MINNESOTA
JANUARY 2020
PHYSICIAN
THE INDEPENDENT MEDICAL BUSINESS JOURNAL
Volume XXXIII, No. 10
Medical aid in dying A complex ethical dilemma BY REBECCA THOMAN, MD
O
regon’s 1994 Death with Dignity Act was the nation’s first law authorizing medical aid in dying, allowing mentally capable, terminally ill adults with six months or less to live the option to request, obtain, and self-ingest medication to die peacefully in their sleep if their suffering becomes unbearable. Since then, eight more states—Washington, Montana, Vermont, California, Colorado, Hawaii, New Jersey, Maine and the District of Columbia (DC)—have authorized medical aid in dying.
Health information “blocking” Denying patients access to health records BY CHRISTOPHER “KIT” CRANCER
P
oliticians continue their promises and academics continue to espouse the need for “interoperability” of patient health records—which would allow different electronic health record (EHR) systems to exchange information between providers—but steps to achieve this are, at best, glacial. At worst, efforts to do so are stuck in political and technological muck, which some people disguise with words such as “security” or “quality.” A top “solution” that is constantly touted in the health care debate usually goes something like this: Patients should be able to have their health care records accessed, in a secure manner, when they give permission to a health care provider to do so. Despite the general consensus that such a solution is good for continuity of care, for cost reduction Health information “blocking” to page 104
In my role as Doctors for Dignity Program Manager at Compassion & Choices, I speak with physicians across the country, some in authorizing states who have written prescriptions for terminally ill patients and others who are just beginning to incorporate medical aid in dying into their practices. I also hear questions and concerns raised by colleagues who live in states where medical aidin-dying legislation is being considered. Here are a few of the common themes that have emerged. Medical aid in dying to page 124
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Volume XXXIII, Number 10
COVER FEATURES Health information “blocking” Denying patients access to health records
Medical aid in dying A complex ethical dilemma By Rebecca Thoman, MD
By Christopher “Kit” Crancer
DEPARTMENTS CAPSULES
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MEDICUS
7
INTERVIEW
8
Redefining addiction Paul H. Earley, MD, DFASAM American Society of Addiction Medicine
BEHAVIORAL HEALTH 14 Mental health in the emergency room A role for the medical family therapist
By Aalaa Alshareef, MS, and Tai Mendenhall, PhD, LMFT PUBLIC HEALTH 18 The MN FEET program
NEPHROLOGY 20 Transplanting HCV-infected kidneys A promising new source of donors By Jeffrey H. Wang, MD, Paul A. Stahler, MD, FACS
WOMEN’S HEALTH 22 Polycystic ovary syndrome Diagnosis and treatment By Amy Hammers, MD
MEN’S HEALTH 26 Male infertility Considering appropriate evaluation By Aaron Milbank, MD
Birth disparities and prenatal mercury exposure By Kate Murray, MPH; Jessica Nelson, PhD, MPH; and Courtney Jordan Baechler, MD, MS
CLINICAL AND NON-CLINICAL CARE TEAMS Improving interoperability Thursday, March 5, 2019, 1–4 p.m. The Gallery, Hilton Minneapolis | 1001 Marquette Avenue South BACKGROUND AND FOCUS: 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: 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.
PANELISTS INCLUDE: Dori Cross, PhD, Division of Health Policy and Management University of Minnesota School of Public Health Vivi-Ann Fischer, DC, Chief Clinical Officer, Fulcrum Health
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Christopher “Kit” Crancer, Senior Director of State Legislative Policy, Center for Diagnostic Imaging Mike Starnes, mstarnes@mppub.com
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ART DIRECTOR_______________________________________________Scotty Town, stown@mppub.com Minnesota Physician is published once a month by Minnesota Physician Publishing, Inc. Our address is PO Box 6674, Minneapolis, MN 55406; email comments@mppub.com; phone 612.728.8600;. 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.
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CAPSULES
Gunderson, Marshfield Clinic scrap merger plans A proposed merger between Gundersen Health System and Marshfield Clinic Health System is a no-go. Seven months after the two Wisconsin-based systems announced they were exploring a potential merger, they announced recently that they have decided to stay independent after all. In a joint statement, the systems said the decision came after months of “productive, collaborative discussions” about how to enhance care across Wisconsin, northeast Iowa, and southeastern Minnesota. “This was an opportunity we had to explore,” Gundersen CEO Scott Rathgaber, MD, said in a statement. “Yet, we have to make the right decision for our patients and for our organizations. We each still have a commitment to delivering the best care possible to those we serve.”
The systems said they will continue to focus on improving access in rural areas through telehealth services, enhanced critical-access hospitals and clinics, and recruiting and retaining clinicians to practice in rural areas. Marshfield CEO Susan Turney, MD, said in a statement that bringing two entities of their size and scope together is incredibly complex. “While we mutually decided to remain independent, we will continue to execute our strategy of smart growth as we look for opportunities to ensure residents across rural Wisconsin have access to excellent healthcare close to home,” she said.
Community-based pharmacy partnership strives to transform practices The Community Pharmacy Foundation (CPF) and CPESN USA hope to transform community-based pharmacies through their new “Flip
the Pharmacy” program. The “flip” refers to a movement away from point-in-time, prescription-level care processes and business models to longitudinal and patient-level care processes and business models. Participants will work to sustain community-based pharmacy practice through the creation of economically viable, scalable, and sustainable care, along with business processes among clinically integrated networks who can contract with payers, purchasers, and partners for high value, reliable, and repeatable services across thousands of pharmacies. Flip the Pharmacy will also emphasize value-based care quality payments, clinical measures, and electronic care plans. Flip the Pharmacy will award qualified Practice Transformation Teams with funding and resources to act as implementation arms for locally based community pharmacy practice transformation efforts. Six transformation domains have been identified as key components of the
transformation efforts, and implementation will be supported at the pharmacy level by transformation coaches. Funding priorities include established payer relationships and lean budgeting, with consideration given to geographic and population density factors. The five-year partnership aims to graduate more than 1,000 pharmacies from a two-year transformation process modeled after similar Centers for Medicare and Medicaid Innovation efforts in primary care practices across the country. Additional program goals include targets for non-product-based reimbursement revenue, care plan submissions, screenings for behavioral health conditions, reductions in systolic blood pressure, HbA1c percentages, and cholesterol in patients with associated chronic conditions, as well as the completion of screenings for social determinants of health. To learn more about the program, visit www.flipthepharmacy.com.
MEDICAL MALPRACTICE ATTORNEYS
Angela Nelson
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Ryan Ellis
Marissa Linden
Jennifer Waterworth
CAPSULES
Opioid prescribing rates improving, says DHS Almost 16,000 providers serving patients in the Medical Assistance and MinnesotaCare programs now receive individualized reports that compare their opioid prescribing practices to those of anonymous peers and recommended thresholds. Department of Human Services (DHS) data show that the numbers of prescriptions over recommended doses have fallen off. The most dramatic decrease occurred in the number of patients simultaneously prescribed chronic opioid therapy and benzodiazepines, a potentially lethal combination. In 2016, 2,541 public health care program enrollees had prescriptions for both drugs at the same time. That number dropped 57% to 1,091 enrollees in a one-year period ending in September 2019. Other areas of improvement include: • 56% fewer prescriptions written over recommended doses during the acute and post-acute pain periods • 51% fewer index opioid prescriptions written over recommended doses (an index opioid prescription is one written for someone who hasn’t had an opioid prescription in 90 days) • 33% fewer index opioid prescriptions written • 54% fewer patients receiving doses of chronic opioid therapy that exceed recommendations State law requires DHS to provide the private reports each year and to manage a quality improvement program for providers whose reports show they continue to prescribe outside of community standards. The current reports, the second round since the program began in 2019, will give providers updated data before they may be required to participate in a quality improvement program when the next round of reports is released, around the end of 2020.
Because abrupt changes in opioid therapy for patients with chronic pain can be harmful, DHS warns providers to avoid rapid tapering or sudden discontinuation of opioids due to the significant risks of withdrawal.
Superior Health selected as QIN-QIO The Centers for Medicare & Medicaid Services (CMS) has awarded a five-year contract to Superior Health Quality Alliance (Superior Health) to serve as a Quality Innovation Network-Quality Improvement Organization (QIN-QIO) in Michigan, Minnesota, and Wisconsin. Superior Health is a consortium of eight organizations dedicated to driving achievement of Medicare quality improvement program goals. The members are Illinois Health and Hospital Association, MetaStar, Michigan Health & Hospital Association, Midwest Kidney Network, Minnesota Hospital Association (MHA), Michigan Peer Review Organization, Stratis Health, and Wisconsin Hospital Association. Stratis Health and MHA play key roles in leading the work across all three states, but with an emphasis in Minnesota, from coalition building and initiative design to quality improvement and subject matter expertise. As part of Superior Health, Stratis Health and MHA will work with communities, health systems, and nursing homes—including those serving rural and vulnerable populations—to: • Improve behavioral health outcomes, including opioid misuse
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CAPSULES
MHA recognizes hospitals for excellence in quality and patient safety The Minnesota Hospital Association has recognized seven hospitals for superior performance in quality and patient safety as part of its Hospital Improvement Innovation Network (HIIN), which strives to reduce overall patient harm by 20% and 30day hospital readmissions by 12%. Six hospitals earned a Partnership for Patients Excellence banner. This award indicates that the hospital is reporting on 75% or more of eligible outcome measures and road maps, is meeting the HIIN reduction goal on 70% or more of eligible outcome measures, and has met patient and family engagement criteria. Those hospitals were: • Alomere Health–Alexandria • Carris Health–Redwood Falls • CHI St. Francis
Health–Breckenridge • Ridgeview Sibley Medical Center–Arlington • Tri-County Health Care–Wadena • Windom Area Health In addition, North Memorial Health Hospital–Robbinsdale earned a Partnership for Patients Excellence certificate. This award indicates that the hospital is reporting on 75% or more of eligible outcome measures and road maps.
Zoning change opens door for Envision The Minneapolis City Council in November unanimously approved a zoning code text amendment titled “Intentional Community Cluster Developments” as part of a strategic effort to create innovative housing types and address homelessness in the city. This amendment allows,
for the first time in Minneapolis, the conditions necessary for people experiencing homelessness to live in housing designed and constructed within an attainable budget, and paves the way for the Envision Community Collaborative to build its proposed two-year demonstration community, housing between 15–30 people in homes clustered around a common house, living cooperatively as an intentional community. William E. Walsh, MD, and Jon L. Pryor, MD, MBA, highlighted the work of Envision Community Collaborative in a prior issue of Minnesota Physician (https://tinyurl.com/ mp-walsh). In that article, the authors described stable housing as one key social determinant of health—one that can drive medical costs higher due to increased emergency department visits—and argued that it could be cost-effective for health systems to contribute to home costs. To make those numbers work,
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however, would require zoning changes such as those contained in the City Council amendment. Zoning regulations such as large minimum square footages and a mandatory kitchen and bathroom in every unit drive up the cost of housing. The “Intentional Community Cluster Development” zoning change creates a new unit type in Minneapolis known as a “rooming unit” that does not require a kitchen or a bathroom, and also drops the required minimum lot square footage to 325 square feet per person in higher density zoning districts. The demonstration project is estimated to cost 60% less to develop per person when compared to similar permanent supportive housing because of the greatly reduced building footprint and decreased utility requirement resulting from the shared facilities that are now allowed under the zoning change.
MEDICUS
Steven Miles, MD, has received the 2019 Shotwell Award, presented by Abbott Northwestern Hospital and the Twin Cities Medical Society Foundation. Dr. Miles, professor emeritus of medicine and bioethics at the Center for Bioethics, University of Minnesota, has tackled controversial medical and public policy issues throughout his career.
Osmo Vänskä /// Music Director
Thomas Kottke, MD, MSPH, medical director for well-being at HealthPartners, has been elected to the Board of Directors of the National Quality Forum. A clinical cardiologist, Kottke is a researcher at the HealthPartners Institute for Education and Research. He is board-certified in internal medicine and the treatment of cardiovascular diseases.
Nicholas Van Deelen, MD, has joined St. Luke’s as chief medical officer and vice president of medical affairs. Dr. Van Deelen has been practicing emergency medicine at St. Luke’s for 22 years, and will continue to practice on a limited basis in the department. He completed his emergency medicine residency at Spectrum Health in Grand Rapids, Michigan.
Tetzlaff Plays Shostakovich Mar 5–6 Kirill Karabits, conductor Christian Tetzlaff, violin
Gerstein Plays Rachmaninoff: Piano Concerto No. 2 Mar 13–15 Juanjo Mena, conductor Kirill Gerstein, piano
JUA NJO M E N A
Adam Nielsen will join Center for Diagnostic Imaging (CDI) as the organization’s chief development officer. In this new role, Nielsen will take over senior executive responsibilities for expanding and growing CDI’s national network of outpatient-based diagnostic imaging centers through acquisitions and other partnership arrangements.
C H R I STIA N TE T Z L A F F
Bill Heegaard, MD, will soon join Essentia Health as president for Essentia’s West Market, which includes eastern North Dakota and northwestern Minnesota. Most recently, Dr. Heegaard served as chief medical officer and chief clinical officer at Hennepin Health System in Minneapolis. He is a professor of Emergency Medicine at the University of Minnesota Medical School.
Chamber Music: Memories and Melodies Mar 22
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MINNESOTA PHYSICIAN JANUARY 2020
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INTERVIEW
Redefining addiction Paul H. Earley, MD, DFASAM American Society of Addiction Medicine The American Society of Addiction Medicine (ASAM) recently revised its definition of addiction. Please share this new language.
whole health can lead to more integrated services provided in a way that achieves and supports longterm maintenance of remission and recovery.
Addiction is a treatable, chronic medical disease involving complex interactions among brain circuits, genetics, the environment, and an individual’s life experiences. People with addiction use substances or engage in behaviors that become compulsive and often continue despite harmful consequences.
How could the new definition affect public policy?
Prevention efforts and treatment approaches for addiction are generally as successful as those for other chronic diseases. Why did ASAM consider this change to be necessary?
Concerted effort went into replacing the word “addiction” with “substance use disorder,” but the new definition uses both terms. What is the new thinking here?
There is a difference between addiction and a “substance use disorder,” or SUD. A diagnosis of SUD is made based on the presence of certain symptoms and is identified according to the substance used. Substance use disorders are categorized as mild, moderate, or severe. Mild SUD involves people excessively using substances and experiencing at most one or two related problems. Often, people in this situation reduce their use in response to changing environments, life circumstances, or upon recognition of their condition. Addiction, meanwhile, is a primary brain disease that reflects the underlying disturbances and
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“...”
Every physician has many patients who are currently struggling with addiction.
“...”
Since the publication of ASAM’s previous definition of addiction in 2011, the public understanding and acceptance of addiction as a chronic brain disease and the possibility of remission and recovery have increased. At the same time, there is growing acknowledgment of the roles of prevention and harm reduction in the spectrum of addiction and recovery. ASAM’s Board understood that the previous ASAM definition could be difficult to explain to some audiences. Accordingly, in 2018, it commissioned the development of an updated definition of addiction that would be more accessible to many of ASAM’s stakeholder groups, including patients, the media, and policymakers.
changes in brain function that manifest themselves as symptoms of moderate to severe SUD. People with addiction can absolutely achieve stability and some healing of dysfunctional brain functions, while no longer exhibiting symptoms of their disease. However, some of the brain changes are so deeply embedded that they persist, leaving patients at risk for relapse even after years of remission and recovery. The new ASAM definition describes addiction as a “treatable, chronic illness” with multifactorial comorbidities, which vary widely between individuals. How can this translate into improved treatment outcomes?
Improved treatment outcomes can be realized when addiction is treated as a chronic, rather than an acute, disease and when treatment for addiction is coordinated with treatment for co-occurring disorders and addiction-related medical complications. Addiction treatment evolved outside of mainstream medicine and has been historically treated with acute interventions. Recognizing its chronic disease nature and impact on a person’s
The new definition informs and supports policy changes to align addiction prevention and treatment funding and research with that of other chronic diseases that have major public health burdens. It also supports a move away from punitive policy responses to prevention and treatment responses that address the various factors influencing the development and severity of addiction, including social determinants of health. The natural course of addiction is relapse and remission; public policy should be aimed at its chronic nature and the full life cycle of the illness. More than other chronic illnesses, there is an insidious nature to addiction that poses very difficult treatment challenges. What can you share with us about this?
Stigma associated with addiction complicates its treatment as it prevents patients from seeking treatment and discourages health care providers from offering it. If not initiated early and provided in a way that affirms the dignity of the patient, treatment may be more difficult or less effective. Approaching addiction treatment as we do treatment for any other chronic disease can improve outcomes and reduce stigma. Further, part of having addiction is an inability to recognize it. When physicians have better diagnostic acumen to recognize the signs and symptoms of addiction, they can use graded communication to help patients recognize their need for treatment. Current models of treating alcoholism have extremely poor outcomes. What are the failings of the treatment industry and how can they be improved?
The addiction treatment field has long struggled with stigma, isolation from mainstream medical care, and woefully insufficient funding. Integrating addiction treatment into
mainstream medical care—meaning, among other things, requiring similar quality oversight and accreditation/certification of programs and adjusting reimbursement for addiction treatment services so that they are on par with those provided for other chronic diseases—can improve quality and accessibility of addiction treatment. Long-term addiction can “rewire” brain pathways crucial to recovery. How do you address it in treatment?
We know that addiction creates profound changes in the brain’s reward circuitry. This in turn produces changes in motivation, attention, learning, and even higher association circuitry. This accounts for the tenacious nature of the illness. Those who have the illness often need to learn and practice new behaviors, attitudes, and activities that counteract the drive to relapse. Therefore, many individuals with addiction need therapy or coaching in new skills that retrain the brain and decrease the probability of relapse or continued use. Medical cannabis is finding increasing acceptance and efficacy. Why—or why not—should this be an option for patients in recovery?
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Cannabis use is associated with multiple harms, including use disorder, reduced motivation among youth, and increased risk for psychosis among young adults. The most recent review by the National Academies of Science, Engineering, and Medicine found that there is inadequate information to assess the effects of cannabis on any condition save for chemotherapy-induced nausea and vomiting, multiple sclerosis-related spasticity, and chronic pain, for which the effects of cannabinoids are modest. It also found that cannabis use is likely to increase the risk for developing substance use disorder (other than cannabis use disorder). Lack of efficacy plus demonstrated harms and significant risk of exacerbating addiction should preclude its use among patients in recovery. What advice do you have for physicians who suspect patients may be in denial over addiction issues?
Addiction is a very common illness. In a 2017 study, the NSDUH [National Survey on Drug Use and Health] reported that 6.4% of individuals 26 years of age or older have a substance use disorder (one in 16 adults in the US). Therefore, every
physician has many patients who are currently struggling with addiction. Physicians can be a major force in helping patients recognize and address the disease. Here are a few first steps that will help physicians: • Don’t ignore medical signs of addiction. For example, one of the most common reasons for elevated liver function tests is unhealthy alcohol use. • Learn more about the social, family, and psychological symptoms of addiction to enhance early diagnosis. • Learn more about addiction as an illness, its biological basis, and the need for comprehensive assessment and long-term care. • Learn how to use evidence-based interventions such as motivational interviewing or patientcentric symptom management. • Work to remove even a hint of judgementalism about addiction. Most patients with addiction suffer from shame and are reluctant to disclose their concerns to caregivers. Paul H. Earley, MD, DFASAM, is president of the American Society of Addiction Medicine.
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3Health information “blocking” from cover through elimination of duplicate services, and certainly for the ease of patients-shuffling-around-with-paper-records at a time when they are most vulnerable, it is not happening. And it is not happening primarily because some health providers and their vendors don’t want it to happen, because it doesn’t contribute to their “business” plan.
shared their personal experiences with a family member not being able to access health records when they sought care outside of certain health systems. Indeed, the 21st Century Cures Act, enacted in 2016 and meant to be a “moonshot” to cure cancer, included major provisions mandating that our health care system become bi-directionally interoperable.
The stories from patients are sometimes agonizing, such as a cancer patient having to redo a painful test because the records couldn’t be transferred electronically and the geographic Federal actions distance was too great to hand carry them. Then, EHRs hold the promise to be an effective tool for Electronic “fences” also there are the downright irritating situations where clinicians and communities when built with the cloak or otherwise inhibit a patient with a high-deductible health plan asks goal of expanding access and empowering patient cost transparency. to use a lower-priced specialist or seek a diagnostic choice. Unfortunately, in many circumstances, this test, only to have the physician who suggested the objective has been far from realized. In fact, some referral refusing to write a referral for a provider health systems and providers have developed their outside of a particular health system, or saying EHRs with the intent of erecting electronic fences that they don’t know how to write an order for instead of achieving bi-directional interoperability. outside the health care system—or telling the These “fences” are often the tool of choice for those engaging in health patient to stay inside the health system for all services so that the patient’s information blocking. The result of health information blocking is the medical record “is complete.” denial of choice by restricting the sharing of patient information through secure, federally certified and HIPAA‐compliant electronic connections between providers. This blocking serves to deny patient choice, even when a patient’s health plan network allows choice, all in the name of profit. Both former Vice President Joe Biden and Seema Verma, current administrator of the Centers for Medicare and Medicaid Services, have
The federal Office of the National Coordinator for Health Information Technology (ONC) recently found that an examination of health information blocking was “both timely and warranted” given the federal government’s investment of nearly $30 billion through the HITECH Act, a 2009 law passed in part to promote interoperability among providers. The ONC has also surveyed stakeholders to measure the exchange of health information using certified electronic health records to ensure that health information technology is interoperable in the coming years. Further, provisions in the 21st Century Cures Act seek to promote interoperability in the design and use of certified electronic health records, including a requirement that providers attest that they will not engage in information blocking as part of “meaningful use.” Rulemaking is still taking place, but the focus at the federal level is promising.
State actions
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Individual states have also taken note of the substantial clinical impediment and systemic additional costs that the intentional blocking of health information creates for patients, providers, and budget makers. Notably, when investigating ways to improve quality of care and reduce costs, the Connecticut General Assembly’s “Bipartisan Round Table on Hospitals and Health Care (2015)” effectively found that major health systems were utilizing their EHRs as part of their strategy in their mission to grow and acquire new practices. Further, the state roundtable determined that “The state must affirm as a matter of policy that health records belong to the patient, not the provider. Patient medical records are not proprietary and should not be used for competitive advantage.” Accordingly, Connecticut has passed laws defining the act of “health information blocking” and has rendered the state attorney general responsible for enforcing the provisions under the state’s “unfair trade practice” statutes, punishable by a $5,000– $25,000 fine per occurrence. Several other states, including Minnesota, have considered similar actions but with variations on their definitions of information blocking and achievement of interoperability. This includes Medicare fee‐for‐service
patients, who, under the Affordable Care Act, are mandated to be able to choose their provider. To ensure that all Medicare beneficiaries are provided with the same access to their own health information, the role of government to define, guide, and encourage bi-directional interoperability is imperative.
Definitions
Additionally, at a time when clear data demonstrates that the consolidation of health care providers increases costs, the blocking of health information constitutes a serious business challenge for independent physicians who are dedicated to providing quality care to their community. If they do not offer all the services of a large health system that their patients need, they are often blocked from providing any care because of a local, potentially dominant, health system’s lack of reasonable responsiveness to establishing a secure electronic connection with them. Particularly in rural Patient medical records are not areas, there is sometimes a confidentiality issue, proprietary and should not be where the patient prefers to seek a certain health used for competitive advantage. care service outside the hometown but risks inappropriate care if the patient’s records cannot follow the patient.
Electronic “fences” also cloak or otherwise inhibit cost transparency and price shopping by the patient. Often, patients are told that if they choose a physician who is not part of a particular health system, their relevant information will not be a part of their health care record, thereby discouraging patients from using cost, geographic or scheduling convenience, or specific provider qualities as part of the decision‐making process. This occurs despite concerns about potential high deductibles and co‐pays and even contributes to duplicative tests, including those which carry risk to the patient. One example of this: duplicating CT imaging studies, thereby exposing the patient to additional and unnecessary radiation. This chilling effect on choice results in increased costs to patients and purchasers, contributes to overburdening of our health care system, and threatens patient access to care. The reduced access to care concern is especially evident in rural regional centers, where health systems “colonize” the region and blatantly fence patients away from independent providers.
“Health information blocking,” as noted above, occurs when a person or entity attempts to interfere with the efficient, timely, and HIPAA-secure transfer of a patient’s medical records or order for additional health services. In practice, this concept includes situations where providers or systems resist or delay sharing patient data with providers of the patient’s choosing, as well as situations where systems or vendors charge a cost-prohibitive amount for electronic connectivity to their system.
Three patients. Who is at risk for diabetes?
Health information “blocking” to page 344
When there are no signs or symptoms, you may not know until it’s too late. Act now. Screen your patients for type 2 diabetes. It’s easy. It’s covered. It will reduce their risk. • Refer your at-risk patients to a proven lifestyle change program and help cut their risk of developing type 2 diabetes in half.
1 in 3 adults are at risk!
• For patients who already have diabetes, send them to a quality diabetes self-management program to improve control and reduce complications. Find groups in Minnesota at www.health.mn.gov/diabetes/programs
Minnesota Department of Health DIABETES PROGRAM
MINNESOTA PHYSICIAN JANUARY 2020
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3Medical aid in dying from cover
Fears of abuse are unsubstantiated
Opponents of medical aid in dying often express concerns that legalizing Safeguards ensure proper application of medical aid in dying medical aid in dying could lead to abuse by physicians, families, or insurers. While specific state laws vary, Oregon’s Death with Dignity Act and every They particularly cite fears that underserved communities or people living other medical aid-in-dying statute requires that with disabilities could be pressured to forgo care a terminally ill patient who requests medical aid or be denied care if medical aid in dying were an in dying be fully evaluated by two physicians option. More than 45 years of cumulative data in who must concur that the patient qualifies. authorizing states belie these concerns. No physician They must agree on a six-month prognosis and has been disciplined, and not a single instance of Insurers have no financial that the patient is capable of making medical abuse or coercion has been substantiated. In fact, incentive to pressure patients decisions and understanding the consequences Disability Rights Oregon, the nonprofit whose to accelerate their deaths. of those decisions. Both doctors are obliged to mission is to protect the rights of people living with ensure that patients are fully informed of all the disabilities, has not had a single complaint of abuse alternative options, including hospice care and of the state’s Death with Dignity law. pain control, and that patients are volitional Regardless of whether a state has authorized and free from coercion. If either physician medical aid in dying, insurance providers cover questions the patient’s capacity, a mental health consultant makes the treatments that are deemed effective and proven, and not those considered final determination. unnecessary or experimental. A research article published in the New Annual reports from the Oregon Health Authority indicate that the vast majority of terminally ill patients who request medical aid in dying are suffering from an advanced disease with a predictable trajectory; the most common diagnoses are cancer and ALS. Most patients are enrolled in hospice care at the time of the request, which ensures another level of protection as hospice enrollees are evaluated by an interdisciplinary team of health professionals on a regular basis.
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England Journal of Medicine concludes that insurers have no financial incentive to pressure patients to accelerate their deaths.
Medical aid in dying does not undermine hospice or palliative care Since Oregon’s Death with Dignity law was enacted, hospice use in Oregon has grown and is now double the national average. Oregon consistently ranks high in hospice quality indicators and appropriate usage. More people in Oregon die at home (80%) than nationally (20%) and fewer experience invasive medical procedures in the last month of life. Ann Jackson, the former CEO of the Oregon Hospice Association and a former opponent of the Death with Dignity law, declared publicly that the law led to more open conversations, improved the ability of hospice programs to address fears, and had been implemented responsibly.
Pain is not the main concern Requests for medical aid in dying do not reflect a failure of palliative medicine. The reasons most patients give for choosing medical aid in dying are related to a desire for control, loss of quality of life, preserving autonomy, and avoiding unnecessary suffering. Physical pain is a less common factor (25%), as are economic concerns (5%). Suffering can take many forms and personal values play an important role. According to ethicist Eric Cassell, MD, while physicians agree that relief of suffering is central to our role, diagnosing suffering requires an understanding of the person, not just the disease. Suffering is not a mental affliction, but a complex interplay of disease symptoms with values, personality, and spiritual meaning. According to Cicely Saunders, founder of the modern hospice movement, total pain is the suffering that encompasses all of a person’s physical, psychological, social, spiritual, and practical struggles. For the vast majority of dying patients, hospice provides much needed support and relief from pain. But for some, prolonging the suffering that accompanies an inevitable death inflicts further suffering.
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Doctors are free to follow their conscience Medical aid in dying is an ethical dilemma because it presents tension between two competing goods: the desire to prolong life and the desire
to alleviate suffering. In the face of such a dilemma, the patient must decide what is best for them. Medical ethics require physicians to respect patient autonomy, act in the interest of the patient, and to do no harm. But who decides? Health care professionals who find that medical aid in dying conflicts with their religious or moral views are under no legal obligation to provide these services. However, a licensed physician is bound by professional ethics that precludes withholding medical information. Requests for medical aid in dying are an opportunity for all physicians to explore the meaning behind the request and better meet the patient’s needs. Ethically, clinicians who choose not to participate in medical aid in dying should, at a minimum, provide patients with a reliable source of information about medical aid in dying and transfer medical records upon request.
Dying,” while the American Academy of Neurology coined the term “Lawful Physician-Hastened Death.” The lens through which we view requests for medical aid in dying can impact the care that patients receive and have implications for suicideprevention strategies. Interpreting a request for medical aid in dying as “suicide” can trigger an inappropriate response and miss the opportunity to explore the deeper meaning behind the request.
Public polls show that more than two-thirds of Minnesota’s voters support medical aid in dying.
Language matters The medical community is grappling with appropriate language to describe and define medical aid in dying. A growing number of authoritative sources have discontinued use of the term “physicianassisted suicide” in favor of language that distinguishes a request by a terminally ill patient to hasten an inevitable death from the suicidal ideation that results from cognitive impairment. The American Academy of Hospice and Palliative Medicine uses the term “Physician-Assisted
Legally, in all jurisdictions where medical aid in dying is authorized, statutes emphasize that: “Actions taken in accordance with [the Act] shall not, for any purpose, constitute suicide, assisted suicide, mercy killing or homicide, under the law.” Assisting a suicide, which would occur outside the boundaries of the law, remains illegal.
Support for medical aid in dying is strong Since 1997, Gallup polls have consistently shown support for medical aid in dying at between 64% and 74%. Public polls (https://tinyurl.com/ mp-thoman01) show that more than two-thirds of Minnesota’s voters support medical aid in dying. That support is bipartisan and diverse, and spans every demographic group. Minnesota State Fair Surveys from 2016 showed support among fairgoers at 68% (https://tinyurl.com/mp-thoman02). Medical aid in dying to page 324
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BEHAVIORAL HEALTH
Mental health in the emergency room A role for the medical family therapist BY AALAA ALSHAREEF, MS, AND TAI MENDENHALL, PHD, LMFT
C
ontemporary efforts to integrate behavioral health care with biomedical services in primary care environments are advancing quickly. As evidence supporting such efforts grows, scholars and practitioners alike are beginning to the consider the utility of doing this in secondary care contexts as well. Emergency medicine represents an especially timely arena to do this, insofar as the intersections of mental—and physical—care needs therein are incontrovertible. The complexity and variety of cases that present in emergency rooms (ERs), however, can make balancing these foci a considerable challenge.
Emergency rooms’ presentations and culture Patients’ and families’ emotional responses to the acute physical presentations that characterize ER visits are remarkably diverse. Common themes relate to struggling with ambiguities about what will happen to sick or injured patients, fears about one’s own or a loved one’s life and survival, and/or misplaced anger directed at each other, health care providers, or administrative staff. Behavioral health presentations per se—without clear physical components—are also common. Suicidality (and the severe depression that
often accompanies suicidal thoughts), anxiety and panic, psychosis, and any myriad of other states defined by psychological decompensation can bring patients to emergency care. Moreover, the worries and fears maintained by family members who bring them in can echo those that we see in response to straightforward physical injuries or conditions. ERs also do not serve or prioritize patients and their families in a firstcome, first-served, manner, attending, instead, to those with the most acute and/or life-threatening conditions first. It is thereby possible that some (or many) patients have to wait a long time before being seen. These patients are at risk of experiencing prolonged discomfort, anxiety, worries, and anger. In addition, providers may (and do) also experience frustration and distress when patients with critical health conditions do not receive care in a timely manner. Patients, families, and providers may experience negative psychological symptoms as they navigate treatment processes sans mental health services and/or behavioral health colleagues.
Background and rationale When family members experience emotional symptoms in ERs, they receive limited (or no) services, because providers characteristically focus most of their attention on the identified patient. Nursing studies—like those published in the Journal of Nursing Scholarship (Anderson & Tomlinson, 1992) and the Journal of Advanced Nursing (Tomlinson, Peden-McAlpine, & Sherman, 2001)—provide evidence that families are of remarkably high importance in emergency care for child and adolescent patients—but that providers are often not adequately trained to engage them in the provision of systemic interventions during and/or after a health crisis. Studies in social work—like Auerbach and Mason’s (2010) account in the journal entitled Social Work in Health Care—highlight the value of support services for patients and families in ERs in admissions and discharge planning—but not during acute care sequences and/or decision-making immediately within these timeframes.
Meeting patients’ and families’ needs in emergency medicine According to scholars such as Nikki, Lepistö, & Paavilainen (2012) and Salminen-Tuomaala (2018), published in outlets like International Emergency Nursing and the Scandinavian Journal of Caring Sciences, patients and their families have expressed the following needs related to treatment in ERs: • Expecting more psychological support • Wanting loved ones to receive information about patients’ health conditions • Assistance in regulating emotions and decreasing anxiety while waiting for and receiving care • Wanting to be active participants in health care services and/or decision-making processes Effectively meeting these needs will require a systems-informed (e.g., biopsychosocial/spiritual) approach that purposefully engages individuals
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within the contexts of the multiple systems that they inhabit, and that attends to the manners in which patients, families, and other systems mutually influence each other.
waiting-room events), engaging police/security (e.g., in concomitance with de-escalation sequences), delivering bad news (e.g., a tragic laboratory result, death notifications), coordinating referrals (e.g., long-term behavioral health care, psychoeducation, social services), and team efforts to reduce and/or mitigate burnout and compassion fatigue through Balint groups of clinicians who meet regularly to present and discuss cases, staff huddles, individual/group debriefings, hallway consultations, and more.
Medical Family Therapists (MedFTs) can provide a systemic orientation for patients and their families. Emerging scholarship—like that advanced by Kassekert and Mendenhall (2018) in Clinical Methods in Medical Family Therapy—situates such applications of clinical engagement across a In addition to helping patients and families, 5-level continuum, with varying (and increasing) Families are of remarkably high importance in emergency care. MedFTs can support health care providers to attention to integrated care provision, training/ manage their stress and frustration, and to share supervision, research, and policy efforts. Said work their insights and systemic understanding of is, however, still in its infancy and is secondary families’ experiences. MedFTs are able to work to political impasses between sibling disciplines’ at the microsystem level to support patients’ and governing boards, payment models, and guild families’ relationships across care journeys (e.g., cultures that tend to exclude family therapists facilitate functional conversations between family members to manage from practicing in emergency contexts. stress and make effective care-related decisions). At the mesosystem level, A call to action they can help patients and their families process their experiences related While there has been some attention paid to the integration of mental to navigating the health care system (e.g., process conflicts with physicians, health services into emergency medicine, little has been written about this assist with advocacy for sundry wants and needs). At the macrosystem level, as it relates to providing family-based care. Family therapists can bring into they can include families’ culture and religion into consideration while these contexts advanced skillsets in systemic assessment (e.g., suicidality, providing sensitive assessments and personalized treatment (e.g., facilitate homicidality, alcohol/drug abuse/dependence, interpersonal violence, couple/family communication, and problem solving), de-escalation sequences (e.g., angry/enraged patients or family members, disruptive Mental Health in the emergency Room to page 164
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3Mental Health in the emergency Room from page 15 conversations about possible cultural and/or religious considerations that may inform care processes). This work is not easy within complex clinical situations wherein life and death issues are commonplace. It is family therapists’ responsibility to create space for and encourage all professionals to work together to facilitate systemic thinking. The time is now; we need to synchronously advance research and clinical efforts into this relatively uncharted arena of care. As we do, it is important to explore the organizational contexts of ERs so that we can develop and provide systems-informed interventions to—and with—patients, families, and providers synchronously. This will allow researchers and clinicians to extend attention beyond the traditional (narrow) definition of ER and MedFT services.
Conclusion Mental health services provided in ERs—if any—generally lack a systemic orientation. Patients and families receive support individually and/or one member-at-a-time. Despite ongoing advancements in health care to integrate systems-informed behavioral health providers into biomedical contexts, a consistent paucity exists for doing this in emergency medicine. There are clinical, operational, and financial barriers to navigate. MedFTs and health psychologists, for example, are often systematically (via hiring policies) excluded from these teams. And, while mental health is generally covered under the purview of social work and/or nursing providers, care is generally advanced in a manner
set up for relatively narrow presentations like assessing for suicidality and/or triage and referral to other care sites and hospital departments (Kassekert & Mendenhall, 2018). Moving forward, we must work past (or through) these interdisciplinary tensions and limited care scopes en route to better care. Our patients, families, providers, and care systems all stand to benefit. Aalaa Alshareef, MS, is a doctoral student in the Couple and Family Therapy Program at the University of Minnesota’s Department of Family Social Science. She holds a Master of Science in Marriage and Family Therapy, and serves as a faculty member in a large psychology department in Saudi Arabia.
Tai J. Mendenhall, PhD, LMFT, is a Medical Family Therapist and Associate Professor in the Couple and Family Therapy Program at the University of Minnesota’s Department of Family Social Science. He is an adjunct professor and clinician in the UMN’s Department of Family Medicine & Community Health, an Associate Director of the UMN’s Citizen Professional Center, and the Director of the UMN’s Medical Reserve Corps’ Mental Health DisasterResponse Teams. He works actively in the conduct of integrated behavioral health care and community-based participatory research (CBPR) focused on a variety of public health issues.
V Alzheimer’s is now an approved condition V
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• Inflammatory bowel disease, including Crohn’s disease
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• Terminal illness, with a probable life expectancy of less than one year
• Severe and persistent muscle spasms, including those characteristic of MS
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PUBLIC HEALTH
The MN FEET program Birth disparities and prenatal mercury exposure BY KATE MURRAY, MPH; JESSICA NELSON, PHD, MPH; AND COURTNEY JORDAN BAECHLER, MD, MS
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he jar of skin lightening cream looked innocuous enough, but investigators found that merely opening its lid released enough mercury vapor to create unsafe living conditions in the home. Using a Lumex portable mercury detector, partners with the MN FEET program (Minnesota Family Environmental Exposure Tracking) found a reading of 800 nanograms per cubic meter of mercury in the air—more than twice the chronic exposure limit set by the Environmental Protection Agency. Fortunately, a few days of fans and open windows were enough to bring the readings down to safer levels. The home visit was part of a voluntary follow-up investigation with a study participant found to have high levels of mercury in her urine. Environmental epidemiologists with the Biomonitoring Program at the Minnesota Department of Health (MDH) hypothesized that the exposure had come from an imported skin lightening product, and the Lumex readings supported their hunch.
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Residents at the house had been at risk from mercury, which can damage the central nervous system, kidneys, and liver. While health consequences vary on the amount and duration of exposure, fetuses and young children are particularly sensitive to mercury, too much of which can cause lasting problems with understanding and learning. While the MN FEET study wrapped up last year, surveillance and prevention efforts are far from over. Findings from the study reveal important information for health care providers to be aware of and discuss with the patients they serve. Here, we share key findings from the MN FEET study and discuss how we are piloting a mercury screening program for pregnant women with two St. Paul clinics.
The MN FEET study Investigators with MN FEET measured mercury, lead, and cadmium in pregnant Twin Cities women and their newborn babies in hopes of learning more about preventing chemical exposures that could impact fetal brain development. Prior to the study’s inception, community concerns and outcomes from other biomonitoring studies suggested that some populations were experiencing marked disparities in exposure to certain chemicals, but more investigation was needed. With oversight from the Environmental Health Tracking and Biomonitoring (EHTB) Scientific Advisory Panel, researchers from the Minnesota Biomonitoring program at MDH designed and implemented the study with an eye on advancing health equity. Collaboration with health care and community stakeholders proved essential to the study. The HealthPartners Institute and Health for Somali, Latinos, and Hmong (SaLaHmo) Partnership for Health & Wellness at Minnesota Community Care (then known as West Side Community Services) recruited pregnant women who were patients at select local clinics and who planned to give birth at Regions or Abbott Northwestern Hospitals. In accordance with community and advisory panel recommendations, recruitment focused on women who identified as Asian, East African, Latina, or White. “This is part of our effort to ensure that every baby has a healthy start,” said Kathleen A. Culhane-Pera, MD, medical director of quality and co-director of community-based research at Minnesota Community Care. “What we learn from MN FEET will be important to the communities, families and patients served at our clinics.” Recruits who consented to being part of the study answered a phone questionnaire about their living conditions, eating habits, use of skin lightening creams, and other factors that could influence exposure levels. When the participants’ babies were born, hospital staff collected urine samples from the women and a small amount of umbilical cord blood, which were then analyzed by the MDH Public Health Laboratory. Some ethnic groups had more women in the study than others: the largest groups were Latina and White women, followed by Asian women, with East African women representing the smallest group. Participation by East African women was unintentionally hindered by different aspects of the study design, including
non-face-to-face recruitment methods and sample collection at two partner hospitals where these women were less likely to deliver. Exposures to lead and cadmium were measured in cord blood samples, and were generally low and not of great concern for women in MN FEET. Cadmium exposure occurs primarily through smoking cigarettes. Lead exposure typically comes from contact with lead-based paints, along with some jobs, hobbies, and products like glazed ceramics with lead. Mercury, on the other hand, showed more troubling and complicated results. The type of mercury detected in cord blood is most often organic mercury, found in fish. The type of mercury detected in urine is usually inorganic mercury, which can come from skin lightening products, light bulbs, and old thermometers. Researchers found elevated levels for both forms of mercury and identified specific populations at higher risk.
Mercury from skin lightening products MN FEET measured mercury in the urine of 396 participants. Women in the study who said they had used a skin lightening cream in the past had more mercury in their urine than those who did not. Such products often do not list mercury on the label, and it cannot be seen, felt, smelled, or tasted by the consumer. In the United States, it is illegal to sell skin lightening products that contain mercury, but they can be ordered from the internet or carried across borders and are available at some ethnic markets. Many women who use the creams are unaware of how hazardous they can be, but it’s a complicated and painful issue with roots in colorism and colonialism. Amira Adawe, founder of the Beautywell Project and key community partner for the study, says that removing the products from markets is not enough—consumer education and a cultural shift around beauty standards are needed. “Skin lightening practice is an issue that is impacting immigrant and communities of color,” says Adawe. “Lighter skin is considered beautiful compared to other skin tones; because of this, many dark-skinned women believe having lighter skin will increase their chances of being accepted in society and in their communities.” Globally, the skin lightening product market exceeds $10 billion annually and is expected to double by 2030.
MN FEET measured mercury in the cord blood of 395 participants and found that women who ate particular species of fish—Walleye, Northern Pike, Bass, White Bass, or King Fish—more than once per month had more mercury in their babies’ cord blood than women who ate fish less often. MDH guidelines advise pregnant women and children to eat these types of fish once a month or less. Nine women had high levels of mercury in their babies’ cord blood. Phone follow-up revealed that most of them ate species of fish with higher mercury more than once per month. All nine of them were Hmong women, though Asian groups in general had higher cord blood mercury than other groups.
Exposures higher in some women Asian women in MN FEET, and especially Hmong women, had the highest levels of mercury. This was true for mercury in urine and cord blood, suggesting that some Hmong women in Minnesota may have high mercury exposures from using skin lightening products with mercury and from eating fish higher in mercury. “The evidence from MN FEET that some groups in Minnesota may be having higher mercury exposures, especially Hmong women and women from other ethnic/immigrant communities, is concerning,” said Mao Thao, Hmong Health Coordinator with St. Paul–Ramsey County Public Health. “It is critical that we work with these communities to find the best ways to share the information and reduce exposures in women and babies.” The MN FEET program to page 304
For MN FEET, six of the nine women with elevated urine mercury levels agreed to take part in further investigation via home visits. With help from St. Paul–Ramsey County Public Health and the Minnesota Pollution Control Agency, the participants’ homes were tested for mercury contamination. The Lumex analysis revealed that airborne mercury was putting everyone in the home at risk, and not just the women using the creams. Additionally, their washing machines could become contaminated from laundering towels that contained traces of the creams, potentially spreading the mercury to other clothing and linens. All nine women with higher mercury in their urine chose to speak Hmong or Spanish in their surveys, and all were born outside of the United States. The group of East African women tested was too small to draw statistical conclusions from their results, but they had the second-highest mercury levels in their urine after Hmong women.
Mercury from eating certain fish The benefits of fish consumption outweigh the risks when people choose fish that are low in mercury and other chemicals. MDH provides guidelines in a number of languages and formats to help people choose which fish to eat and how often in order to keep mercury exposures low.
MINNESOTA PHYSICIAN JANUARY 2020
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NEPHROLOGY
Transplanting HCV-infected kidneys A promising new source of donors BY JEFFREY H. WANG, MD, PAUL A. STAHLER, MD, FACS
O
n July 26, 2019, Hennepin County Medical Center transplanted a hepatitis C (HCV)-infected kidney into a 54-year-old man with end-stage renal disease who did not have HCV. Although kidney transplants between HCV nucleic acid test positive (NAT) donors and HCV-negative recipients have been performed previously in a handful of other states, this was the first one performed in Minnesota. In this article, we will describe how this type of transplant can benefit waitlisted patients by increasing the number of kidneys available for transplant.
The deceased donor waitlist Why would patients knowingly consent to being infected with HCV? The reason is that they likely will get transplanted sooner. Approximately 95,000 people in the U.S. are waiting for a kidney transplant, 2,155 of whom live in Minnesota. Due to a critical shortage of organ donors, wait times are long. Historically, the average wait time in Minnesota for a kidney transplant from a deceased donor with a non-high kidney donor profile index (a numerical measure that combines ten donor factors, including clinical parameters and demographics) was five years. However, wait times in Minnesota have been increasing, and currently it is
not uncommon for candidates with O and B blood types to wait up to six–seven years, respectively (A and AB blood types have significantly shorter wait times). There are several published risk prediction models that can give patients personalized estimates of their probability of being transplanted in a certain time frame at their center. Using one commonly cited model developed by Hart and colleagues at the Scientific Registry of Transplant Recipients (http:// www.srtr.org), a 60-year-old Caucasian woman who is an O blood type and has co-morbidities of diabetes mellitus, hypertension, and end-stage renal disease with initiation of dialysis two months ago has only a 13% chance of being transplanted in five years in Minnesota, compared to a 45% chance of still waiting and a 42% chance of being too sick or having died on the wait list. Although living donor transplant or being waitlisted in a region of the U.S. such as Florida, which has shorter wait times, would increase a patient’s chance of being transplanted, these are not viable options for most candidates, as two-thirds do not have living donors and most do not have the financial resources to travel to a center out of state. As a result, a large number of patients on the kidney transplant wait list will end up never being transplanted.
Treatment of hepatitis C with direct acting antivirals Until a few years ago, most kidneys from donors with HCV were either discarded or never procured, resulting in the loss of thousands of potential transplants. The reason these kidneys were underutilized was because effective HCV treatments were not available. Pegylated interferon alpha and ribavirin, which was the standard of care for HCV in that era, was associated with low cure rates of around 40% and numerous debilitating side effects. In addition, use of interferon after a kidney transplant increased the risk of acute rejection. Chronic HCV after renal transplant was associated with poor outcomes, including transplant glomerulopathy, post-transplant diabetes, and de novo glomerulonephritis. Hence, transplant of HCVpositive kidneys was limited to patients who already had chronic HCV, and even then this type of transplant was infrequently performed. The advent of the direct acting antivirals (DAAs) fundamentally changed how HCV is treated. Telaprevir and boceprevir were the first DAAs released in 2011, but it wasn’t until ledipasvir/sofosbuvir in 2014 when cure rates were substantially better compared to interferon-based therapies. Cure of HCV is defined as achievement of a sustained virologic response 12 (SVR12), which is the absence of detectable viremia 12 weeks after completion of the DAA course. DAAs work by inhibiting key proteins (NS5A, NS5B, NS3) involved in the replication of the virus. Treatment durations are eight to 12 weeks and patients report relatively few side effects. There are currently nine Food and Drug Administration-approved DAA regimens with studies reporting SVR12 rates over 90%, even in hard-totreat populations such as dialysis and transplant patients.
Benefits of HCV NAT-positive donor to HCV-negative recipient kidney transplant The availability of an effective treatment for HCV led members of the
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JANUARY 2020 MINNESOTA PHYSICIAN
transplant community to explore transplanting kidneys from HCV NATpositive donors into HCV-negative recipients, followed by DAA treatment post-transplant. The advantages with such a strategy are several-fold: Wait time reduction. Candidates who agree to receive an HCV-infected kidney experience shorter wait times to transplant. In their 2018 study in the Annals of Internal Medicine, Reese et al reported a median wait time of 57 days between listing for an HCV-positive kidney and transplant. The patient described above transplanted at our center after a wait of 20 days. Although wait times are expected to increase as more patients opt in for HCV-positive kidneys and “compete” for the same kidneys, it is likely that they still will experience shorter wait times compared to waiting for an HCV non-infected kidney. High quality organs. Patients who agree to an HCV-infected kidney might end up receiving a higher quality kidney than they would with a HCVnegative kidney. According to the CDC, the opioid epidemic is responsible for the increased incidence of HCV since 2010. The majority of these new HCV cases are due to intravenous drug use in persons less than 30 years old, and this is reflective in the changing demographic of deceased donors. According to a 2017 study by Levitsky et al in the American Journal of Transplantation, the median age of deceased donors with HCV has been decreasing since 2012 and was 36 compared to 41 for HCV-negative donors in 2016. Given that HCV-infected donors are younger, they are likely to have fewer co-morbid conditions such as hypertension and diabetes mellitus that may adversely affect kidney function. Kidneys transplanted from these patients may last longer. High SVR12 rates. Two studies published in 2018 in the Annals of Internal Medicine demonstrated that this type of transplant was safe and efficacious. In the EXPANDER study, 100% SVR12 rate was seen in 10 HCV-negative recipients who received HCV-infected kidneys and were treated empirically with grazoprevir/elbasvir post-transplant. The THINKER-2 study also reported a 100% SVR12 mark in 20 HCVnoninfected patients transplanted with HCV-positive kidneys receiving grazoprevir/elbasvir upon HCV seroconversion. Cost effective. Dialysis is an expensive treatment, costing about $95,000 a year per patient. Transplanting a patient sooner with an HCV-infected kidney can decrease societal end-stage renal disease health costs by reducing the time spent on dialysis. Gupta et al, in a 2018 American Journal of Transplantation study, reported that HCV-positive donor to negative recipient kidney transplantation followed by DAA treatment was less expensive than remaining on dialysis waiting for a HCV-negative donor, provided the wait time for an HCV-infected kidney was less than 2.5 years.
Evaluation by a transplant pharmacist is essential, as there are numerous drug-drug interactions between DAAs and commonly prescribed medications. For example, DAAs can significantly increase the levels of various statins, placing an individual at risk for rhabdomyolysis, and may require switching to an alternative agent or a dose reduction before they can be used concurrently. Finally, a prior authorization is submitted to the candidate’s insurance carrier. Although prices are decreasing, the cost of a DAA course still can range between $25,000–$50,000, which most patients cannot afford out of pocket.
In the operating room The surgical procedure to implant a kidney from a donor with hepatitis C is unchanged from a standard deceased donor kidney transplant. The Transplanting HCV-infected kidneys to page 254
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With all of these potential benefits, it is not surprising that the number of kidney transplants between HCV-infected donors and HCV-noninfected recipients has been increasing from 43 among U.S. transplant centers in 2016 to 338 in 2018.
Preoperative evaluation and perioperative management Although there is no universal eligibility criteria among transplant programs for patients to receive an HCV-positive kidney, interested patients typically undergo additional testing beyond what is normally required to be placed on a waitlist. At our transplant center, the pretransplant workup entails a comprehensive hepatic evaluation, including blood work and liver elastography. Patients who are found to have cirrhosis or other chronic liver disease are ruled out. Similarly, patients with human immunodeficiency virus or hepatitis B are not eligible.
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WOMEN’S HEALTH
Polycystic ovary syndrome Diagnosis and treatment BY AMY HAMMERS, MD
S
ome five million women of childbearing age in the United States struggle with polycystic ovary syndrome (PCOS), leading to an annual price tag of $4 billion for PCOS identification and management, as reported by the National Institutes of Health’s Office of Disease Prevention.
The most common hormone disorder among women of reproductive age, PCOS presents varying clinical and biochemical features, including hyperandrogenism and ovulatory dysfunction. With symptoms that include irregular or absent uterine bleeding, infertility, hirsutism, chronic acne, obesity, insulin resistance, and Type 2 diabetes, PCOS can particularly impact women hoping to conceive, just one of the reasons that early detection is crucial. Even women on the mild end of the spectrum of PCOS symptoms can have severe underlying metabolic changes that increase overall health risks.
Debates on overdiagnosis
Telephone Equipment Distribution (TED) Program
There has been some recent discussion in the medical community and literature that the Rotterdam Criteria—three indications of potential PCOS, described below—should be revised, because they may lead to
Given the risks of PCOS, particularly among women of reproductive age, I personally believe that each patient that presents with possible features of PCOS should receive a proper work-up of said symptoms and a thorough diagnosis. It is also important to have differential diagnoses of other potential endocrine disorders (thyroid disease, pituitary disfunction, premature ovarian failure, etc.) While there are psychological impacts on women being labeled as “sick” or having a “disease,” there is equal emotional impact on not feeling well or knowing something is “wrong” but not having an explanation. These women get labeled as obese, diabetic, or hypertensive, and are told to improve these conditions. In my opinion, this also can cause poor self-esteem and body image and can increase anxiety and depression symptoms. Once a woman gets an explanation of the underlying processes in her body causing PCOS and these symptoms, she can gain a better understanding of her health and be motivated to make the right changes to see improvements. In my experience, the proper diagnosis and treatment of PCOS can be lifechanging for women as they take ownership of their own bodies and health.
PCOS and the pregnancy journey
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overdiagnosis of the condition. Other commentators question the potential psychological impacts on young women being labeled as having a “disorder” following a possible misdiagnosis. At the same time, many of the patients I have diagnosed with PCOS were told by earlier providers that they were simply “obese” or “insulin resistant,” with no consideration of the underlying PCOS diagnosis/etiology.
JANUARY 2020 MINNESOTA PHYSICIAN
Due to its varying degrees of biochemical dysfunction, polycystic ovary syndrome can have a wide range of symptoms and associated risks, with infertility serving as one of the most recognized difficulties. Not only do the symptoms of PCOS make it more difficult to achieve pregnancy, but those who do become pregnant may face additional complications, including increased rates of spontaneous abortion in the first trimester, gestational diabetes, and pregnancy-inducted hypertensive disorders such as preeclampsia—all of which add up to increased rates of pre-term delivery in women with PCOS. Some women don’t know they have polycystic ovary syndrome until they try to conceive and struggle to get pregnant. Some patients aren’t concerned about irregular periods up until this point or don’t realize their cycles are abnormal since that has been their experience since menarche. For this reason, an annual discussion with your female patients about their menstrual cycles is essential. Cysts on the ovaries and elevated androgen hormones can prevent ovulation or make it irregular, so many women require some sort of treatment and sometimes medication to help promote regular ovulation. If pregnancy is achieved, careful monitoring of early pregnancy viability, screening for gestational diabetes, and monitoring of blood pressure are imperative. Pre-pregnancy awareness, treatment interventions, and preparation can help lead to a healthier pregnancy and delivery in women with PCOS.
Pinpointing a PCOS diagnosis
an individual over the long term. Regular exercise and healthy eating, regardless of the specific diet plan, can lower blood pressure and cholesterol levels and Beyond the clinical symptoms of PCOS, labs can indicate elevated androgen decrease the risk of diabetes and heart disease, and should be encouraged for levels in the blood, while ultrasound imaging may reveal polycystic ovaries. all women with polycystic ovary syndrome. At a new diagnosis of PCOS, I When evaluating a patient with possible PCOS, physicians should consider typically refer my patients for additional education the following three criteria; adults need two of the in this area with a dietician or functional medicine three criteria to receive a PCOS diagnosis: provider who can help guide them with individual 1. Clinical or laboratory evidence of lifestyle plans that focus on the most natural ways hyperandrogenism, which can be clinically to help improve their symptoms through dietary characterized by severe acne, hirsutism, or [PCOS is] the most common changes and the addition of appropriate vitamin/ male-pattern hair loss; hormone disorder among women nutritional supplements. of reproductive age. 2. Evidence of oligo/anovulation—irregular or In addition, combined hormonal (estrogenabsent menstrual cycles; progestin) oral contraceptives (CHCs) are the 3. Ultrasound evidence of at least one first-line medication therapy, if there are no polycystic ovary, with an ovarian volume contraindications for the patient. The Centers for greater than 10 cubic centimeters or the Disease Control and Prevention’s U.S. Medical presence of 12 or more follicles, each Eligibility Criteria for Contraceptive Use can help physicians determine measuring between two to nine millimeters in diameter. potential contraindications in certain patients. Contraceptives can help When a patient displays all three of these Rotterdam Criteria, she is patients manage hyperandrogenism symptoms while supporting menstrual determined to have “classical PCOS,” or Phenotype 1. On the other hand, regularity and contraception, if desired. Aim for a pill with at least 20 women with only two of the criteria are determined to have: mcg of ethinyl estradiol and a progestin with lower androgenicity, such as norethindrone or norgestimate. If patients continue to struggle with acne • Phenotype 2, characterized by hyperandrogenic anovulation or other hyperandrogenic symptoms after six months on that contraceptive, (criteria 1 and 2); • Phenotype 3, or ovulatory PCOS (criteria 1 and 3); • Phenotype 4, or non-hyperandrogenic PCOS (criteria 2 and 3). Regardless, all polycystic ovary syndrome symptoms can be improved with a unified treatment approach. The goals include alleviating the bothersome symptoms of hyperandrogenism, managing the underlying metabolic abnormalities to reduce the risk of cardiovascular disease/Type 2 diabetes, preventing endometrial hyperplasia, and achieving pregnancy for women wishing to conceive (or providing reliable contraception, since sporadic ovulation can lead to unplanned pregnancies). Early diagnosis can be critical to a woman’s health. Beyond infertility, other concerns include metabolic syndrome, obstructive sleep apnea, cardiovascular disease, increased risk of endometrial cancer, and other notable issues. Recent studies indicate that women with PCOS are also at increased risk for anxiety and depression. Symptoms can commonly be mistaken for other hormone abnormalities, including thyroid disorders, so it is important to discuss a woman’s full range of symptoms in addition to a physical exam, ultrasound, and lab work when polycystic ovary syndrome is a possibility.
A combination approach to treatment Typically, a combination of lifestyle changes and medications come together in a successful PCOS treatment plan to manage symptoms and prevent worsening of the outcomes of PCOS. Weight loss alone, for example, can restore regular ovulatory cycles and decrease metabolic risks, so this is often the first line and most important treatment modality, when applicable. Women who are significantly overweight have been found to resume regular menstrual cycles after losing just 5% to 10% of their body weight. While a low-carb, high-fat diet mixed with periods of intermittent fasting may be the most successful for women with PCOS, according to some studies, typically the best option is whatever is sustainable for
Polycystic ovary syndrome to page 244
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3Polycystic ovary syndrome from page 23 you can consider adding in an antiandrogen, such as spironolactone at 50–100 mg twice per day. Finally, a referral to an obstetrician/gynecologist can help to support women with polycystic ovary syndrome who are interested in becoming pregnant. Ovulation induction protocols can be effective for women hoping to conceive, including the use of letrozole, which has been shown to have higher pregnancy outcomes in women with PCOS as opposed to the previously well-used clomiphene citrate. A majority of my patients with PCOS are able to achieve successful pregnancy with oral ovulation induction protocols or continuing care with a reproductive endocrinologist for more aggressive fertility treatments, including possible in vitro fertilization, if necessary.
Research into PCOS remains ongoing While the exact cause of PCOS remains unknown, it appears to arise from a complex interaction of genetic and environmental factors. Some researchers believe it is similar to the “two-hit” hypothesis of cancer manifestation: Women with the underlying congenital predisposition for hyperandrogenic production have one “hit,” which can lead to polycystic ovary syndrome when it is combined with a second “hit” such as metabolic syndrome, obesity, or insulin resistance. Researchers continue to study specific genes that may be involved in polycystic ovary syndrome. Some recent findings focus on polymorphisms, linkages, and differential expression of gene encoding as well as other potential players in the development of PCOS, such as steroidogenic enzymes,
sex hormone-binding globulin, the androgen receptor, transcription factors, gonadotropins and gonadotropin receptors, genetic variants associated with insulin sensitivity and susceptibility to obesity, and congenital adrenal hyperplasia. However, it remains unclear how such factors are specifically related to the development of PCOS, again pointing to the combination of genetic and environmental factors that can impact a woman’s health. While polycystic ovary syndrome has traditionally been studied more extensively in adults, further clinical interest is arising in PCOS among adolescents, especially as rates of childhood obesity increase. Since a PCOS diagnosis can take years, most women are diagnosed with the syndrome in adulthood, but it is worth paying attention to the potential for polycystic ovary syndrome in your younger patients as well. Regardless of age, early and accurate diagnosis are critical to a woman’s ability to conceive later in life and her overall health. Ultimately, the silver linings to the challenge of PCOS are that we are now better than ever at diagnosing polycystic ovary syndrome and can help patients achieve greater comfort and outcomes while research into the matter is now taking place on a constant, ongoing basis. Amy Hammers, MD, sees patients at the Maple Grove location of Clinic Sofia, an OBGYN clinic known for its personalized approach to women’s health care. A graduate of Creighton University School of Medicine, she is a member of the American College of Obstetrics and Gynecology, the American Institute of Ultrasound in Medicine, and the American Medical Association.
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3Transplanting HCV-infected kidneys from page 21 of waitlisted patients will never undergo a transplant due to a shortage of donors. Transplanting kidneys from HCV-infected donors into HCVnegative recipients followed by treatment with DAAs with intent to cure is a novel strategy that can, potentially, significantly shorten a candidate’s wait time to transplant and allow more patients to receive a transplant by reducing the organ discard rate. Although the collective experience with this type of kidney Candidates who agree transplant is brief, short-term allograft outcomes to receive an HCV-infected appear good and should be considered in select kidney experience shorter transplant candidates. wait times to transplant.
kidney is placed in the right or left iliac fossa in the retroperitoneal position with anastomoses between the donor renal artery to recipient external iliac artery, donor renal vein to recipient external iliac vein, and donor ureter to recipient bladder. Either basiliximab or anti-thymocyte globulin is used for induction.
Maintenance immunosuppression is identical to kidney transplants from donors without HCV, with the notable exception that cyclosporine is contraindicated with some DAAs. The timing of DAA initiation post-transplant to treat the HCV is variable. Some transplant programs start empirically prior to the transplant, while others start once the recipient has detectable HCV viremia, and some wait until a few months post-transplant. Given that there have been case reports of severe transaminitis from fibrosing cholestatic hepatitis in kidney transplant recipients receiving an HCV-infected kidney with delayed DAA initiation, we recommend starting DAAs as soon as possible post-transplant. Treatment durations are 12 weeks with frequent monitoring of transaminases and HCV viral loads.
Conclusion
Jeffrey H. Wang, MD, is a staff nephrologist with Hennepin Healthcare. He completed his nephrology fellowship at the University of Michigan and practices at the Transplant Center at Hennepin County Medical Center in Minneapolis.
Paul A. Stahler, MD, FACS, is a transplant surgeon at Hennepin Healthcare. He graduated from the University of Minnesota Medical School and completed his general surgery residency at Hennepin Healthcare. He completed his transplant surgery fellowship at the University of Wisconsin-Madison.
Kidney transplantation is the gold standard treatment for end-stage renal disease. However, wait times are long and a significant proportion
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MEN’S HEALTH
Male infertility Considering appropriate evaluation BY AARON MILBANK, MD
T
he drive to have genetically conceived children is very strong for many couples, yet as many as 15% are not able to conceive a child, even with frequent, unprotected intercourse for a year or more. It is an unfortunate but common notion that infertility is a woman’s issue, yet according to the American Society of Reproductive Medicine, 20% of infertile couples are infertile solely due to a male infertility factor. In 30% to 40% of infertility cases, there are combined male and female factors. This means that in at least half of infertile couples, the inability to conceive is at least partially explained by male infertility. For these reasons, I believe that a female fertility evaluation should begin with a semen analysis from the partner. I often see couples who have been trying to conceive for several years, and the woman has undergone extensive testing. Sometimes, azoospermia (no sperm in the ejaculate) is not diagnosed until the man provides a specimen for an insemination. While most physicians are aware of the prevalence and significance of male factor infertility, many of our patients are not. Moreover, many men are reluctant to be tested, fearing that the results, if unfavorable, might question their masculinity.
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In Minnesota, there are only a handful of formally trained male infertility physicians. This shortage contributes to the delay in appropriate evaluation of the infertile man.
Why do we pursue a male infertility evaluation? There are four main reasons to conduct a thorough male fertility evaluation: 1. To identify significant and undiagnosed medical problems: Approximately 1% of infertile men have testicular cancers. One or two percent have endocrinologic disorders involving the hypothalamus or pituitary gland. 2. To identify risk factors for the development of significant medical problems: Some studies suggest that men with abnormal semen parameters have a higher all-cause mortality rate, making semen quality a potential health marker. Moreover, a majority of my patients have not seen a physician within the past five years. The male infertility evaluation represents a precious opportunity to identify correctable risk factors, such as obesity, diabetes, excessive drug and alcohol use, tobacco use, and environmental exposures. 3. To identify correctable male infertility factors: Studies have demonstrated that treatments for specific male factor conditions are both medically effective and cost-effective. 4. To identify uncorrectable male infertility factors and direct management toward empiric therapies: When male factor infertility cannot be altered, it is important to recognize that expeditiously and present the couple with other options. We are fortunate to partner with reproductive endocrinologists to offer options with well-established success rates.
Specific causes of male infertility Many conditions affecting male fertility can be identified and treated effectively. Common medical issues include: Varicocele. Varicoceles are the number one correctable cause of male infertility. The majority of men who have this condition repaired experience a clinically significant improvement in semen analyses and improved chances of contributing to a pregnancy. They do not hold dust, dander or pollen like carpet and are much easier to clean. They are surprisingly affordable and increase the value of your home. Properly maintained they should last 100 years. We service metro area residential and commercial projects of all sizes. We offer a wide range of wood options and custom designs for new or existing homes. We also refinish existing wood floors.
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Infection. Infections can include epididymitis, orchitis, gonorrhea, or HIV. If they result in permanent damage to the genital ducts, we can often retrieve sperm after the infection has been eliminated. Ejaculation issues. Retrograde ejaculation (semen that enters the bladder instead of emerging through the penis during orgasm) can occur as a result of diabetes, spinal injuries, medications, and surgery. Spinal cord injuries can affect ejaculation, but often sperm can be retrieved through surgical and nonsurgical means. Tumors. Cancers and benign tumors can affect hormones related to reproduction, and treatment with surgery, radiation, or chemotherapy can affect male fertility.
Undescended testicles. When one or both testicles fails to descend, decreased fertility can result.
This sperm retrieval process is called microsurgical testicle sperm extraction. It involves opening the coating over the testicle to expose the tiny tubules. Using an operating microscope that magnifies the site Hormone imbalance. Diseases of the hypothalamus, pituitary, thyroid, or 30 to 40 times, we identify the largest tubules, process microscopic adrenal glands can affect fertility. samples, and look for sperm real time. At least Genetic disorders. Klinefelter syndrome is an one andrology technician is in the operating inherited disorder in which a man is born with room with us during the procedure. In almost two X chromosomes and one Y chromosome all circumstances, this extraction is timed with instead of one X and one Y. Other karyotypic the partner’s ova retrieval, usually within 12 to abnormalities, cystic fibrosis, Kallmann syndrome Twenty percent of infertile 24 hours. Published rates for sperm retrieval (a form of hypogonadotropic hypogonadism), and couples are infertile solely range from 40% to 65%, depending upon the Kartagener syndrome (a type of primary ciliary due to a male infertility factor. patient population. dyskinesia) also can affect male fertility. Sexual factors. Anything that affects sexual intercourse can impact fertility, including the inability to maintain an erection, premature ejaculation, and painful intercourse. Medications. Certain medications can impair sperm production, such as testosterone replacement therapy, steroid use, and chemotherapy. Surgery. Surgeries that may affect fertility include hernia repairs, retroperitoneal or pelvic surgeries, and, of course, vasectomies.
Diagnostic procedures Diagnosing male infertility almost always starts with a detailed medical history and physical exam. This is followed by, ideally, two semen analyses to determine semen volume, sperm count, sperm motility, and sperm morphology. Additional specialized testing may include scrotal ultrasound, hormone testing, post-ejaculation urinalysis, specialized sperm function tests, transrectal ultrasound, and testicular biopsy. Genetic abnormalities, such as numeric and structural chromosomal variations, can lead to infertility. About 10% of men with nonobstructive azoospermia will have an abnormal karyotype and/or an abnormal Y chromosome microdeletion. It is important for patients with genetic abnormalities to undergo genetic counseling prior to assisted reproduction. There may be implications for their own health, as well as for the health of their children.
Treatment options for men with nonobstructive azoospermia Obstructive azoospermia, which accounts for about 40% of men with azoospermia, often can be repaired through surgery to bypass the obstruction. Men with non-obstructive azoospermia are either not making any sperm or making so few sperm that none make it to the ejaculate. Nonobstructive azoospermia affects about 1% of the male population. Typically, the history is unremarkable in these men. Physical examination usually, but not always, shows small testes. The semen analyses typically show normal or slightly low volume with no sperm and normal pH. A hormonal assessment generally reveals a high follicle stimulating hormone (FSH). In most cases, a diagnostic biopsy is not needed, since we can determine whether there is an obstruction or not based on the FSH and testicular examination. The next step is to obtain a karyotype and y-chromosome microdeletion test. If there is an abnormality, genetic counseling is undertaken. At this point, the couple can adopt, they can use donor sperm for intrauterine inseminations, or we can attempt to find some sperm in the testicles. If sperm are found, they are used fresh to fertilize the partner’s ova as part of the IVF process.
Other treatments for male infertility
Varicocele is the most common correctable form of male infertility. Most infertility specialists perform varicocele repair using a microsurgical subinguinal approach. This minimally invasive option has fewer adverse effects and similar efficacy compared with the older inguinal approach. For all but the most active work, a weekend off is typically adequate for recuperation. Men who are fertile but who have had a vasectomy may opt for vasectomy reversal. The use of operating microscopes and the development of extremely fine needles, sutures, and instruments enable precise Male infertility to page 284
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3Male infertility from page 27 We collaborate with a man’s primary care physician, if he has one, as well as any specialists who are treating other conditions. We also work with reproductive endocrinologists in a coordinated team approach to provide a complete list of reproductive treatment options. These options may include insemination, IVF, donor insemination, and adoption. Ultimately, only the patients can make the best decisions for their reproductive goals, The mix of options available armed with the information we provide after a to treat epilepsy has thorough assessment.
suture placement for aligning the two ends of the vas deferens or the vas deferens to the epididymis, if a more extensive bypass is needed. Urologists specializing in vasectomy reversal and incorporating these techniques typically achieve sperm in the ejaculate more than 90% of the time after a vasectomy reversal.
Medications In certain populations, we can improve the overall semen quality, most commonly the count, with medical management. This is especially true for men with low FSH and low testosterone, who frequently respond well to clomiphene citrate, or men with high estradiol levels who may respond to anastrozole.
expanded considerably.
If we find an elevated prolactin level on our initial workup, we pursue an evaluation for a pituitary adenoma and recommend medical management in collaboration with our endocrinology colleagues.
Focusing on the entire picture Some men are not proactive when it comes to their health. Because we know that low sperm counts often are associated with all-cause mortality, we focus on more than just helping a couple conceive a child. We view this as a golden opportunity for beneficial intervention, if a patient is open to it.
For many years and for many reasons, male infertility has not received much attention. As male infertility factors into at least half of all cases of infertility, we owe it to our patients to provide them with timely, guidelines-based evaluations. Once that evaluation is complete, patients should receive a full and detailed discussion regarding the risks and benefits of all reasonably possible treatment options. Treating male infertility can be challenging, but the joy of success when a couple achieves their dream makes it all worthwhile. Aaron Milbank, MD, is a urologist with Minnesota Urology, specializing in
male infertility and microsurgery.
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3The MN FEET program from page 19 communities most impacted by the results. More multi-faceted, targeted messages and messengers are still needed—especially for women who speak languages other than English and/or were not born in the United States. Community-led programs continue to be instrumental as well, and a bill passed earlier this year will help fund local outreach and awareness campaigns to reduce the use of skin lightening products. Communications with patients in clinic Many women who use [skin can bolster these efforts.
Although relatively few women overall had elevated levels, the seriousness of potential effects from mercury exposure, widespread use of products containing mercury, and increased burden in some vulnerable subgroups garner significant public health concern.
Call to action: from research to practice
MN FEET reveals an important opportunity to halt or prevent mercury exposures in pregnant women, lightening] creams are unaware And while prevention begins with awareness, an their babies, and their households. Health care of how hazardous they can be. offshoot clinic-based project is conducting routine providers can help patients understand potential urine mercury screening of all prenatal patients sources of these harmful chemicals that may at two St. Paul community clinics and offering otherwise go unnoticed. Dr. Culhane-Pera agreed: exposure reduction assistance to any women found “The MN FEET results shed light on some really to have elevated exposures. An additional project important exposure prevention information that we with a clinic that serves a large East African population is in the planning stages. as health care providers need to share with the patients, families and communities These projects will help determine the effectiveness and feasibility of this type we serve.” MDH has information sheets available in Spanish, Somali, Hmong, of screening, and will move toward integrating the issue into clinical practice, and English about both skin lightening product use and choosing fish wisely, where exposure reduction will be most effective. as well as a fact sheet for health care providers (https://tinyurl.com/mp-mdhmercury) that lists symptoms and provides recommendations for doctors about discussing skin lightening products and mercury exposure with patients. After sharing the study results with participants, the biomonitoring team disseminated the findings to partners and stakeholders before rolling out a community report and press release. Outreach is ongoing in the
“Mercury exposure can be a significant health concern, but in this case the good news is that those groups we found to be at elevated risk have the power to reduce that risk,” Minnesota Commissioner of Health Jan Malcolm said. “This study shows that we have an opportunity to help people better understand the potential dangers of using skin lightening products and frequently eating fish higher in mercury.” Get more information about the study and resources for patients at www.health.mn.gov/MNFEET. MDH would like to thank the following partners: MN FEET participants, SoLaHmo/Minnesota Community Care, HealthPartners Institute, Regions Hospital, Abbott Northwestern Hospital, St. Paul–Ramsey County Public Health, Minnesota Pollution Control Agency, EHTB Advisory Panel, East Africa Health Project, and Amira Adawe. All funding provided by the State of Minnesota. Kate Murray, MPH, is a communications planner for the environmental epidemiology unit at MDH. Her breadth of experience includes creative and technical writing, multimedia production, and community engagement. She
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THE INDEPENDENT MEDICAL BUSINESS JOURNAL
Volume XXXII, No. 05
CAR T-cell therapy Modifying cells to fight cancer BY VERONIKA BACHANOVA, MD, PHD
U
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.
Physician/employer direct contracting
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. CAR T-cell therapy to page 144
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Exploring new potential BY MICK HANNAFIN
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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.
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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
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(612) 728-8600
holds a Master of Public Health degree in Administration & Policy from the University of Minnesota.
Jessica Nelson, PhD, MPH, is Program Director and Epidemiologist with the Minnesota Biomonitoring Program at the Minnesota Department of Health. She was a Principal Investigator for MN FEET, the MDH biomonitoring study that measured mercury, lead, and cadmium in pregnant women and babies.
Courtney Jordan Baechler, MD, MS, is a board-certified internist and cardiologist who focuses on the prevention of heart disease and change that supports overall well-being. Her interest is on prevention from the bedside to the community. She is passionate about helping individuals, families, and communities to find their highest state of well-being—body, mind and spirit.
YOU’D MAKE A REALLY GOOD DOCTOR IF YOU WEREN’T BEING AN OFFICE MANAGER.
Family Medicine & Emergency Medicine Physicians • • • • •
For more information, contact TSgt James Simpkins 402-292-1815 x102 james.simpkins.1@us.af.mil or visit airforce.com
Great Opportunities
Immediate Openings Casual weekend or evening shift coverage Set your own hours Competitive rates Paid Malpractice
763-682-5906 | 763-684-0243 michelle@whitesellmedstaff.com www.whitesellmedstaff.com
©2013 Paid for by the U.S. Air Force. All rights reserved.
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:
Current opportunities include:
• Nephrologist
Internal Medicine/Family Practice
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 JANUARY 2019
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3Medical aid in dying from page 13
As public awareness grows, physicians will have a unique opportunity to engage in the conversation. Becoming educated about medical aid in dying In a 2018 Medscape poll of 5,200 physicians across 29 specialties and separating fact from fiction will prepare physicians to answer questions (https://tinyurl.com/mp-thoman03), nearly six out of 10 (58%) said that that may arise. Compassion & Choices offers peer-to-peer resources for “’physician-assisted suicide’ or ‘physician-assisted dying’ should be made physicians, including Doctors for Dignity and legal for terminally ill patients.” As a result, a Doc2Doc, which helps physicians provide growing number of national and state medical unbiased information and better care to patients societies have endorsed or adopted neutral who ask about available end-of-life options. Up To positions regarding medical aid in dying in Date provides clinical guidance in dealing with Not a single instance of order to respect and protect both members who patient requests for medical aid in dying. abuse or coercion has participate in medical aid in dying and those The grassroots movement to expand access been substantiated. who opt out. to medical aid in dying is led by terminally ill The Minnesota Medical Association created a individuals and the families of those who suffered task force to study physician aid in dying, which unnecessarily at the end of life. Their mission is to resulted in a position of conditional neutrality. empower every patient to chart their own end-ofAs long as adequate safety parameters are met, life course. the MMA will not oppose medical aid-in-dying legislation (https:// tinyurl.com/mp-thoman04). Rebecca Thoman, MD, is Doctors for Dignity Program Manager at
The growing movement in Minnesota
Compassion & Choices. She has more than 15 years of experience in
Legislation modeled after Oregon’s Death with Dignity law was first introduced in Minnesota by Sen. Chris Eaton and Rep. Mike Freiberg in 2015. Feedback from legislative hearings and regional listening sessions resulted in the current End-of-Life Option Act. In September 2019, over 120 Minnesotans packed an informational hearing in support of the End-of-Life Option Act, which is likely to be revisited during the 2020 session.
public policy and government relations, most recently in the areas of tobacco control, health care access, and gun-violence prevention. Her training is in family medicine and community health.
Carris Health
is the perfect match
Carris Health is a multi-specialty health network located in west central and southwest Minnesota and is the perfect match for healthcare providers who are looking for an exceptional practice opportunity and a high quality of life. CURRENT OPPORTUNITIES AVAILABLE FOR BE/BC PHYSICIANS IN THE FOLLOWING SPECIALTIES: • • • • • •
Anesthesiology Dermatology ENT Family Medicine Gastroenterology General Surgery
• • • • • •
Hospitalist Internal Medicine Nephrology Neurology OB/GYN Oncology
Loan repayment assistance available.
FOR MORE INFORMATION: Dr. Leah Schammel, Carris Health Physician
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JANUARY 2020 MINNESOTA PHYSICIAN
Shana Zahrbock, Physician Recruitment Shana.Zahrbock@carrishealth.com (320) 231-6353 | carrishealth.com
• • • •
Orthopedic Surgery Psychiatry Psychology Pulmonary/ Critical Care • Rheumatology • Urology
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:
SHARE YOUR INSPIRATION.
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.
Learn more at healthcare.goarmy.com/nz72
• 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 Maly at 952-883-5425 or maly.p.yang@healthpartners.com. EOE
©2018. Paid for by the United States Army. All rights reserved.
A Place To Be Your Best. Dr. Julie Benson, MN Academy Family Physician of the Year
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
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
Apply online at www.mankatoclinic.com MINNESOTA PHYSICIAN JANUARY 2019
33
3Health information “blocking” from page 11 “Front end” health information blocking occurs when the treating clinician can only electronically order tests or refer to another clinician within his/her health system. This is also referred to as “white listing.” “Back end” health information blocking is when, for example, a hospital will not allow diagnostic images from another provider into the surgical suite, despite both providers having secure, certified electronic platforms. Both types of information blocking may also be a HIPAA security issue, as more errors are made when health information is transferred manually than securely through certified EHRs (e.g., wrong fax numbers, mailing a report to the wrong address, or labeling a CD with the wrong name). Some health systems mask their true values by “accepting” health records from outside their EHR but find ways to refuse to “share” any patient information which they hold, even when the patient requests it to seek care outside of that particular health system. This is why “bidirectional” interoperability must be pursued. The patient’s information can be securely sent out of the health system and be accepted, electronically, by the health system.
One provider’s experience The Center for Diagnostic Imaging (CDI), which operates in 49 states, has a top security rating and is securely interfaced with hundreds of other health care providers. Yet, CDI still encounters health providers who have stated it is “not in our business interests” to electronically interface
with CDI, or they have provided such an obtuse, round-about electronic connection—or have stated they may possibly work on an interface with CDI in 18 months or more. Considering the intent of federal laws and what is best for the patient, all of these responses are highly unethical. If a large imaging provider like CDI has these difficulties, how can a small physician office that offers costeffective, high quality, patient-focused care have the ability to remain a resource to the community?
Summing up Public policy makers, at all levels of government, must push forward with regulatory teeth to back up their words. Purchasers/employers and commercial health plans must do likewise. This is not a solution that will be achieved without the involvement of elected officials and those managing the finances of our health care system. Secure, bi-directional interoperability of health care records is doable and pertinent. Christopher “Kit” Crancer is director of the Center for Diagnostic Imaging (CDI) and currently serves as Senior Director of State Legislative Policy. He is a registered lobbyist in a number of state capitols, including Hartford, and manages CDI’s contract lobbyists and legislative priorities. Prior to joining CDI, Mr. Crancer served as chief of staff to multiple Missouri state senators and managed one of the state’s largest political action committees.
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
2harvest.org
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JANUARY 2020 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
Insurance products issued by ProSelect® Insurance Company and Preferred Professional Insurance Company® MINNESOTA PHYSICIAN JANUARY 2020
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Sofia Lyford-Pike, MD
TRANSFORMING HEALTH & MEDICINE Leaders • Educators • Innovators
mphysicians.org