizona Alvernon Family Medicine Clinic, published in the Journal of Healthcare for the Poor and Underserved, found that patients noted 30 percent less stress and had a 41 percent increase in well-being following an intervention from the legal services team. Legal interventions may also be a means to lower rising health care costs. According to the Pennsylvania Healthcare Cost Containment Council, a state agency charged with reducing health care costs, a study showed a 51 percent reduction in per-patient health care costs following a targeted legal intervention with high cost or “super utilizer” patients within Lancaster County, Pennsylvania. Another partnership in New York demonstrated a 90 percent decrease in emergency room visits and hospital admissions for asthma patients following a legal intervention targeting substandard housing, according to a study published in the Journal of Asthma. Physician wellness and the effects of burnout affect many physicians, but especially those serving low-income populations. A national survey

conducted by the National Center for Medical-Legal Partnerships at the George Washington University showed that 38 percent of providers working in a health care legal partnership felt they were “better able to work at the top of their license” because of the presence of the partnership. Eighty-six percent felt that the partnership improved patient outcomes, and 64 percent felt it improved patient compliance with medications and treatment plans.

Tailoring partnerships to serve patients Each health care legal partnership is different, designed to fit the strengths and needs of both the legal and the health care partner. There are over 15 health care legal partnerships across the state of Minnesota. The first partnership, between Community-University Health Care Center (CUHCC) and Stinson Leonard Street Law Firm, formed in 1993. There are partnerships in a variety of clinical settings, including dental clinics, behavioral health centers, pediatric hospitals, and Federally Qualified Health Centers. Some legal partners include legal aid organizations like SMRLS, but others utilize private law firms whose attorneys provide pro bono services or law students through partnerships with law schools. For SMRLS and Bethesda, strong pre-existing relationships, overlapping missions and visions, and shared target communities provided the basis for the partnership. Bethesda has a strong interdisciplinary team model already, which includes clinical pharmacists, behavioral health professionals, and social workers. This served as a framework for the addition of a legal team member. The Bethesda-SMRLS partnership is located within the clinic, with the legal aid attorney onsite approximately 80 percent of the time. The attorney has her own office adjacent to the exam rooms, allowing patients

to be seen as issues are identified during medical visits. When a healthharming legal need is identified, a referral is placed within the electronic medical record, just as it would be for other specialty appointments. Upon conclusion of the legal work, the attorney sends the referring provider a written follow-up that identifies the type of legal intervention taken on behalf of the patient. When not with a patient, the attorney is available for consultations with the providers, and clinic staff regularly stop by to ask questions or discuss potential legal issues. She also works closely with the clinic social worker and care coordinators to identify the appropriate types of intervention. In the first year, 191 referrals for legal services were placed. Housing was the most common issue addressed, followed by public benefits, family law, insurance coverage, and immigration. Patients have had an overwhelmingly positive response to their interactions with the legal team. One patient shared, “She won the case for me. Now I have low-income housing. It helped me strengthen my mind, my heart.” Physicians also see the positive changes in their patients served by the partnership. “As a provider, I feel empowered to ask about difficult issues because I know there is a team behind me to help me and my patients with answers to social/legal problems,” said one doctor. Additionally, because Bethesda is the home site for a residency program and hosts family medicine and pharmacy residents, behavioral health fellows, and medical and pharmacy students, education has been a central Health care legal partnerships to page 154

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3Social determinants of health from page 11 ways to partner with other organizational and societal advocacy groups to address social inequities.

to local community organizations that can address SDoH issues. To this end, we are connecting with NowPow, an internet-based tool that, through the patient’s EMR, can connect patients with targeted/needed community resources. And we are planning on instituting a Medical Legal Partnership to support patients with legal needs.

For pap smears, these results seem to indicate that we are doing well with young women, and Latina women, regardless of insurance status. Our Spanish-speaking staff and providers, our discount program, our connections with the SAGE Cancer Screening program, and our relationship with young women seem to be working Communities with high SDoH well. We are looking at designing specific clinic burdens experience higher rates approaches to reach out to older women, non-Hispanic of disease and disabilities. women, stressed women, women who attend our mental health services, and women with unstable housing in new ways.

Recommendations For physicians and organizations interested in exploring, identifying, and then targeting social factors that influence health, we recommend a process similar to our own:

For diabetes control, we seem to be doing well with older people, women, and non-Latinos. Our current discount program for medical care and medicines may be helping people without insurance have rates equal to people with insurance. To improve control, we could design special efforts to target younger people, to identify and approach stressed people, and to create telemedicine programs and use mobile health technology to reach people with transportation barriers.

• Use the Kotter Model for Leading Change to assess and guide your organizational process. Create a sense of urgency by connecting with others who care about this and work with your leadership to create a coalition of people to carry the work forward. • Decide whether you want to collect data to affect population health or individual health—or both, as we did. The tension is inherent: we are asking individuals to report on their personal situation, so we can collate population data, but in doing so, we decided to also respond to individual needs by adding a question to the survey: Do you want to see a social worker today?

For these two examples and for our other quality metrics, we are examining how to outreach beyond our clinic walls to partner with and refer

• Choose a data collection tool, then adjust it to fit your organization’s goals and your populations. Consider types and number of questions, wording of questions, length of time to complete, language, literacy, and your local context.

Solutions through experience and collaboration

• Plan and implement a pilot program, review process results, and adjust as needed. • Review the results—who answered, what they answered— and relate the results to measures that are important to your organization’s goals and quality improvement projects. Finally, reach out to others who are attempting to identify and respond to SDoH. You are not alone in this effort, as we Minnesota physicians continue our dedication to improving health of Minnesotans. Kathleen A. Culhane-Pera, MD, MA, is medical director of quality at Minnesota Community Care. She is a family physician, having received her medical doctoral degree from Michigan State University and completed her family medicine residency from the University of Minnesota. She is also a medical anthropologist with a master’s degree in anthropology from the

The Gray Plant Mooty Health Law team knows the health care business. Partner with us for smart, practical solutions to all of your legal challenges.

University of Minnesota.

Chris Singer, MAN, RN, CPHQ, is chief operating officer at Minnesota Community Care. She has over 20 years of experience in clinical care leadership focused on improving quality for patients in a variety of health care settings. She has a clinical background as a registered nurse and holds an MA degree in nursing from Bethel University with a focus on health systems leadership as well as certifications in health care quality and leadership.

APRIL 2019 MINNESOTA PHYSICIAN

3Health care legal partnerships from page 13

complications down the road, such as chronic kidney disease, heart attacks, and foot infections. His provider referred him to the onsite attorney— part of the partnership. The legal team provides monthly conferences to who discovered he was unlawfully denied affordable housing—and took staff and providers on a variety of health-harming legal issues, and learners his case. Now Walter has a stable place to live, store and cook fresh and are given an opportunity to attend housing court with SMRLS attorneys. healthy food, and a better way to manage his Bethesda’s provider survey showed a greater than diabetes. He’s taking his insulin regularly and 20 percent increase in providers asking about and his A1C and blood pressure have come down, addressing family life, housing, income supports, preventing further hospitalizations. It’s a win for public benefits, and educational needs following patients, a win for providers, and a win for our Patients have had an the addition of the attorney. health care system. overwhelmingly positive There have been some obstacles to forming response to their interactions and maintaining the partnership, including the with the legal team. Kathryn Freeman, MD, is an assistant professor need to secure ongoing funding. To ensure that of family medicine and community health at the partnership is working for both organizations the University of Minnesota St. Joseph’s Family and is appropriately responding to the needs of the Medicine Residency Program, where she practices patients, a group of professionals from SMRLS full spectrum family medicine with obstetrics. and Bethesda meets monthly to review referrals, address issues relating to patient privacy and client confidentiality, and work on ways to secure Meghan Scully, JD, is a supervising attorney at Southern Minnesota Regional continued funding for the project. Despite these challenges, the presence of Legal Services, Inc., a nonprofit law firm, where she also represents clients in a legal aid attorney provides the rest of Bethesda’s care team a viable solution public benefit matters. In addition to the Bethesda Clinic, SMRLS has health to complex social issues affecting patient health, and this has had a positive care legal partnerships with Children’s Minnesota in St. Paul and Open Door impact for both patients and providers.

One success story

Health Center in Mankato.

Walter is just another patient at Bethesda Clinic. His A1C was too high, he was non-compliant with his insulin regimen, and he was at risk for further

Experts at integrating food prescriptions into care for patients with type 2 diabetes and other illnesses Research shows that food prescriptions, like those filled by FOODRx, can lower HbA1c scores and the total costs of caring for patients with type 2 diabetes. FOODRx brings healthy food directly into health care settings, removing common barriers to nutrition and creating a cost effective, simplified prescription for wellness. “We need to take off our blinders and start learning new ways to address the real-life circumstances that make our patients sick. FOODRx creates the partnerships we need to do this work. We’ve got some real ‘Ah-ha’ moments ahead of us.“ —Dr. Diana Cutts, Hennepin Healthcare To learn more, contact us at 651.282.0887 or at foodrx@2harvest.org

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MINNESOTA PHYSICIAN APRIL 2019

PAIN MANAGEMENT

Dialing down opioid use Alternative treatments BY DAVID SCHULTZ, MD

As a result, from 2000 to 2010, the rate of opioid prescribing, the number of opioids distributed, and the average prescription size all increased markedly as deaths from opioid overdoses ramped up in parallel.

How did we get here?

Patients with chronic pain present with a broad continuum of different problems, ranging from nociceptive (biological) pain caused by severe inflammatory conditions like rheumatoid arthritis, to neuropathic pain caused by damage to the nervous system, to pain behaviors driven primarily by psychological mechanisms and personality disorders. Sorting out the causes for chronic pain and developing an effective treatment plan are challenging tasks for physician pain specialists. Regardless of the cause for pain, it has become increasingly apparent that prescribing opioids to treat chronic pain may lead to addiction in susceptible patients and overdose death in some of these patients. And most experts agree that the liberal opioid prescribing practices of the past have contributed to our current national opioid crisis.

he opioid crisis currently gripping the U.S. presents significant challenges for the treatment of chronic pain. For much of the 2000s, opioids were liberally prescribed to treat pain, but in recent years, it has become clear that prescription opioids may lead to abuse, addiction, and overdose death in a certain population of chronic pain patients. The risks associated with opioid treatment have forced patients dealing with chronic pain—and physicians attempting to treat that pain—to look for alternative treatment options. Fortunately, a variety of alternative, non-addictive pain treatments are available and will be discussed in this article.

In the 1990s, the under-treatment of acute and chronic pain in the U.S. became recognized as a major public health problem. In response, Congress ushered in the “Decade of Pain Control” in 2000 at the same time that health care regulators designated pain to be the “Fifth Vital Sign” and prominent physicians advocated for more liberal opioid prescribing. This trend toward more aggressive pain management was bolstered by the pharmaceutical companies as they developed and marketed powerful new opioid formulations.

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By 2012, the U.S. was in the midst of a full-blown opioid crisis that persists today. According to the recently published Surgeon General’s Spotlight on Opioids, opioid overdoses killed more than 48,000 Americans in 2017, and deaths from opioids in the U.S. have surpassed deaths from motor vehicle accidents and shootings combined in every year since 2013. Although illicit fentanyl is now a major contributor to the current crisis, prescription opioids administered for pain have been implicated in causing the addictions that have led to many opioid overdose deaths.

Options beyond opioids: multidisciplinary intervention

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Fortunately, the science and technology of pain management has advanced over the past two decades to the point where there are now alternatives to opioid management for chronic pain that may provide better pain relief with less risk. Physicians in the new medical specialty of interventional pain management (CMS designation 09) have pioneered the use of minimally invasive, image-guided procedures to identify and treat the physical generators of pain and utilize high tech, fully implantable pain control systems for extreme pain that proves unresponsive to more conservative measures. Multidisciplinary, interventional approaches coordinate these pain-relieving procedures with physical therapy and behavioral health treatments to effectively treat chronic pain in a holistic fashion with less reliance on opioids. Nura is a multidisciplinary, interventional pain clinic in the Minneapolis/St. Paul area. When a patient is referred with complex chronic pain, we start with a comprehensive, pain-focused evaluation to create a tailored treatment plan that best fits the patient’s needs. We begin by optimizing medication management using non-addicting medications such as NSAIDs, acetaminophen, anti-depressants, and nerve-stabilizing drugs like gabapentin.

New drugs in development There is intense international research within academic institutions and large pharmaceutical companies aimed at developing highly selective

APRIL 2019 MINNESOTA PHYSICIAN

stimulation is often tried first because it is an epidural system that is not in drugs to block specific pain pathways with minimal side effects. Nura direct contact with the spinal cord and does not involve medications. Pain participates in research studies on some of these investigational treatments, pumps are somewhat higher risk because they utilize an intrathecal catheter giving selected patients access to new and novel therapies. The monoclonal that deposits medication directly onto the spinal cord to provide targeted antibody tanezumab is one such drug that belongs to an investigational drug delivery (TDD). group of pain medications targeting nerve growth factor, a protein involved in the growth of nerve TDD eliminates addiction potential cells. In 2012, U.S. regulators banned monoclonal Although TDD is considered only as a last resort, antibodies to treat chronic pain because of a concern it is perhaps the most powerful and effective that medicines targeting nerve growth factor treatment available for refractory, intractable pain There are now alternatives could worsen osteoarthritis in a small percentage from cancer, multi-level spinal degeneration, and to opioid management of patients. That ban has recently been lifted and other severe conditions. TDD is a reversible, nonfor chronic pain. tanezumab, along with other highly targeted oral destructive method for controlling severe chronic and parenteral drugs, are currently being evaluated pain that moves patients from the “fix it” path of to treat lower back and cancer pain, as well as other more surgeries and more medical interventions types of chronic pain in the U.S. to the “quality of life” path of reduced pain In the future, medications may treat pain and improved function. Pump medications are so effectively that other methods of pain relief will become largely ”targeted” to the spinal cord, rather than the brain, and block pain at the unnecessary. At present, however, medications alone are often not sufficient spinal cord level, thus keeping the brain free from drug effects. to manage complex chronic pain, and medication side effects are sometimes A typical pump infusion consists of an opioid (fentanyl, morphine, and/ as bad as the pain these medicines are treating. In comparison to opioids, or hydromorphone) mixed with a local anesthetic (bupivacaine). These approximately 100,000 U.S. patients are hospitalized, and 16,500 patients drug admixtures are continuously infused at low dose into the spinal fluid at die each year from NSAID-related complications, whereas acetaminophen the spinal level of maximal pain, blocking pain receptors within the spinal toxicity is responsible for 56,000 emergency department visits, 2,600 cord and avoiding brain drug effects such as mental clouding, somnolence, hospitalizations, and 500 deaths each year. The take-home message is that medication management of chronic pain has limited efficacy and is Dialing down opioid use to page 344 associated with significant morbidity and mortality.

Integrating non-drug treatments If medications are not adequately controlling pain or are causing untenable side effects, interventional techniques can be utilized for those patients with identifiable structural abnormalities contributing to pain. The goal of the interventional pain specialist is to identify the physical generators of pain and to precisely target and treat them to the greatest extent possible using image-guided, minimally invasive procedures. At Nura, we coordinate interventional procedures with physical therapy and behavioral health treatments as necessary for a comprehensive, multi-point approach. For those who fail to respond to therapeutic procedures, physical therapy, and behavioral health treatments, we consider implantable pain control options. We believe in moving from simple to more complex treatments as necessary to reach our goals of reducing pain and improving function. For those patients who respond to non-addictive medications, physical therapy, chiropractic adjustment, and/or complementary medical treatments such as acupuncture, we encourage the patient to continue these low-risk therapies. For pain that does not respond to conservative, non-invasive treatments, we first consider diagnostic and therapeutic procedures such as targeted spinal steroids and radiofrequency nerve ablations. When these minimally invasive procedures fail, we consider implantable pain control systems as last-resort alternatives to long-term oral or skin patch opioids. Implantable pain control options include spinal cord stimulators that generate electrical signals to block pain transmission in the spinal cord and pain pumps that block pain receptors within the spinal cord using small doses of targeted medications delivered by an intrathecal catheter. Both options involve a trial of the therapy and, if successful, a minimally invasive outpatient surgery to implant the permanent delivery system. Spinal cord

Specialists in Musculoskeletal Pain Treatment

Effective Non-Opioid Treatment Evidence-based Biopsychosocial Approach Active Therapy Multidisciplinary Care Team Quality Outcome Reporting

PDR Outcomes

• 67% of patients rate their pain reduction between 50-100% • 74% of patients rate their headache reduction between 50-100% • 64% of patients rate their use of medications decreased 50-100% • 109% increase in Lumbar Extension ROM & strength • 165% increase in Cervical Rotation ROM & strength

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PROFESSIONAL UPDATE

Heartburn Individualizing diagnosis and treatment BY KOURTNEY KEMP, MD, FACS

atients with heartburn often begin a lengthy journey of diagnosis and treatment before their conditions are accurately identified and their symptoms resolved. A new, comprehensive, personalized approach to diagnosing and managing patients with heartburn is necessary, taking into account the unique needs and issues of each patient.

The incidence of conditions causing heartburn symptoms, including acid reflux and gastroesophageal reflux disease (GERD), is growing, according to the American Society for Gastrointestinal Endoscopy (ASGE). Up to 40 percent of the U.S. population experiences GERD, a chronic digestive disorder in which stomach acid flows back into the esophagus, causing heartburn and irritation in the lining of the esophagus. Today, proton pump inhibitors (PPIs) are among the top selling drugs in the U.S. While they often are the first line of treatment for patients with acid reflux, about 30 percent of GERD patients do not respond to standard dose PPI medications. In addition, long-term use of PPIs can sometimes mask the symptoms of heartburn. PPIs may make the patient feel better, but they might not be treating the cause of the discomfort. If

left untreated, heartburn can result in more serious esophageal disorders, such as dysphagia, chronic reflux damage, adult-onset asthma, Barrett’s esophagus, and esophageal cancer. Through our Heartburn Center, we specialize in caring for patients with esophageal and digestive disorders that frequently present as heartburn. In addition to GERD, these can include: • Achalasia, a degeneration of the nerves in the esophagus, causing the esophagus to fail to move food and liquids into the stomach and tighten the sphincter between the esophagus and stomach. • Barrett’s esophagus, a condition in which the lining of the esophagus is replaced with tissue similar to the stomach lining, often as the result of long-standing GERD and sometimes leading to esophageal cancer. • Esophageal cancer, which can occur in any part of the esophagus and spread to lymph nodes, windpipe, large blood vessels in the chest, and nearby organs. • Hiatal hernia, a weakness in the diaphragm that causes the abdominal contents to move upward into the chest cavity.

Diagnosis options

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Because the symptoms of GERD are so diverse, diagnosis can be difficult. Reflux testing is a reimbursed procedure that enables providers to definitively diagnose esophageal disorders and determine the best course of treatment for their patients. Here are the most common diagnosis options available today. Esophagram. An esophagram is often the first choice of physicians when seeing patients with an initial concern of heartburn. It provides X-ray imaging of the esophagus and upper stomach, including the anatomy and motility of the esophagus. We use it to evaluate swallowing problems, as well as reflux. Allergic reactions to the barium patients drink are uncommon. Endoscopy or esophagogastroduodenoscopy (EGD). An endoscopy or EGD enables providers to visualize the esophagus, stomach, and duodenum, spotting conditions such as ulcers, erosions, and Barrett’s esophagus. EGDs are performed in our procedure centers and involve only a slight risk of sore throat, bleeding, or perforation of the upper GI tract. While this is a good diagnostic tool, the ASGE reports that up to 70 percent of patients who do not respond to optimized PPI therapy have a negative EGD. High resolution impedance manometry (HRIM). HRIM measures pressures and fluid movement in the esophagus, helping to diagnose esophageal motility disorders. Performed in the office, the procedure involves placing a small, flexible catheter into the esophagus through the nose. Patients are asked to swallow small amounts of salt water 10 to 12 times during the test. Some patients have difficulty with gagging, but with relaxation most patients can complete the procedure.

APRIL 2019 MINNESOTA PHYSICIAN

24-hour esophageal impedance pH test. This test evaluates the extent of Surgical options gastric reflux that flows into the esophagus during 24 hours. Sensors on a Surgery is often the best option for patients with severe esophageal disease catheter measure the level of acidity at various levels in the esophagus, as who have failed to respond to short-term medication use. Today, we have well as the reflux of stomach contents up into the esophagus. The catheter a wide range of surgical options available to us: is connected to a pocket-sized recording device Nissen or partial fundoplication. This procedure worn by the patient. It is the most accurate test wraps the top of the stomach around the lower to document gastroesophageal reflux and is esophagus to reinforce the lower esophageal generally our preferred test because it measures sphincter, creating a new sphincter between the acidity at different levels, as well as non-acid esophagus and stomach. reflux events. Up to 40 percent of the U.S. Hiatal hernia repair. Most hiatal hernias population experiences GERD. Bravo capsule esophageal pH test. The Bravo require surgery to pull the stomach down, reduce capsule test measures and records the level of pH the opening in the diaphragm, and reconstruct the in the esophagus over 48 to 96 hours, enabling esophageal sphincter. providers to document relationships between LINX. The LINX procedure is a relatively new symptoms and acid reflux events. The device way to treat heartburn with implanted magnetic consists of a capsule about the size of a vitamin beads that tighten the esophageal sphincter. pill that attaches to the esophagus via a catheter and transmits information Designed for patients diagnosed with GERD through abnormal pH testing, wirelessly to a pocket-sized receiver that the patient carries. The Bravo the device is about the size of a quarter and is implanted around the outside usually is placed during an endoscopy procedure while a patient is under of the lower esophageal sphincter through a minimally invasive laparoscopic sedation. The capsule dislodges itself in about three to seven days and passes procedure. Despite the fact that the beads are magnetic, patients with a out with the stool. In rare cases, patients can experience chest pain, the LINX device can continue to have MRIs. capsule may not fall off spontaneously, or food may become lodged on the capsule. Patients should not undergo an MRI if they suspect the capsule is still in the body.

Lifestyle and medication treatment options

Bariatric weight loss surgery. Nissen or LINX procedures may be ineffective and too high risk for patients who are severely overweight. In Heartburn to page 224

Each patient is unique and deserves a personalized treatment approach. In some cases, lifestyle changes can make significant improvements to a patientâ&#x20AC;&#x2122;s heartburn symptoms. Maintaining a healthy weight, learning what foods aggravate the heartburn, and avoiding large meals, especially late at night, sometimes can solve the problem. Avoiding carbonated and caffeinated beverages also can be helpful, as can avoiding clothes that fit tightly around the waist. We also remind patients that smoking and drinking alcohol can both decrease the esophageal sphincterâ&#x20AC;&#x2122;s ability to close properly, thus increasing reflux and heartburn. Some patients also find that elevating the head of their bed or placing a wedge between the mattress and box spring makes a difference in their ability to be symptom free at night. If lifestyle changes are not helpful, we often turn to short-term use of medications. There are three classes of medications prescribed for heartburn: 1. Antacids, such as Tums, neutralize the stomach acid for quick relief. 2. H-2 receptor antagonists, such as Zantac, work to reduce stomach acid, but most people will develop a tolerance to these medications, making them ineffective over time. 3. Proton pump inhibitors, including Prevacid, Nexium, and Dexilant, may provide longer-term relief, but are not without possible side effects, such as osteoporosis, bone fracture, hypomagnesaemia, and pneumonia. In some cases, medications other than those specifically aimed at treating heartburn may be useful, including muscle relaxants, steroids, antianxiety medications, and pro-motility agents. MINNESOTA PHYSICIAN APRIL 2019

OPHTHALMOLOGY

Advances in treating eye disease A look at new FDA-approved devices BY THOMAS SAMUELSON, MD, AND DAVID HARDTEN, MD, FACS

he field of ophthalmology continues to change dramatically, with advancements in technology—tested and approved following clinical trials—drastically improving treatment options for patients facing vision-threatening eye disease. New FDA-approved prostheses and devices, implanted surgically, hold great promise for patients with glaucoma and those with damage or injury to the iris.

CustomFlex Artificial Iris In May 2018, the U.S. Food and Drug Administration approved the first prosthetic iris in the U.S. The surgically implanted device treats patients whose iris (the colored part of the eye around the pupil) is missing or damaged. Typical reasons for the iris to be missing are trauma or a congenital condition called aniridia. Congenital aniridia is a rare genetic disorder in which the iris is completely or partially absent. It affects approximately 1 in 50,000 people in the U.S. With the iris missing, the amount of light entering the eye is extreme, and those with aniridia have sensitivity to light and glare with loss of vision.

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The CustomFlex Artificial Iris can also be used to treat iris defects due to trauma, intraoperative damage to the iris during cataract surgery to treat intraoperative floppy iris syndrome due to alpha-one blockers such as tamsulosin, or in patients with small iris melanomas that have been removed surgically. The iris plays an important part in our vision, adjusting incoming light as we change environments. An absent or partially functioning iris can cause extreme light sensitivity and glare, and even impact the sharpness of vision by allowing abnormal light scatter. The CustomFlex Artificial Iris is made of thin, foldable medicalgrade silicone and is custom-sized and colored for each individual patient. A surgeon makes a small incision, inserts the device under the incision, unfolds it, and smooths out the edges using surgical instruments. The prosthetic iris is held in place by the anatomical structures of the eye or, if needed, by sutures. Colors are created to replicate those in the iris of the patient’s uninjured or unaffected eye (if one is present). The silicone prosthesis is made in Germany and takes approximately two months to customize for the patient. The safety and effectiveness of the CustomFlex Artificial Iris was demonstrated primarily in a non-randomized clinical trial of 389 adult and pediatric patients with aniridia or other iris defects. The study measured patients’ self-reported decrease in severe sensitivity to light and glare post-procedure, health-related quality of life, and satisfaction with the cosmetic improvement or appearance of the prosthesis. Following the procedure, more than 70 percent of patients reported significant decreases in light sensitivity and glare, as well as an improvement in health-related quality of life. In addition, 94 percent of patients were satisfied with the artificial iris’ appearance. The study found low rates of adverse events associated with the device or the surgical procedure. Complications can occur such as dislocation of the iris, especially if the zonules were damaged along with the initial damage to the iris. Increased intraocular pressure (IOP) or glaucoma is more common in patients with damage to the iris because the trabecular meshwork is in close contact with the iris. Inflammation such as uveitis or adhesion of the residual native iris to the cornea or lens (synechiae) can occur. Bleeding is not uncommon during the surgery, and swelling of the retina (cystoid macular edema), corneal edema, or retinal detachment can occur in eyes with difficult underlying issues such as prior trauma. The findings were similar to those from a 32-patient retrospective caseseries published in the May 2016 issue of Ophthalmology. Both studies reported a low rate of adverse events associated with the device and surgical procedure. Complications included dislocation, strands of device fiber in the eye, increased IOP, and iritis. Prior to the FDA approval, Minnesota Eye Consultants (MEC) had been involved with Artificial Iris research studies for 18 years, treating 35 eyes within the most recent Artificial Iris research study (2013–2018). Altogether,

MEC has performed this procedure over 90 times since 2000, often under the compassionate use process, under which the FDA allows practitioners to use medications or procedures that have not yet been approved when no comparable or satisfactory alternative therapy options are available.

Glaukos iStent inject and Ivantis Hydrus In 2018 the FDA approved two new minimally invasive glaucoma surgery (MIGS) devices designed to lower intraocular pressure by improving aqueous outflow through the eye’s natural physiological outflow pathway. Both of these implanted stent devices improve aqueous outflow through the trabecular meshwork. Glaucoma is one of the most common causes of irreversible blindness worldwide. The primary pathophysiology is permanent injury to the optic nerve, a collection of delicate axons that communicate vision-related neurologic impulses between the retina and the occipital cortex of the brain. Glaucomatous damage to this delicate network of neural tissue results from eye pressure, most often due to sluggish drainage of aqueous humor from the eye’s natural outflow pathways. By enhancing the eyes’ natural physiological outflow pathways, the iStent inject (Glaukos), approved in June, and the Hydrus (Ivantis), approved in August, provide a therapeutic mechanism in stark contrast to more traditional glaucoma surgeries that completely bypass the natural outflow pathways. While the traditional glaucoma surgeries have greater efficacy than those that enhance physiological outflow, the increased efficacy comes at a steep price, namely significantly more risk. Accordingly, they have been reserved for those with far advanced disease. Newer, safer procedures allow earlier surgical intervention. Surgeons can now individualize surgical risk for patients specific to their disease severity. Those at high risk for glaucomarelated blindness are candidates for the more invasive traditional surgery, while those at lower risk for functional impairment are candidates for the newer, minimally invasive procedures, typically performed simultaneously with cataract surgery. The opportunity to combine safe glaucoma procedures with cataract surgery has changed the glaucoma management paradigm in recent years. For most patients with glaucoma, medicines and laser treatments are used to manage the condition until a visually significant cataract develops, at which time surgeons can address both of these common conditions. Cataract and glaucoma are among the most common ocular comorbidities. The glaucoma specialists at Minnesota Eye Consultants have been very involved in the development of each device, either as investigators or as medical monitors for the multicenter trials. To date there have been five prospective, randomized trials comparing cataract surgery alone to cataract surgery performed in conjunction with one of these MIGS procedures. One of the important takeaways from each of these trials has been that cataract surgery itself lowers intraocular pressure and is a meaningful intervention for patients with mild to moderate glaucoma. Removing the native lens (cataract) allows the iris-ciliary complex to assume a more posterior position, an anatomic change that improves outflow. By combining cataract surgery with a safe, minimally invasive stenting procedure, surgeons are able to augment that favorable effect on intraocular pressure, without adversely affecting the elegance and precision of modern cataract surgery.

Because iStent and Hydrus also improve physiologic outflow, the effect tends to be additive. With MIGS surgery, we can augment the pressurelowering effect of cataract surgery in a synergistic and safe fashion, while retaining the well-known benefits of cataract surgery—including improved visual function—and reduce dependence on spectacles. The recently completed iStent inject study was conducted at 41 sites with 380 subjects receiving phacoemulsification (which emulsifies the lens with ultrasound) plus iStent inject and 118 patients receiving phaco alone. Smaller than 0.5 mm, the iStent inject is the smallest device ever implanted in human subjects. The recently reported FDA trial efficacy endpoints at 24 months were a >20 percent reduction in diurnal IOP (primary endpoint) and Advances in treating eye disease to page 234

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body will regenerate new tissue in the esophagus. This is often followed by surgery to treat the underlying cause of Barrett’s esophagus to prevent recurrence of irregular cells.

these cases, we often recommend bariatric weight loss surgery, such as Rouxen-Y gastric bypass and gastric sleeve (gastrectomy) surgeries. Roux-en-Y Many esophageal surgeries can be performed robotically. We have the is the most common gastric bypass procedure. largest number of robotic-trained surgeons in Surgeons divide the stomach to create a small the Upper Midwest and have found that treating pouch to which a portion of the small intestine esophageal diseases with minimally invasive is attached, causing food to bypass a large section robotic surgery results in improved outcomes of the stomach and intestine. With a gastrectomy, with less pain and faster recovery time. a portion of the stomach is actually removed, Treating patients with heartburn Summing up creating a narrower stomach called a sleeve. Both can be complex. Treating patients with heartburn can be complex, make long-term changes to the digestive system but today physicians have a number of outstanding by limiting the amount of food a patient can eat diagnostic and treatment options to help their or reducing the absorption of nutrients. Like other patients reach a successful—and personalized— major surgeries, bariatric surgery carries a number outcome much sooner and more safely than ever. of serious risks and should only be considered when less extensive options have failed. Minimally invasive esophagectomy. During this surgical procedure, surgeons remove part of the esophagus and reconstruct it using a piece of another organ, usually the stomach. It typically is reserved for esophageal cancer, but also may be used for Barrett’s esophagus if aggressive precancerous cells are found. Radiofrequency ablation. This minimally invasive procedure uses electrical energy and heat to remove irregular cells as part of a treatment for Barrett’s esophagus. Once the diseased tissue is removed, a patient’s

APRIL 2019 MINNESOTA PHYSICIAN

Kourtney Kemp, MD, FACS, is board-certified in general surgery and leads the Specialists in General Surgery Heartburn Center.

3Advances in treating eye disease from page 21

efficacious, but none are likely to be proven safer. There will be proponents of both canal devices. Some surgeons might prefer the iStent the mean reduction in diurnal IOP (secondary endpoint). At 24 months, inject because it’s a “stealth” approach and the least-tissue-disruptive 75.3 percent of the iStent inject cohort achieved a 20 percent or greater canal intervention. On the other hand, some surgeons may prefer the reduction in unmedicated IOP, compared to 61.9 Hydrus design, and the fact that you can more percent of the phaco-only cohort. At 24 months, easily verify that it’s exactly where you want it the iStent inject cohort had a mean unmedicated to be in the canal because of its 8 mm length IOP reduction of 6.9 mmHg, compared to a and the fact that you can see it through the 5.4-mmHg reduction in the phaco-only cohort. translucent inner wall. Each procedure adds Importantly, there were no meaningful betweengreatly to the rapidly expanding portfolio of Newer, safer procedures allow group differences in safety parameters. Surgeons glaucoma surgical options. earlier surgical intervention. at Minnesota Eye Consultants recently implanted the first iStent inject devices in the nation Thomas Samuelson, MD, is a partner and following FDA approval earlier this year. attending surgeon at Minnesota Eye Consultants.

The Hydrus trial (HORIZON) was a prospective, multicenter randomized trial in which 369 individuals received a Hydrus shunt in addition to phaco, while 187 received phaco only. The primary endpoint at 24 months was a 20 percent reduction in diurnal IOP; the secondary endpoint was the change in mean diurnal IOP. At 24 months, 77.2 percent of the Hydrus group had at least a 20 percent drop in DIOP; 57.8 percent of the phaco-only group achieved that endpoint. The mean reduction in DIOP was 7.6 mmHg at 24 months for the Hydrus group and 5.3 mmHg for the phaco-only group.

He specializes in glaucoma, cataract, and refractive surgery and performs iStent inject procedures at Minnesota Eye Consultants locations in Bloomington and Minnetonka.

David Hardten, MD, FACS, is a partner and attending surgeon at Minnesota Eye Consultants. He specializes in cornea, cataract, and refractive surgery and performs Artificial Iris cases at Minnesota Eye Consultants locations in Bloomington and Minnetonka.

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NEUROLOGY

Obstructive sleep apnea Examining the adverse consequences BY TACJANA K.E. FRIDAY, MD

bstructive sleep apnea (OSA) is a common sleep disorder affecting at least 25 million adults in the U.S. Those at increased risk for OSA include males; postmenopausal women; overweight/obese individuals; and patients with larger neck circumference and crowded oropharynx, positive family history of OSA, and use of sedative hypnotics. Associated chronic medical conditions (e.g., atrial fibrillation, heart failure, diabetes mellitus, stroke, or obesity) also increase risk for OSA. There has been a rise in numbers over the last few decades in association with the obesity epidemic. Untreated OSA is associated with adverse consequences, including cardiovascular and cerebrovascular complications such as hypertension, coronary artery disease, heart failure, arrhythmias, and stroke. Individuals often suffer from impairments in vigilance, concentration, and cognitive function. Evidence shows that there are higher rates of job-related and motor vehicle accidents due to excessive daytime sleepiness related to untreated OSA. People often experience a decline in their mental health, resulting in increased mood disorders such as depression, which are often

more refractory to treatments with untreated OSA. There is also evidence that OSA is associated with metabolic dysregulation, affecting glucose control and risk for diabetes. Obstructive sleep apnea is characterized by repetitive episodes with cessation of breathing (apneas) or partial upper airway obstructions (hypopneas). This narrowing of the upper airway results in increased breathing effort and impaired normal ventilation during sleep. These events are often associated with reduced blood oxygen saturation. Five or more respiratory events (apneas, hypopneas, or respiratory effortrelated arousals/RER As) per hour of sleep are required for diagnosis of OSA. The severity of the apnea is determined by the frequency of airway obstructions per hour (<5=normal, 5–15=mild, 15–30=moderate, >30=severe). Patients who report sleep-related concerns—excessive snoring, frequent insomnia, or fatigue during the day—to their primary care doctor are often referred to a specialist in sleep medicine. These specialists may include neurologists, otolaryngologists, pulmonologists, dentists, and other physicians with additional training in the field. Neurologists can identify neurological issues that may affect sleep, as well as long-term risk of

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dementia and other conditions. Primary care doctors should follow up with these patients to ensure compliance with treatment regimens.

Diagnosis Diagnostic testing for OSA should be performed with a comprehensive sleep evaluation and adequate follow-up with a sleep specialist. The clinical evaluation for OSA should include a thorough sleep history and a physical examination that includes the respiratory, cardiovascular, and neurologic systems. Sleep specialists should inquire about snoring, witnessed apneas, nocturnal choking or gasping, restlessness, insomnia, waking unrefreshed, and/or excessive sleepiness. A complete sleep history is essential, since many patients suffer from more than one sleep disorder or present with atypical sleep apnea symptoms. Sleep specialists should screen for medical conditions associated with increased risk for OSA, such as obesity, atrial fibrillation, hypertension, stroke, and congestive heart failure. The evaluation should serve to establish a differential diagnosis, which can then be used to ensure that the appropriate diagnostic testing is performed to address OSA, as well as other comorbid sleep complaints such as insomnia, REM behavior disorder, parasomnias, restless limbs syndrome and periodic limb movement disorder, nocturnal seizures, and/or pathologic hypersomnia. Follow-up under the supervision of a board-certified sleep medicine physician ensures that study findings and recommendations are relayed appropriately, and that appropriate therapy is made available to the patient.

Nonsurgical treatment options The most widely used nonsurgical treatment for moderate and severe OSA in adults is positive airway pressure (PAP) machines, which deliver gently pressurized room air or oxygen through a mask attached to the patientâ&#x20AC;&#x2122;s nose and/or mouth, ensuring that airways remain open during sleep. Modern technology offers PAP machines that are compact and quiet. New models include modem capability, allowing the provider and patient to continue close monitoring without the need to transport the machine back to the clinic. The mandibular advancement device (MAD), an oral appliance that increases airway diameter, is another nonsurgical treatment option employed both as primary or as adjunctive treatment for OSA. MAD is beneficial in Obstructive sleep apnea to page 284

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Sleep apnea-focused questionnaires lack diagnostic accuracy, making direct measurement of patient sleep patterns necessary to establish a diagnosis of OSA. This may take two forms: Home sleep testing (HST) is performed in the patientâ&#x20AC;&#x2122;s residence with a portable monitor that records sleep patterns for subsequent review by a physician specializing in sleep medicine. Some insurance companies require an HST as an initial sleep test. While the home equipment is considered an alternative initial method to diagnose OSA in adults, it cannot diagnose the majority of sleep disorders, and should be followed with an in-lab sleep study when home studies have not adequately confirmed or ruled out OSA. Polysomnogram (PSG), performed overnight in a sleep study lab with an attendant on hand, is the gold standard for diagnostic testing of OSA. In-lab PSGs can also identify co-existing sleep disorders. Another benefit of doing in-lab PSG monitoring is that positive airway pressure (PAP) therapy (described below) may be initiated during the test. This allows for more precise treatment and potentially better compliance, by determining appropriate follow-up therapy (e.g., selecting a PAP machine and masks, identifying individualized airflow pressure settings, and addressing challenges encountered in using PAP therapy). It also allows patients to determine if PAP therapy is a desired treatment or whether other options should be pursued early on.

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Disadvantages of PSG include the cost associated with evaluating all patients suspected of having OSA with PSG, limitations with insurance coverage, and potentially restricted access to in-laboratory testing in some regions. HST may be less costly and more efficient for some populations. There are a variety of treatment options available for OSA, including both surgical and nonsurgical options.

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PEDIATRICS

Parenteral nutrition Helping youth thrive at home BY LISA TOLLEFSON, PHARMD; SARAH KEYES, RN, BSN; AND MARIA MAHADY, RD, LD

G-tube to help her meet her daily calorie and nutrient requirements—and to lead a full teenage life.

n many ways, Amanda is a typical teenager. She loves shopping, practices yoga, and hangs out with her boyfriend on the weekends. If you saw her, you might not realize that Amanda is able to live a morenormal teenage life thanks to a therapy called parenteral nutrition (PN), which can be administered in homes, hospitals, and long-term care facilities. Unlike enteral feeding, which employs a gastrostomy tube (G-tube), PN is a method of feeding intravenously, bypassing the normal process of eating and digesting. It’s essentially a shortcut that gets nutrients directly to the bloodstream.

Advances in enteral and parenteral nutrition

Amanda has short bowel syndrome (SBS), which results in less surface area in the small bowel and contributes to malabsorption, malnutrition, and electrolyte disturbances. Along with SBS, Amanda has other metabolic demands that require her to receive 4,000 calories per day, approximately twice that of many girls her age, due to her body’s inability to absorb adequate nutrition. In addition to PN administered at home (HPN) or during daily activities outside the home, Amanda supplements oral intake with enteral feedings through a

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Advances in enteral and parenteral nutrition have made these therapies more adaptable for outpatients. Thanks to the developments made in the portability of food and intravenous pumps, patients wear just a small backpack to receive their feedings or PN while they are at school, at home, or in the car. Enteral and parenteral nutrition formulas have improved to meet specific nutrition needs of patients. One example of this is a new lipid source that is fish-based, rather than soy-based, and ameliorates liver toxicity—one of the adverse events of PN. Careful monitoring and assessment of PN from a team-focused home care provider—based on the recommendations of a physician—is an essential piece of success when working with this population and leads to improved outcomes for patients with intestinal disorders requiring nutrition support.

Use and administration of parenteral nutrition There are children who receive all their nutrition through home parenteral nutrition (HPN) and others, like Amanda, who use PN intermittently to supplement oral intake or enteral feedings and help regulate electrolytes altered by malabsorption. There are other conditions where HPN may benefit outpatients, such as bowel obstructions, Crohn’s disease, post-operative patients, and some malignancies. A provider evaluates patients with intestinal disorders and, based on their nutrition deficiencies, current nutrition status, and prognosis, may decide to initiate PN. Addressing the nutritional needs of growing children is imperative for organ development, growth, and energy demands and is one of the reasons children often receive HPN. This intravenous therapy may be comprised of carbohydrates, electrolytes, minerals, proteins, fats, and vitamins. For younger children and infants, inadequate nutrition may keep them from achieving developmental milestones, such as rolling over and walking. For the administration of HPN, patients with short-term nutritional needs may use a peripheral intravenous line, depending on the recommendation of the attending physician. Patients who have long-term requirements are best served with access through a central venous line. Parents and families are instructed in implementing HPN for the child, which includes care of the entrance site, programming the pump, and connecting the PN bag.

The benefits of home care Patients can receive parenteral nutrition in the comfort of their own home from an infusion company that coordinates a care plan with their physician and helps monitor patient health. Pediatric Home Service (PHS) specializes in children with medical complexities and provides specialty enteral formulas, tailored PN, lab draws, and nutrition recommendations by PHS’ registered dietitians working with physicians.

The services PHS provides allow these children to thrive at home, in their communities, and participate in day-to-day activities while minimizing exposure to hospital-acquired infections.

HPN requires a team approach While the physician leads the implementation of nutritional care starting with the initial order for HPN through PHS, successful patient outcomes require communication and coordination with the team. The nutrition support team (NST) at PHS includes infusion nurses, registered dietitians, pharmacists, and referring physicians.

• If a patient receives HPN from the PHS pharmacy but lives outside the service area of infusion nursing, regional nursing agencies coordinate lab draws that are sent to PHS for review by the NST. Regardless of location, nearly all patients receiving HPN are followed by a PHS dietitian, who will connect with the family on a weekly basis or as frequently as needed.

Patients can receive parenteral nutrition in the comfort of their own home.

When the patient comes on service:

• A PHS pharmacist works with the PHS dietitian to ensure that the PN recipe is safe and appropriate and communicates with the patient’s physician to determine further recommendations for preparing the PN and monitoring its delivery.

• Infusion nurses teach the family and child, depending on their age, how to set up and manage the IV and prepare PN for infusion. Older children may be more willing to comply with instructions when empowered to manage their own health care. • On a weekly basis, a nurse visits the home to record weight, perform lab draws, and review dietary logs including oral, enteral, and parenteral intake. The results of lab testing may impact future compounding of PN. • A dietitian works closely with the NST to analyze data gathered during the weekly visit and share that information with nurses, patient family members, and the physician.

• Weekly NST meetings allow for the collaborative review of each patient’s labs and data. Team members make recommendations for changing the nutrition plan. Any proposed recommendations are always reviewed with the patient’s physician for approval.

The partnership between physicians and members of the nutrition support team is collaborative, with open communication by phone or email to ensure the best outcomes for patients. The frequent assessments of patient data help to prevent adverse effects and increase the potential for patients to progress off of PN. Parenteral nutrition to page 324

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3Obstructive sleep apnea from page 25

activates the hypoglossal nerve to tighten the muscles of the tongue and upper airway during sleep, improving airflow. The hypoglossal nerve stimulator is a treatment option for adult patients (age 22 or older) with moderate to severe OSA (AHI 15–65) who have failed or are unable to tolerate PAP therapy and have a BMI of 32 or less. Patients who meet these criteria will be referred to the implanting surgeon, who performs endoscopy to determine if they are an appropriate candidate.

that it is compact and portable, making it easy to travel with. This therapy is more discreet and allows individuals to be more intimate with their bed partner (no machine in the way). No electricity is needed, which can be ideal for camping, cabins, and travel. Consequences of MAD that need to be monitored include TMJ (temporomandibular joint disorders) arthritis or arthralgia (pain); bite changes or teeth shifting; and hypersalivation, Many patients suffer from more mouth dryness, and/or tooth discomfort.

than one sleep disorder.

Neurological sleep disorders

Surgical options for treating OSA include UPPP (uvulopalatopharyngoplasty) —removal of the uvula, part of the soft palate, and tonsils—which can help reduce the severity of the OSA. Mandibular advancement surgery or other surgical procedures may be explored as well. These surgical options may be a useful adjunctive treatment option for patients with OSA.

Several sleep disorders can be associated with different neurological conditions. Abnormal nocturnal behaviors, for example, can be easily distinguished by clinical presentation. REM sleep behavior disorder (RBD) may present as an early manifestation of an evolving neurodegenerative disorder with alpha-synucleinopathy (Parkinson’s disease, dementia with Lewy bodies, and multiple systems atrophy). RBD typically manifests during the second half of the night, when REM sleep is typically observed, and consists of dream enactment behavior. Often, the patient is redirectable, is able to recall the dream content, and was observed or aware of acting out the dream.

Another new technology for treating OSA involves upper airway stimulation using a hypoglossal nerve stimulator (Inspire device), which

Obstructive sleep apnea to page 304

If clinically indicated, patients should be encouraged to lose weight. Positional therapy (promoting lateral sleep and/or elevating the head of the bed) should also be considered for certain populations.

Surgical treatment options

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Volume XXXII, No. 05

CAR T-cell therapy Modifying cells to fight cancer BY VERONIKA BACHANOVA, MD, PHD

niversity of Minnesota Health is now among the few selected centers in the nation to offer two new immunotherapy drugs for the treatment of diffuse large B-cell lymphoma. Both drugs—Yescarta and Kymriah—are part of an emerging class of treatments, called CAR T-cell therapies, that harness the power of a patient’s own immune system to eliminate cancer cells. CAR T-cell therapy involves drawing blood from patients and separating out the T cells. Using a disarmed virus, the patient’s own T cells are genetically engineered to produce chimeric antigen receptors, or CARs, that allow them to recognize and attach to a specific protein, or antigen, on tumor cells. This process takes place in a laboratory and takes about 14 days. After receiving the modification, the engineered CAR-T cells are infused into the patient, where they recognize and attack cancer cells. Kymriah received initial FDA approval in 2017 for the treatment of pediatric acute lymphoblastic leukemia.

Physician/employer direct contracting

CAR T-cell therapy to page 144

Advertising in Minnesota Physician is, by far, the most cost-effective method of getting your message in front of the over 17,000 doctors licensed to practice in Minnesota. Among the many ways we can help your practice: •

Exploring new potential BY MICK HANNAFIN

ith the continuing escalation of health care costs, large and midsized selfinsured employers are once again looking for an edge to manage their medical plan costs and their bottom line. They understand that they are ultimately funding health care as they pay for their population’s claims.

•

Many of these employers have employed the same overarching set of strategies: shop for a new carrier that is willing to lower the administrative costs or underprice the risk, Physician/employer direct contracting to page 124

On the U.S. Army health care team, you will enjoy the satisfaction of providing quality care to Soldiers and their families, in a setting with innovative technologies, robust resources and a dedicated, supportive team.

•

Share new diagnostic and therapeutic advances Develop and enhance referral networks Recruit a new physician associate

Learn more at healthcare.goarmy.com/nz72

Advertise! IN MINNESOTA PHYSICIAN www.mppub.com

(612) 728-8600

SICIAN

Practice Opportunities throughout Greater Minnesota: Our nation faces an unprecedented number of individuals who having served their country now receive health care benefits through the VA system. We offer an opportunity for you to serve those who have served their country providing community based health care in modern facilities with access to world-leading research and research opportunities. We provide outstanding benefits with less stress and burnout than many large system policies create. We allow you to do what you do, best – care for patients.

Minneapolis VA Health Care System Metro based opportunities include: • Chief of General Internal Medicine • Chief of Cardiology • Cardiologist • Internal Medicine/Family Practice • Gastroenterologist • Psychiatrist

Ely VA Clinic

Hibbing VA Clinic

• Tele-ICU (Las Vegas, NV)

Current opportunities include:

• Nephrologist

Internal Medicine/Family Practice

US citizenship or proper work authorization required. Candidates should be BE/BC. Must have a valid medical license anywhere in US. Background check required. EEO Employer.

Possible Education Loan Repayment • Competitive Salary • Excellent Benefits • Professional Liability Insurance with Tail Coverage

For more information on current opportunities, contact: Yolanda Young: Yolanda.Young2@va.gov • 612-467-4964 One Veterans Drive, Minneapolis, MN 55417

•

www.minneapolis.va.gov MINNESOTA PHYSICIAN APRIL 2019

3Obstructive sleep apnea from page 28

the health care system, with increased health care utilization and cost due to chronic health consequences.

Parasomnias, on the other hand, typically occur during the first It is therefore important that our patients be appropriately evaluated half of the night out of slow wave sleep and consist of complex motor and treated for their underlying sleep disorder. Diagnostic testing for OSA behaviors (e.g., sleep walking, sleep eating, sleep should be performed with a comprehensive sleep texting, sleep sex). The patient will have no evaluation. PSG or HST can be used for the recollection of the event and is not redirectable. diagnosis of OSA in patients at increased risk of Nocturnal seizures are unique in that they are OSA. If a single HST is negative, inconclusive, or stereotyped (repeat the same pattern), are short technically inadequate, PSG should be performed Untreated OSA results in lived, and occur out of sleep. Patients may or for the diagnosis of OSA. The gold standard for significant cardiovascular and may not be aware of having them. It is also diagnostic testing continues to be the in-lab PSG, cerebrovascular complications. important to recognize sleep disorders in our however. Many treatment options are available to patients with dementia. It is now thought that individuals with OSA. Providers should consider chronic sleep deprivation may increase the risk using alternative treatments early on if indicated for dementia due to the accumulation of betato help increase compliance to therapies. amyloid protein in the brain. Patients with It is important for us to remember that the dementia can also have reversal of their sleep patterns, or advanced sleep best brain is the rested brain. phase syndrome, resulting in earlier bedtimes and awakenings. This can be disruptive to families and is the leading cause of institutionalization for patients with dementia. Tacjana K.E. Friday, MD, practices at the Minneapolis and Blaine offices of Noran Neurological Clinic. She is board-certified in neurology, sleep

Summary There is a high prevalence of OSA in major chronic diseases, and untreated OSA results in significant cardiovascular and cerebrovascular complications. It is critical that sleep specialists monitor for symptoms of OSA, and screen those at risk for it. Undiagnosed OSA can result in a significant burden on

medicine, and epilepsy.

Join the Best. Join Entira Family Clinics. Entira Family Clinics is an award-winning, physician owned and operated group of primary care, after hours care, and express care clinics serving the East Metro for over 50 years. If you want the opportunity to influence how your practice is run, then look no further. Where Generations ThriveÂŽ: Our community-based clinics offer high-quality care specializing in family medicine and serve families at all stages of life.

Join our team today!

For more information, contact: Len Kaiser: 651-772-1572 or lkaiser@entirafamilyclinics.com

| entirafamilyclinics.com | 30

APRIL 2019 MINNESOTA PHYSICIAN

Urgent Care Physicians HEAL. TEACH. LEAD.

St. Health Cloud VA Care System Brainerd | Montevideo | Alexandria

As an Urgent Care Physician with HealthPartners, you’ll enjoy: • Being part of a large, integrated organization that includes many specialties; if you have a question, simply pick up the phone and speak directly with a specialty physician • Flexibility to suit your lifestyle that includes expanded day and evening hours, full day options providing more hours for FTE and less days on service

Opportunities for full-time and part-time staff are available in the following positions:

• Physician (Care In the Community/ Integrative Whole Health)

• An updated competitive salary and benefits package, including paid malpractice

• Physician (Hospice & Palliative Care)

HealthPartners Medical Group continues to receive nationally recognized clinical performance and quality awards. Find an exciting, rewarding practice to complement all the passions in your life. Apply online at healthpartners.com/careers or contact Diane at 952-883-5453 or diane.m.collins@healthpartners.com. EOE

• Physician (Hematology/Oncology) Part-Time

• Physician Psychiatrist (Mental Health) • Physician (Pulmonologist) Part-Time

• Physician (Orthopedic Surgeon) Part-Time • Physician (IM/FP) St. Cloud MN • Physician (IM/FP) Brainerd MN

• Physician (IM/FP) Montevideo MN

• Associate Chief of Staff/ Education (Office of the Director)

• Associate Chief of Staff Primary & Specialty Ambulatory Medicine

with a Mankato Clinic Career Established in 1916, physician-owned and led Mankato Clinic is 100 years strong and seeking Family Physicians for outpatient-only practices. Over 50% of our physicians are involved in leadership positions and make decisions for our group. Full-time is 32 patient contact hours and 4 hours of administrative time per week. Four-day work week available. Clinic hours are Monday-Friday, 8 a.m.-5 p.m. OB is optional. Call is telephone triage, 1:17, supported by a 24/7 Nurse Health Line. Market-competitive guaranteed starting salary, followed by RVU production pay plan. Benefits include 35 vacation / CME Days annually + six holidays, $6,600 annual CME business allowance and a generous profit-sharing 401(k) plan. We’re just over an hour south of the Mall of America and MSP International Airport. If you would like to learn more about building a Thriving practice, contact:

Dennis Davito Director of Provider Services 1230 East Main Street Mankato, MN 56001 507-389-8654 dennisd@mankatoclinic.com

US Citizenship required or candidates must have proper authorization to work in the U.S. Physician applicants should be BC/BE. Education Debt Reduction Program funding may be authorized for the health professional education that was required of the position. Possible recruitment bonus. EEO Employer. Competitive salary and benefits with recruitment/ relocation incentive and performance pay possible.

For more information:

Visit www.USAJobs.gov or contact Jane Blommel, STC.HR@VA.GOV Human Resources 4801 Veterans Drive, St. Cloud, MN 56303

(320) 255-6301

Apply online at www.mankatoclinic.com MINNESOTA PHYSICIAN APRIL 2019

3Parenteral nutrition from page 27

Growing and thriving at home

Adjusting to life with parenteral nutrition PHS wants to minimize disruption of a family’s and child’s life and the goal is to help patients and their families integrate into a normal routine despite being HPN-dependent. Consequently, the infusion is often delivered at night, which frees up a child for daytime activities.

For children unable to get adequate enteral nutrition through other means, HPN is critical to promote growth and thrive at home. Part of growing up healthy is time with family and friends, and providing this important service at home allows children to remain active in their communities. Lisa Tollefson, PharmD, is a clinical pharmacist at Pediatric Home Service.

When HPN is administered during the day, the infusion pump can be transported in a small backpack, allowing kids to stay active while they are receiving an infusion. Children receiving HPN will likely need to avoid contact sports and water sports, but can engage in most of the activities of their age-matched peers, although they may fatigue more easily.

She graduated with her Doctor of Pharmacy from the University of Minnesota

For older children and teenagers, body image is important. Joining a support group where they can share their experiences with other HPN children and adolescents may be beneficial.

Sarah Keyes, RN, BSN, is an infusion nurse at Pediatric Home Service. After

One of the risks involving central lines is acquiring a central lineassociated bloodstream infection (CLABSI). Families are instructed to watch for signs of systemic or local infection and infusion nurses check the catheter site each time they visit the home.

nurse and then went on to complete her BS degree at Bemidji State University.

Other potential complications for patients receiving HPN include dehydration, liver failure, blood clots, electrolyte imbalances, central catheter occlusion, and micronutrient deficiencies. Infants and younger children with developing organs may be more at risk for liver disease and damage from HPN.

Sioux Falls VA

School of Pharmacy. Post-graduation, Lisa worked at Children’s Hospitals and Clinics of Minnesota–Minneapolis campus for 12 years prior to working in home care with Pediatric Home Service since 2014.

graduating from North Hennepin Community College in 2013 with her AS in nursing, Sarah started working with Pediatric Home Service as a home care In February 2015 she joined PHS’s Infusion Department.

Maria Mahady, RD, LD, is the registered dietitian supervisor at Pediatric Home Service. She graduated with a BS in nutrition from the University of Minnesota–Twin Cities and completed her dietetic internship at University of Minnesota Health. Following the internship, Maria worked at the University of Minnesota Medical Center for three years. She has been working in home care with Pediatric Home Service since 2012.

HEALTH CARE SYSTEM

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, the VA offers an incomparable benefits package.

The VAHCS is currently recruiting for the following positions: ★ Cardiologist

★ Psychologist

★ Compensation & Pension

★ Women’s Health (PACT)

★ Neurologist

★ Emergency Medicine (part-time)

★ Oncologist

★ ENT (part-time)

★ Psychiatrist

★ Gastroenterologist (part-time)

★ Pulmonologist

★ Urologist (part-time)

★ PACT

apply online at www.USAJOBS.gov 32

APRIL 2019 MINNESOTA PHYSICIAN

(605) 333-6852 ·

www.siouxfalls.va.gov

YOU’D MAKE A REALLY GOOD DOCTOR IF YOU WEREN’T BEING AN OFFICE MANAGER.

Urgent Care Physicians HEAL. TEACH. LEAD.

At HealthPartners, we are focused on health as it could be, affordability as it must be, and relationships built on trust. Recognized once again in Minnesota Physician Publishing’s 100 Influential Health Care Leaders, we are proud of our extraordinary physicians and their contribution to the care and service of the people of the Minneapolis/St. Paul area and beyond. As an Urgent Care Physician with HealthPartners, you’ll enjoy: • Being part of a large, integrated organization that includes many specialties; if you have a question, simply pick up the phone and speak directly with a specialty physician • Flexibility to suit your lifestyle that includes expanded day and evening hours, full day options providing more hours for FTE and less days on service • An updated competitive salary and benefits package, including paid malpractice HealthPartners Medical Group continues to receive nationally recognized clinical performance and quality awards. Find an exciting, rewarding practice to complement all the passions in your life. Apply online at healthpartners.com/careers or contact Diane at 952-883-5453 or diane.m.collins@healthpartners.com. EOE

For more information, contact TSgt James Simpkins 402-292-1815 x102 james.simpkins.1@us.af.mil or visit airforce.com

A Place To Be Your Best. Dr. Julie Benson, MN Academy Family Physician of the Year

Family Medicine & Emergency Medicine Physicians • • • • •

Great Opportunities

Immediate Openings Casual weekend or evening shift coverage Set your own hours Competitive rates Paid Malpractice

POSITIONS AVAILABLE:

OB GYN & FAMILY MEDICINE – Full-scope practice available (ER, OB, C-Section, Hospitalist, Clinic) • Independent/growing system • Located in the heart of lakes country, Staples, MN • Critical access hospital with 5 primary clinics and a senior living facility • 15 family medicine physicians and 16 advanced practice clinicians • Competitive salary, benefits, and sign-on bonus available Contact Michael Paul at 218.894.8633, or michaelpaul@lakewoodhealthsystem.com

763-682-5906 | 763-684-0243 michelle@whitesellmedstaff.com www.whitesellmedstaff.com MINNESOTA PHYSICIAN APRIL 2019

3Dialing down opioid use from page 17 and confusion. Intrathecal opioids are not absorbed to any great extent into the bloodstream and therefore exert far weaker systemic effects compared to drugs administered by any other route. Although physical dependence may develop with pump opioids and withdrawal may occur if the pump infusion is abruptly stopped, there is no addiction potential with pump opioids because there is no euphoria and no “high” feeling. Furthermore, for those pump patients with severe physical pain and active addiction, the physician controls the drugs within the pump and they cannot be abused and/or diverted by the patient. The pump itself consists of three components in one package: a mechanical pump to deliver medications continuously over a period of years, a drug reservoir to hold several months of medication inside the pump to be delivered slowly over time, and a computer chip that can be programmed to deliver the medications to meet patient needs and desires. Once the pump is implanted, the patient begins a gradual transition from systemic oral or skin patch opioids to targeted spinal opioid/local anesthetic solutions so that opioids are administered primarily by the spinal route within three to six months. The average pump in our practice is filled about once every two months, at home or in the clinic, and continuously infuses spinal opioid at about one-tenth to one-hundredth of the usual oral opioid dose previously required. In addition to the continuous infusion capability, the pump comes with a remote-control device the patient may use to deliver pre-programmed boluses of pump medications that take the

place of breakthrough oral pain pills. We recently polled our pump patients and found that the vast majority of them felt the pump was a very helpful intervention that had changed their lives for the better.

Conclusion Reducing pain down to tolerable levels with medications, injections, and/ or implantable pain control systems is an important first step in pain management, but improving physical functioning through ongoing physical therapy and managing anxiety and depression with behavioral techniques are equally important for long-term recovery. Although there is no single best treatment for most complex chronic pain, combining interventions, physical therapy, and psychology-based treatments in a coordinated fashion offers pain patients the best chance to lead a more productive life free from opioids. David Schultz, MD, is the medical director and founder of Nura pain clinics. Dr. Schultz is a board-certified anesthesiologist with additional board certification in pain medicine from the American Board of Anesthesiology, the American Board of Interventional Pain Physicians, and the American Board of Pain Medicine. He has been a full-time interventional pain specialist since 1995. He is past president of the American Society of Interventional Pain Physicians (ASIPP) and has taught physician courses in the field of interventional pain management for the past 25 years as an instructor and course director for ASIPP, International Spinal Injection Society (SIS), Medtronic, and Abbott. He is a prolific author of clinical articles and book chapters, a frequent speaker at national meetings, and a principal investigator in pain research.

Change Lives Boynton Health is a national leader in college student health. We serve the University of Minnesota, delivering comprehensive health care services with a public health approach to campus well-being. Our patients are motivated and diverse undergraduate, graduate and international students, faculty and staff. On campus, you will have access to cultural and athletic events and a rich academic environment. Boynton is readily accessible by transit, biking and walking. With no evening, weekend or on-call hours, our physicians find exceptional work/life balance.

PHYSICIAN The University of Minnesota, Boynton Health, Twin Cities, is looking for a primary care physician to join our talented staff at one of the country’s largest and most progressive University student health services. Appointment 80-100% FTE. We have in-house mental health, pharmacy, physical therapy, lab, x-ray and other services to provide holistic care of your patients. This position offers a competitive salary, comprehensive benefits, CME opportunities and a generous retiremetnt plan. Professional liability coverage is provided.

To learn more, contact Michele Senenfelder, Human Resources at 612-301-2166, msenenfe@umn.edu Apply online at http://www1.umn.edu/ohr/employment and search Keyword 329054. The University of Minnesota is an Equal Opportunity, Affirmative Action Educator and Employer.

410 Church Street SE, Minneapolis, MN 55455 612-625-8400 www.bhs.umn.edu

APRIL 2019 MINNESOTA PHYSICIAN

STAY FOCUSED AMONG THE DISTRACTIONS.

Minimize the things that get in the way of why you’re in healthcare to begin with. A focus on reducing lawsuits is just one way we do this. For more information or your nearest agent, contact us at 800.225.6168 or through coverys.com. M E D I C A L P R O F E S S I O N A L L I A B I L I T Y I N S U R A N C E  A N A LY T I C S  R I S K M A N A G E M E N T  E D U C A T I O N

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is for cardiology. University of Minnesota Health Heart Care As leaders in heart care interventions for over 60 years, we make innovative care our mission. We’ve transformed lives with major breakthroughs in valve replacements, transplants, cardiac resuscitation and other pioneering techniques to treat heart disease. With multiple centers and clinic locations throughout the region, we’re just a heartbeat away. We see patients six days a week. Learn more about our expert, innovative care.

Visit

MHealth.org/heartcare

University of Minnesota Health is a collaboration between University of Minnesota Physicians and University of Minnesota Medical Center. ©2018 University of Minnesota Physicians and University of Minnesota Medical Center