C M S Bulletin - Allegheny County Medical Society

Allegheny County Medical Society
Bulletin
May 2014
Gratitude
Gluten-free
fad diet ...
Responses to
ACEP report card
Allegheny County Medical Society
Bulletin
May 2014 / Vol. 104 No. 5
Articles
Articles
Departments
Materia Medica .................... 196 Special Report .................. 212 Activities & Accolades ....... 189
Considerations for antipsychotic use in
agitation and aggression of dementia
Nadia Kudla, PharmD
Amy Haver, PharmD, BCPS
Heather Sakely, PharmD, BCPS
Legal Summary ................... 199
Security risk assessments and HIPAA
audits: Prepare now for round 2 of the
HIPAA police
Beth Anne Jackson, Esq.
Helping to ensure your patients take
the medications you prescribe
Anne M. Jacques, PharmD
Perspectives
Calendar .............................. 189
Continuing Education ........ 189
Society News ...................... 190
• ACMS, POS member is guest
speaker at meeting
Editorial ............................... 182 • PAMED offers opioid prescription Gratitude
Deval (Reshma) Paranjpe, MD, FACS
guidelines
• ACMS members judge PRSEF
• Clinical Update in Geriatrics
Practice Management ........ 200 Editorial ............................... 183 • HELP Conference
Happiness is a warm gun
Staff recruitment and retention
• ICD-10 Workshop
Kenneth E. Hogue
Special Report ................... 203
Emergency medicine chairs
respond to ACEP report card
(bang bang, shoot shoot)
Robert H. Howland, MD
In Memoriam ....................... 192
• Henry R. Madoff, MD
Perspective ......................... 187 • John “Jack” Gaisford, MD
As they say on Avenue Q,
• Paul M. Vaughan, MD
‘The Internet is for Porn’
Special Report .................. 206 Evan Dreyer, MD
Still much to learn about asthma
Todd Green, MD
Allyson Larkin, MD
Special Report .................. 210
Gluten-free fad diet ...
David Limauro, MD
ACMS Alliance News .......... 194
Community Notes ............... 195
On the cover
French Prairie by Elias Hilal, MD
Dr. Hilal specializes in otolaryngology and head
and neck surgery.
Bulletin
Affiliated with Pennsylvania Medical Society and American Medical Association
2014
Executive Committee
and Board of Directors
President
Kevin O. Garrett
President-elect
John P. Williams
Vice President
Lawrence R. John
Secretary
David J. Deitrick
Treasurer
Robert C. Cicco
Board Chair
Amelia A. Paré
DIRECTORS
2014
Kenneth P. Cheng
William K. Johnjulio
Jan W. Madison
Donald B. Middleton
Brahma N. Sharma
2015
Vijay K. Bahl
Patricia L. Bononi
M. Sabina Daroski
Sharon L. Goldstein
Karl R. Olsen
2016
Robert W. Bragdon
Thomas B. Campbell
Douglas F. Clough
Jason J. Lamb
Adele L. Towers
PEER REVIEW BOARD
2014
Albert W. Biglan
Edward Teeple Jr.
2015
Paul W. Dishart
G. Alan Yeasted
2016
John G. Guehl
Rajiv R. Varma
PAMED DISTRICT TRUSTEE
John F. Delaney Jr.
COMMITTEES
Bylaws
Lawrence John
Communications
Amelia A. Paré
Finance
Christopher J. Daly
Nominating
Donald B. Middleton
Occupational Medicine
Teresa Silvaggio
Primary Care
Lawrence R. John
ADMINISTRATIVE STAFF
Executive Director
John G. Krah
(jkrah@acms.org)
Assistant to the Director
Dorothy S. Hostovich
(dhostovich@acms.org)
Bookkeeper
Susan L. Brown
(sbrown@acms.org)
Communications
Bulletin Managing Editor
Meagan Welling
(mwelling@acms.org)
Assistant Executive Director,
Membership/Information
Services
James D. Ireland
(jireland@acms.org)
Manager
Dianne K. Meister
(dmeister@acms.org)
Field Representative
Nadine M. Popovich
(npopovich@acms.org)
Medical Editor
Deval (Reshma) Paranjpe
(reshma_paranjpe@hotmail.com)
Associate Editors
Michael Best
(bestmw@upmc.edu)
Robert H. Howland
(howlandrh@upmc.edu))
Timothy Lesaca
(tlesaca@hotmail.com)
Scott Miller
(millers8@upmc.edu)
Gregory B. Patrick
(gpatrick@hvhs.org)
Brahma N. Sharma
(bsharma763@aol.com)
Frank Vertosick
(vertosick@acms.org)
Michael W. Weiss
(mww@tririversortho.com)
Managing Editor
Meagan K. Welling
(mwelling@acms.org)
Contributing Writer
Heather A. Sakely
(bulletin@acms.org)
ACMS ALLIANCE
President
Kathleen Reshmi
First Vice President
Patty Barnett
Second Vice President
Joyce Orr
Recording Secretary
Justina Purpura
Corresponding Secretary
Doris Delserone
Treasurer
Josephine Martinez
Assistant Treasurer
Sandra Da Costa
www.acms.org.
Leadership and Advocacy for Patients and Physicians
EDITORIAL/ADVERTISING
OFFICES: Bulletin of the Allegheny
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ALLEGHENY COUNTY
MEDICAL SOCIETY
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ISSN: 0098-3772
Editorial
Gratitude
T
he simple secret of the happiest
people is a sense of gratitude. At
least that is what the writers of most
popular articles on happiness and
fulfillment would have us believe. Is
this really possible? Could it be that the
secret to being happy in our daily lives
is that simple?
Being grateful is perhaps one of the
most difficult things to do in the midst
of calamity, catastrophe, or even just a
really bad day. When you’ve just been
diagnosed with cancer, what is there to
be grateful for? When your house has
just been consumed by fire, how can
you say “gee, thanks!” to life? When
you’ve lost a loved one, how can gratitude help comfort you?
It seems impossible. In the midst of
pain, being grateful or saying “thank
you” to the universe seems absurd. Or
is it?
We’ve all seen patients of similar
backgrounds and histories and ages
with nearly identical diagnoses. And
yet some do better than others for no
discernible reason. The family support
(or lack thereof) may be identical, as
may be the financial and insurance
status. And yet it’s often the optimists,
the patients who stop panicking long
enough to count their assets instead
of their liabilities, who seem to pull
through in the best shape.
I remember as an intern taking care
of two elderly ladies named Clara who
were hospitalized for identical and
serious diagnoses. Both were widows
who lived alone. When I rounded on
them both on the night of admission,
Clara #1 was alone, and had told her
182
Deval
(Reshma)
Paranjpe,
MD, FACS
sole visitor to go home. All she could
think of was how to handle her affairs
and was filled with a growing sense
of dread. Clara #2 was surrounded by
her granddaughters, who had brought
her fast food as a forbidden but special
treat. She was smiling and glowing.
“Even if I die tonight,” she said, “I’ll
die happy, because I’m so lucky and
grateful to have these girls.” She didn’t,
thankfully.
I just remember thinking: Each of
these women has an equal chance
of dying tonight. I know which one I’d
rather be.
Optimism, gratitude and courage go
hand in hand. As John Wayne famously said, “Courage is being scared to
death, but saddling up anyway.” No
one ever said optimism in the face of
despair was easy. Nor is it the purview of a chosen few who were born
optimists. Optimism is a choice. Bobby
Kennedy, one of America’s favorite
optimists, was fond of George Bernard
Shaw’s quote: “I dream things that
never were, and ask ‘why not?’”
Gratitude, like optimism, also is
a choice. Gratitude is more than an
action; it is a perspective and a filter
through which you can view your life.
But it requires an active, if difficult,
choice on your part. Be grateful for the
small things that make a bad situa-
tion better. Be grateful for the small
kindnesses levied on you in daily life –
either by others or by the universe. The
list of things for which you can be grateful are endless, and these things are
much more beautiful to think about than
your troubles. The absence of a ticket
in the face of an expired meter. The
sunshine, the trees, the blue sky. The
end of winter. The birds singing again.
Seeing a favorite patient again. Seeing
your patients get better. Your loved
ones being healthy, or being alive, or
having loved you if they are gone.
In closing, I think of Tom Hanks in
a pivotal scene in a charming morality
tale of a movie called “Joe Versus the
Volcano.” All his life, he has been a
hypochondriac drudge, barely alive in
a grey zombie-like existence of work.
Suddenly through circumstance, he is
now alone, starving, dying of thirst and
adrift on a makeshift raft in the middle
of the Pacific with no hope in sight. The
gigantic full moon rises over the ocean,
and in the midst of the overwhelming
beauty of the stars and the waves, he
finally grasps the meaning of it all.
“Dear God,” he says, “thank you for
my life.”
Be grateful for the opportunity to
make someone else’s day or life better
through your own acts of kindness,
and use that opportunity often. You will
through your actions inspire gratitude,
and optimism, and courage in others.
Dr. Paranjpe is an ophthalmologist
and medical editor of the ACMS Bulletin. She can be reached at reshma_
paranjpe@hotmail.com.
Bulletin / May 2014
Executive
Editorial
Committee
Happiness is a warm gun
(bang bang, shoot shoot)
I
n an interview in Rolling Stone
magazine, John Lennon said “I think
he [Beatles producer George Martin]
showed me a cover of a magazine that
said ‘Happiness Is a Warm Gun.’ It
was a gun magazine, that’s it: I read it,
thought it was a fantastic, insane thing
to say. A warm gun means that you just
shot something.”
“When I hold you in my arms
(oh yes)
When I feel my finger on your
trigger (oh yes)
I know nobody can do me no harm
Because happiness is a warm gun, momma
Happiness is a warm gun
-Yes it is.
Happiness is a warm, yes it is ...
Gun!
Well don’t ya know that happiness is
a warm gun, momma? (yeah)”
[John Lennon & Paul McCartney,
“Happiness Is a Warm Gun,” on The
Beatles (EMI Records 1968)]
It would not be very original for me
to point out the ironic fact that Lennon
was shot and killed by an assailant a
dozen years after the Beatles’ socalled White Album was recorded and
released. As a pre-teen in 1968, I have
no recollection of the release of this
record or hearing the song at the time.
I do, however, have certain memories
of the shooting deaths of Nguyen
Van Lem, Martin Luther King Jr. and
Robert F. Kennedy earlier that year.
Especially poignant to me, then and
even now, was the widely publicized
Bulletin / May 2014
Robert H.
Howland,
MD
photograph of Nguyen Van Lem with
a pistol pointed at his head, moments
before he was executed in Saigon.
That image, seared into my memory,
would later earn a Pulitzer Prize for the
photographer, Eddie Adams.
My first memorable experience
involving the White Album came a few
years later as a teenager. A friend’s
older brother had a copy of the record.
We had heard a rumor that you could
hear something creepy by listening to
the song “Revolution 9” backwards. I
would not have believed this rumor if
I hadn’t listened to the music myself.
The phrase “number nine” is spoken
by Lennon sporadically and repeatedly
throughout this song. On my friend’s
turntable, we were able to manually
rotate the record in reverse and play
the song backwards. Sure enough,
“number nine” was clearly heard as
“turn me on, dead man” when the song
was played backwards. Lennon was
very much alive at the time. Years after
his death, you can still listen to this
audio recording, forwards and backwards, on the Internet, with Lennon’s
unforgettable voice saying “turn me on,
dead man.”
Looking back, I think I first realized on the day I learned that Lennon
Looking back, I think I first
realized on the day I learned
that Lennon had been
murdered that a gun, in an
instant, could bring an end
to happiness ...
had been murdered that a gun, in an
instant, could bring an end to happiness and make many more people
unhappy. I was in college at the time,
studying late into the night, when I
heard the shocking news on the radio.
That same night Howard Cosell announced on Monday night football: “…
John Lennon, outside of his apartment
building on the West Side of New York
City, the most famous, perhaps, of all
of the Beatles, shot twice in the back,
rushed to Roosevelt Hospital, dead on
arrival ...” Like Lennon’s haunting audio
recording, the video of Cosell’s sadly
dramatic announcement can be found
on the Internet.
In the prologue to his memoir, “My
Losing Season,” Pat Conroy writes:
“On October 2, 1993, I read that Dickie
Jones, a flashy point guard for the ‘Blitz
Kids,’ the best team in Citadel history,
had put a bullet in his brain while seated on a park bench in Mount Pleasant,
a suburb of Charleston.” Reading this
passage prompted a memory for me of
a long-ago event that occurred more
than 6 years before Dickie’s death.
Continued on Page 184
183
Editorial
From Page 183
During the first month of my first rotation as a resident in psychiatry, I vividly
remember the day that I learned that
the state treasurer of Pennsylvania, R.
Budd Dwyer, during a news conference
in Harrisburg, had pulled a revolver
from a manila envelope and put it in his
mouth and shot himself dead.
Taped footage of Dwyer’s self-inflicted gunshot was only later broadcast
on television, unlike the case of the
television news reporter, Christine
Chubbuck, who shot herself during a
live morning television broadcast in
1974 and died later that day. Moments
before pulling out her gun, Chubbuck
had said “In keeping with Channel
40’s policy of bringing you the latest in
blood and guts, and in living color, you
are going to see another first – attempted suicide.” Dwyer’s tragic video
can still be found on the Internet; the
tape of Chubbuck’s telecast was never
shown again.
All of these memories were brought
to mind recently when I saw someone
who had just survived a self-inflicted
gunshot wound to the face. As luck
would have it, or perhaps because of
poor aim, the bullet entered under the
chin, passed through the base of the
tongue and up through the hard palate,
and exited just lateral to the left nares.
I was amazed. Unlike Dickie, the bullet
missed the brain. Even when guns are
involved, it seems, some people may
live just as many will die.
Conroy wrote, “Dickie Jones, a
man who seemed to have everything
going for him and no acquaintance with
darkness or calamity, killed himself
and changed the history of his family
forever.”
Guns do change history, not only of
families, but also in the lives of each
of us, directly or indirectly, whether we
realize it or not.
Dr. Howland is a psychiatrist and
associate editor of the ACMS Bulletin.
He can be reached howlandrh@upmc.
edu.
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184
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Pittsburgh, PA 15222
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Bulletin / May 2014
Welcoming
George Michel Eid, MD
General & Bariatric Surgeon
Dr. Eid, nationally known for his work in pursuing new, minimally invasive
technologies in the fight against obesity, has joined Allegheny Health
Network as Division Director of Minimally Invasive Surgery and Division
Chief of Bariatric Surgery.
He specializes in minimally invasive general surgical techniques and is
renowned for introducing and evaluating new techniques and modalities
for minimally invasive and robotic surgery, with particular expertise in
bariatric (weight-loss) surgery and dedication to patient care.
For an appointment
please call
George Michel Eid, MD
138 Gallery Drive
McMurray, PA 15317
412.359.5000
In addition to bariatric surgery, he also specializes in laparoscopic hernia
repair, including sports hernias, the surgical treatment of gastrointestinal
disorders, including laparoscopic colon and gastric resection, adrenalectomy,
pancreatectomy, splenectomy and laparoscopic anti-reflux surgery.
Dr. Eid received his medical training at the American University of Beirut
and completed a general surgery internship and residency at the University
of Iowa. He also completed a minimally invasive surgical fellowship at
the University of Pittsburgh. He is board-certified by the American Board
of Surgery.
Dr. Eid is on staff at Canonsburg and Saint Vincent hospitals and is
accepting patients 15 years and older. Please call for an appointment.
As always, new patients are welcome. Most major insurances are accepted.
Bulletin / May 2014
185
2015 Board and Delegate Nominations
A Candidate for the ACMS Board of Directors:
• Represents physicians on issues impacting the practice of medicine and makes policy decisions for the medical society.
• Meets four times per year, special meetings as needed.
[Please print name] I am interested in the Board of Directors
(Phone)
A Candidate for the ACMS Delegation to the PAMED:
• Represents physicians of Allegheny County in creating statewide policy on issues impacting physicians, patients and the practice of medicine.
• Meets as necessary prior to attending House of Delegates in October in Hershey, PA.
(Please print name) I am interested in the ACMS Delegation
(Phone)
I would like to recommend the following individual(s) [Please print]
for
Board
Delegate
for
Board
Delegate
Please FAX completed form to (412) 321-5323 by Wednesday, June 11.
Thank you for your membership in the
Allegheny County Medical Society
The ACMS Membership Committee
appreciates your support. Your
membership strengthens the society
and helps protect our patients.
Please make your medical society stronger by encouraging your colleagues to
become members of the ACMS. For information, call the membership department at (412) 321-5030, ext. 110, or email membership@acms.org.
186
Bulletin / May 2014
Perspective
As they say on Avenue Q,
‘The Internet is for Porn’
The Internet is for shopping, banking and wasting time – not for medical info
A
s the United States and the global
economy move further into the
digital age, the impact of the Internet
becomes ever more pervasive. Like
all the members of my family, I am a
card-carrying member of a pluggedin generation. I rarely go even a few
hours without consulting the Net.
Although it clearly has a detrimental effect on my attention span, the Internet
is a powerful and useful tool for many
of my endeavors. Imagine trying to find
Steelers tickets without Stubhub or
Ticketmaster. The Internet also has had a profound effect on my practice as an ophthalmic surgeon in Allegheny County.
I read the relevant literature online (I
no longer subscribe to any hard copy
journals). If anything, online access
has made it easier for me to remain
current in my field. It is a far cry from
the time when I would search Index
Medicus and then wade through dozens of articles to hopefully find relevant
ones for a problem at hand. Although
my Boolean search strategies are not
foolproof, PubMed wins hands down
over hours in the stacks. The Internet is substantially more
problematic when individuals use it
to garner “facts” about their health.
Internet information, of any stripe, is
frequently unreliable. Legitimate news
outlets have been fooled into broadcasting stories that were originally
Bulletin / May 2014
Evan
Dreyer,
MD
written as satire by the Onion. Although
it is quite some time since Dewey’s
presidential victory over Truman was
reported in the Chicago Daily Tribune,
it seems that the only change is that
more misinformation is disseminated
even more rapidly. Medical information from the Internet is furthermore,
by its very nature, isolated and out of
context. When I read about a new approach to the management of cataract,
that is through the lens of 25+ years
experience; the context with which I
can (hopefully) judge the reliability of
such information.
A report of eye drops to relieve
cataracts is (to me) obvious snake oil
(at least in 2013). But, were I to review
new interventions for primary biliary
cirrhosis, I would have no faith in my
ability to intelligently compare two
websites. Patients often have difficulty
accepting the limitations of Internet
accuracy. Think of how many people
have been fooled into disgorging funds
for either the Nigerian bank scam, or
the “FBI has seized your computer”
virus. As a patient, one’s judgment
is no better and may even be worse
(because of fear) when searching for
medical help. Patients might easily
panic that they will become the “poster
child” for whatever disease is under
discussion. If one diagnoses a young female
with optic neuritis, and does not at
least allude to multiple sclerosis, the
problems are obvious. After her quick
Google search, she may be lost to
another practitioner, and perhaps to
medical care altogether. Such a patient, unless one carefully cautions her
about the unreliability of the Internet,
will be convinced that her next steps
will be her last, and she is doomed to
a wheelchair existence before an early
death. I therefore take a proactive approach in dissuading patients from Internet guidance. I frequently share the
following story. My brilliant daughter (of
course; she’s my daughter) has a black
belt in online shopping, and can find
designer bargains that escape even
Google searches. In eighth grade, she
was asked to investigate a disease of
her choice, online.
For her research topic, she picked
glaucoma; I was not involved in the
process. She scored somewhere in the
high 90s, if not 100 on the assignment,
and only then was I allowed to take a
look. The results were laughable. She
even quoted one site that offered a
Continued on Page 188
187
Perspective
From Page 187
vitamin cure for glaucoma. My patients
are no better off; websites don’t come
with a grade, or a reliability score (of
course, neither do physicians, as a
rule). I have found over the years that
more and more of my patients (young
and old) are turning to the Net to compare diagnostic tools and therapies.
I generally comment that I am more
than willing to discuss various options
with them, but that no one should go
online for other opinions. I am never
offended by patients seeking a second
opinion from other practitioners, and
often suggest that as far preferable to
Internet searching. I also do not offer
brochures from either drug companies
or the Academies in my office; I would
prefer not to defend medical advice
from something I have not written. The downside (if there is one) is that
I have to be willing to discuss options
with any and all (which frequently
includes family members). With more
and more patients each year, I find
that the Internet has become a major
source of inaccurate information. In
my opinion, the time I invest in trying
to prevent my patients from being
exposed to pseudo-medicine is much
less than the time I would spend in
debunking bad Internet information.
I also offer my patients reprints of
one or two articles (citations at right)
that argue effectively that the Internet is
no substitute for informed discussions
with one or more competent practitioners.
Although I sincerely endorse
patients taking an active role in their
medical decisions, it cannot be done
with guidance from the Internet.
Dr. Dreyer is director of Glaucoma
Services at Glaucoma-Cataract Consultants Inc., in Pittsburgh. He can be
reached at eye@fastmail.fm.
References
BMJ. 2000 July 15; 321(7254): 136
Health information on internet is often
unreliable
http://www.news-medical.net/
news/20100325/Internet-cannot-substitute-for-professional-medical-advice.aspx
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188
Bulletin / May 2014
Activities & Accolades
PAMED president appointed
to head joint venture
Bruce MacLeod,
MD, Pennsylvania
Medical Society
(PAMED) president
and chair of the department of emergency medicine at West
Dr. MacLeod
Penn Hospital, has
been appointed president of Allegheny
Health Network Medicine Management
LLC, which will focus exclusively on
enhancing and coordinating emergency patient care in the Western Pennsylvania region.
Effective April 1, Allegheny Health
Network and Emergency Medicine
Physicians (EMP) joined together to
manage the emergency departments
of eight hospitals in Western Pennsylvania.
Dr. MacLeod quoted in article
Dr. MacLeod was quoted in several
newspapers recently, giving his opinion
in an article, “OP-ED: Corbett plan
addresses health, not just insurance.”
Dr. MacLeod commented on Gov.
Tom Corbett’s Healthy Pennsylvania
Initiative regarding the impending
shortage of doctors.
“We can’t just turn a spigot and
suddenly we’re going to have a bunch
more primary physicians pop out. It
doesn’t work that fast.”
Medical society president
co-authors article
Kevin O. Garrett,
MD, FACS, president
of Allegheny County Medical Society
(ACMS) co-authored
an article in the Bulletin of the American
Dr. Garrett
College of Surgeons
called, “The aging surgeon: When is it
time to leave practice?”
The piece was part of a series of
excerpts from the book “Being Well
and Staying Competent: Challenges
for the Surgeon.” Members of the ACS
can access the complete document at
www.efacs.org.
Calendar
May is:
• Global Employee Health and Fitness Month
• Healthy Vision Month
• Melanoma/Skin Cancer Detection and Prevention Month®
• Mental Health Month
• National Celiac Disease
Awareness Month
• National High Blood Pressure Education Month
• Preeclampsia Awareness Month
• ALS Awareness Month
Bulletin / May 2014
• Asthma Awareness Month
• Ultraviolet Awareness Month
• National Toxic Encephalopathy and Chemical Injury Awareness Month
• 5-11: North American Occupational Safety and Health Week
• 12-18: Food Allergy Awareness Week
• 13-19: National Alcohol- and
Other Drug-Related Birth Defects Awareness Week
• 24: Heat Safety Awareness Day
Ophthalmologist finalist for
Most Outstanding Volunteer
Evan L. “Jake”
Waxman, MD, was a
recipient of the Jefferson Award, as noted in
the January Bulletin,
page 22.
Dr. Waxman also
Dr. Waxman
was chosen as one
of six finalists for Most Outstanding
Volunteer, selected from 50 local
Jefferson Award winners. He was honored at an award ceremony at Heinz
Field May 6, where the winners were
announced.
Two fourth-graders from O’Hara Elementary, Griffin Kerstetter, 10, of Fox
Chapel, and Annie Yonas, 9, of O’Hara,
were chosen as Most Outstanding
Volunteers for creating the Home Lost
Project, which turns T-shirts into blankets for the homeless. The winners will
serve as area representatives at the
national Jefferson Awards ceremony in
Washington, D.C., this summer.
Continuing
Education
Free Online CME Activities. Sponsor: Pennsylvania Medical Society. All
meet patient safety and risk management requirements. For information,
visit www.pamedsoc.org/mainmenucategories/cme/cme-activities.
HIV/AIDS Trainings. Sponsor:
Pennsylvania/MidAtlantic AIDS Education and Training Center, various
locations. Visit www.pamaaetc.org.
189
Society News
ACMS, POS member
is guest speaker at meeting
Thierry Verstraeten, MD, was
the guest speaker at
the Cleveland Ophthalmology Society
meeting held Feb.
11 at the DoubleTree
hotel in Cleveland and Dr. Verstraeten
was presented with a
certificate of appreciation.
He spoke twice, presenting: “When
to Call Your (Retina) Friend! (Management of Lens complications and
Edophthalmitis),” and “The Plasmin
Story: The First Biologic Treatment of
Vitreomacular Adhesion.”
PAMED offers opioid
prescription guidelines
The Pennsylvania Medical Society
(PAMED) has pads available for physicians that provide guidelines for opioid
prescriptions. The pads can be ordered
at http://www.pamedsoc.org/store/
Products/Opioid-Prescription-Guidelines__14250-15.aspx.
The cost for 5 pads of 25 is $4.95
for society members and $19.95 for
nonmembers. An example of the pad
can be seen at right.
ACMS members serve
as judges for PRSEF
The 2014 Pittsburgh Regional
Science & Engineering Fair was held
March 28. Allegheny County Medical
Society (ACMS) members Maryann
Miknevich, MD, Ellen Mustovic, MD,
and Amelia A. Paré, MD, FACS, served
as judges for the fair.
The first-place winner was Vibha
Reddy, a sophomore at North Allegheny High School, with a project called
190
Dorothy Hostovich / Assistant to ACMS Executive Director
From left are Amelia Paré, MD, FACS, Maryann Miknevich, MD, first-place
winner Vibha Reddy and Ellen Mustovic, MD, at the Pittsburgh Regional Science & Engineering Fair March 28.
“Preventing Vision Loss after Ocular
Trauma Using ECM Technology.”
The second-place winner was Sruthi
Muluk, a junior at the Ellis School,
with the project of “Prediction of Aortic
Aneurysm Rupture.”
High attendance for Clinical
Update and HELP conference
More than 400 geriatrics professionals from all disciplines, including physicians, nurses, pharmacists, physician
assistants, social workers, long-term
care and managed care providers, and
health care administrators participated
in the 22nd Annual Clinical Update in
Geriatric Medicine conference held
at the Pittsburgh Marriott City Center
Hotel March 27-29.
Previously awarded the American
Geriatrics Society Achievement Award
for Excellence in a CME program, this
conference continues to be a well-respected resource to educate those
involved in the direct care of the elderly
by providing evidence-based solutions
for common medical problems that
afflict older adults.
Under the leadership of course
directors Drs. Shuja Hassan, Judith S.
Black and Neil M. Resnick, the course
is a premier educational event in the
region, while attracting prominent
international and national lecturers and
nationally renowned local faculty. This
year’s guest faculty included: Sally
Brooks, MD; Daniel Foreman, MD;
Corita Grudzen, MD, MSHS, FACEP;
Sharon Inouye, MD, MPH; and Barbara
Messinger-Rapport, MD, PhD, FACP,
CMD.
During the 3-day session, audience
Bulletin / May 2014
Society News
members had the opportunity to attend
key plenary sessions, 40 state-of-theart breakout sessions, and featured
“Ask the Physician” sessions. This
year’s “Ask the Physician” sessions
allowed participants to pose specific
clinical management questions to
experts in geriatric gastroenterology, pain medicine, dermatology and
radiology. One of the many highlights
of the conference was a symposium on
Geriatric Neurology and Psychiatry and
included lectures on Assessment of
Capacity/Decision Making, Anxiety and
Depression, and Non-Pharmacologic
Treatment of Dementia and Delirium.
The conference is jointly sponsored
by the Pennsylvania Geriatrics Society
– Western Division; the Aging Institute
of UPMC Senior Services; and University of Pittsburgh, in partnership with
UPMC and the University of Pittsburgh
School of Medicine Center for Continuing Education in the Health Sciences.
Members of the Pennsylvania Geriatrics Society – Western Division receive
a discount when registering for the
conference. To inquire about becoming
a member, contact Nadine Popovich
at (412) 321-5035, ext. 110, or visit the
society website at www.pagswd.org.
Photos provided
Above, from left, Pennsylvania Geriatrics Society – Western Division President Fred Rubin, MD; course directors Shuja Hassan, MD, and Neil Resnick,
MD; guest speaker Sharon Inouye, MD; and Secretary-Treasurer and course
director Judith Black, MD, are shown with David C. Martin awardee Mr. Eduardo Nunez. Not pictured are award recipients Ms. Gabrielle Langmann and
Ms. Adi Shafin. Below, course directors Dr. Rubin and Dr. Inouye, flanking the
sign, are pictured with attendees of the 2014 HELP Conference.
12th Annual HELP Conference
The 12th annual international Hospital Elder Life Program (HELP) was held
in Pittsburgh March 27-28 in conjunction with the Clinical Update in Geriatric
Medicine. This two-day conference is
designed to educate HELP teams regarding strategies for delirium prevention, and using HELP as a way to improve hospital-wide care of the elderly
and create a climate of change. Expert
clinicians and seasoned members of
the HELP sites shared evidence-based
Continued on Page 192
Bulletin / May 2014
191
In Memoriam
Henry R. Madoff, MD, 89, of Pittsburgh, died Friday, April 11, 2014.
Dr. Madoff graduated in medicine from New York University; served his
internship at Boston City Hospital; and served his residency at Boston City
Hospital as well as the New York VA. He specialized in thoracic and cardiovascular surgery.
Dr. Madoff was a veteran of the U.S. Army.
He is survived by his wife, Judy Madoff; daughter KarenLin Madoff; motherin-law Mary Waskowicz; brother-in-law Robert (Patience) Waskowicz; as well
as many nieces, nephews, great-nieces and great-nephews.
Services and interment were private.
***
John “Jack” Gaisford, MD, 98, of Pittsburgh, died Sunday, April 13, 2014.
Dr. Gaisford graduated in medicine from Georgetown University and served
his residency at the Pittsburgh Medical Center.
He was a veteran of the U.S. Army, serving as a surgeon in the Pacific
Theater when the atomic bombs were dropped on Japan. He stayed behind
for months to treat burned victims of the blasts.
Dr. Gaisford founded the West Penn Burn Center in 1969, after becoming
renowned for his proficiency at treating burns and removing head and neck
tumors.
His wife, Frances Jacobs Gaisford, is deceased.
Dr. Gaisford is survived by children Linda Tedder (Mike), Cindy Close
(Chuck) and Carolyn Imbriglia (Joe); six grandchildren; and three great-grandchildren.
Services were held at John A. Freygovel Sons Inc.
***
Paul M. Vaughan, MD, 63, of Pittsburgh, died Wednesday, April 16, 2014.
Dr. Vaughan graduated in medicine from Temple University and served his
internship and residency at Pennsylvania Hospital in Philadelphia. He specialized in emergency medicine.
At the time of his death, Dr. Vaughan was serving as the medical director at
U.S. Steel Corp.
Dr. Vaughan is survived by his wife, Kathryn Krahe Vaughan; daughter
Jessica (Christopher) Marra; grandson Everett; son Matthew Vaughan; father
Douglas (Ann) Vaughan; and brother Douglas “Toby” Vaughan.
Also surviving are many brothers- and sisters-in-law and nieces and nephews through marriage.
Services and burial were private. Family and friends were received April 21,
2014, at Mark Pi’s (China Gate) Restaurant, Mt. Lebanon.
192
Society News
From Page 191
information and their clinical insights on
selected topics regarding the influence
of HELP, dementia disorders, and
addressing diversity and cross cultural
issues in HELP. More than 90 registrants were on-hand with international
participants from Canada, Germany,
Ghana and Japan. The program also
attracted attendees representing 19
states including California, Florida,
Texas and Utah.
Serving as course directors were
Fred Rubin, MD; chair, Department of
Medicine, UPMC Shadyside, professor
of medicine, University of Pittsburgh
School of Medicine, and president of
the Pennsylvania Geriatrics Society
– Western Division; Sharon Inouye,
MD, MPH; professor of medicine Beth
Israel, Deaconess Medical Center,
Harvard Medical School; Milton and
Shirley F. Levy Family Chair; director,
Aging Brain Center, Institute for Aging
Research, Hebrew SeniorLife; and
Sarah Dowal, MSW, MPH, of The
Aging Brain Center Institute for Aging
Research Hebrew SeniorLife, served
as program coordinator.
This innovative model program,
designed by Dr. Inouye, improves the
hospital experience for older patients
by helping them maintain their cognitive and functional abilities; maximizing independence at discharge;
assisting with the transition to the
home; and preventing unplanned
readmission.
Through HELP, the hospital becomes a place where older patients
can feel secure as they participate in
their course of treatment and maintain
some control over their own recuperation. Hospitals around the world have
implemented the program, and HELP
has received extensive coverage in
Bulletin / May 2014
Society News
medical journals and mainstream
media. For more information on HELP
and delirium, or to learn how to become a HELP site, visit www.hospitalelderlifeprogram.com.
ICD-10 workshop draws crowd
ACMS was abuzz with activity
March 26 as 85 attendees were on
hand for an ICD-10 Workshop. The Kell
Group provided generous sponsorship
for the dynamic session.
The workshop, a collaborative
partnership with PAMED, CMS and
PMSCO Healthcare Consulting, included comprehensive code set training
with an in-depth look at ICD-10-CMED
guidelines and conventions, as well
as hands-on coding. Participants were
awarded 4 CEU’s for participating in
this activity.
Although the implementation of
ICD-10 has been delayed until Oct. 1,
2015, the session provided attendees
with a solid foundation with which to
apply the skills learned and to continue
to build an ICD-10 educational strategy
that meets the needs of the individual’s
practice.
Lara Brooks, associate director,
Practice Economics, and PMSCO
staff members Linda Benner, senior
consultant, and Tracey Glenn, director
of Practice Management Consulting,
provided their vast expertise and
knowledge in providing an exceptional
session.
Highlights of the program included
a complete review of the ICD-10-CM
guidelines and conventions, nuances
found in the new coding system and
coding tips, and comprehensive coding exercise with practical real-world
case scenarios which were designed
to demonstrate proficiency in ICD-10CM.
Bulletin / May 2014
Meagan Welling / Bulletin Managing Editor
Above, from left, are ICD-10 workshop speakers Tracey Glenn, director of
Practice Management Consulting for PMSCO; Lara Brooks, associate director of Practice Economics with PAMED; and Linda Benner, senior consultant
at PMSCO.
Nadine Popovich / Membership Services Assistant
The ICD-10 Workshop drew 85 attendees to ACMS March 26.
PAMED staff is available to answer questions and provide refresher
exercises that will keep your ICD-10
skills sharp. ACMS will offer ongoing
educational sessions as the ICD-10
implementation date approaches.
193
Alliance News
Pride and joy in
the Kunkel family
Jonathan Kunkel, youngest son
of the late William Kunkel, MD, and
our own Rose Kunkel, was the guest
of honor at the Dauphin County Bar
Association President’s Gala held Saturday, February 8, 2014, at the West
Shore Country Club in Harrisburg. The
Gala celebrated Jonathan’s term as the
President of the Association, which is
the fourth largest county Bar Association in Pennsylvania.
Pictured at the Gala, from left, is
honoree Jonathan W. Kunkel, Esq.,
an attorney with the Governor’s Office
of General Counsel assigned to the
Pennsylvania Department of Corrections; Jonathan Kunkel’s brother,
James V. Kunkel, MD, an anesthesiologist at UMPC Passavant Hospital;
second from right is sister Carolyn
Kunkel Saybel, a retired Pittsburgh City
School teacher; and far right is brother
William H. Kunkel, Jr., a Casino Compliance agent with the Pennsylvania
Gaming Control Board.
Centered in the photo and central
to the Kunkel family is matriarch Rose
Kunkel, three times Allegheny County
Medical Society Alliance (ACMSA)
president and currently serving as
adviser to ACMSA. Now known as
Mrs. Rose Kunkel Roarty, she and her
husband, Joseph Roarty, Ph.D., continue to vitalize the ACMSA with their
time, attention and support in ways too
many to count! Indeed, we congratulate Rose, the late Dr. Bill and Kunkel
family and too, we acknowledge with
gratitude Rose and Joe for who they
are and for all they do to enhance our
Alliance!
Kick-off for Alliance year 2015
The Kick-off for Alliance year 2015
194
Content
and text by
Kathleen
Jennings Reshmi
Photo provided by
Mrs. Rose Kunkel
Roarty
LXXXX will be held Tuesday, June 24,
at 10:30 am, at Panera’s at the Galleria, Mt. Lebanon. For Alliance information, call (412) 321-5030.
Join us … get to know us! ACMS
member physician spouses are welcome; we will mentor you into Alliance
for leadership, or on committees for
fundraising events or community service projects. Plans for the coming year
are being finalized. Your participation at
any level will be warmly welcomed.
2013 ACMSA 2014 year-end
gifting (Res Ipsa Loquitur)
ACMSA DONATIONS (Includes
a contribution of Designated Use
proceeds from General Meeting,
September 24, 2013):
• Brother’s Brother Foundation Hurricane
Sandy Relief, USA (Autumn 2013)
• Brother’s Brother Foundation Super
Typhoon Haiyan Relief, Philippine, Pacific Rim
(Winter 2014)
• Carnegie Science Center, Scholarship:
Pittsburgh Regional Science and Engineering
Fair (March 28, 2014)
• PMSA Convention Direct Giving AMES
Fund (October 2013)
• PMSA Confluence Direct Giving AMES
Fund (April 2014)
ACMS Foundation: Proceeds
from General Meetings of ACMSA
• Holiday Champagne Brunch Edgewood
Country Club (December 1, 2013)
• Annual Meeting and Luncheon, Avanti
Award, Pittsburgh Athletic Association (May 20,
2013)
ACMS Foundation:
Direct giving from ACMSA
• National Doctor’s Day (March 31, 2014)
• President’s Prerogative (May 13, 2014)
2013 GRAND TOTAL 2014
DISTRIBUTIONS: $4,500
The custom and tradition
of ACMSA
Traditional beneficiaries include, but
are not limited to:
• Carnegie Science Center; CCAC;
Henry the Hand Foundation; Operation
Safety Net; Project Bundle-Up; University of Pittsburgh School of Medicine;
AMAA; Pennsylvania Medical Society (PAMED) Alliance AMES Fund;
PAMED Foundation; ACMS Foundation; shelters for women and children;
and disaster relief-direct giving.
Selection decisions are determined
by the ACMSA Governing Board as described in by-laws of the organization.
Thanks to ACMSA leadership, general
membership, family, guests and to the
community for interest in and support
of the Alliance.
Bulletin / May 2014
Community Notes
ASK Campaign seeks support
The Allegheny County Medical
Society supports the Center to Prevent Youth Violence’s Asking Saves
Kids (ASK) Campaign. Support of the
ASK Campaign is critically important
because of physicians’ connection to
parents.
The ASK Campaign is a public awareness campaign to inspire
life-saving conversations between parents to prevent gun injuries. The Campaign encourages parents to ask one
simple question: “Is there an unlocked
gun in your house?” when arranging
playdates and visits to others’ homes.
National ASK Day is Saturday,
June 21. The campaign will be run-
ning TV, radio and print public service
announcements (PSAs) across Allegheny County. The PSAs focus on
conversations between parents, with
the take-home line, “Parenting requires
awkward conversations. But one could
save a child’s life: ‘Is there an unlocked
gun in your house?’”
Physicians are encouraged to participate in National ASK Day.
• The campaign can provide brochures for your patients.
• The campaign can provide ASK
posters for your offices.
• Physicians can participate in the
Campaign’s Facebook page (facebook.
com/askingsaveskids) by liking it, sharing it and posting content.
• Physicians can post information to
websites they manage.
• Visit the ASK Campaign website
(www.askingsaveskids.org).
Finally, if you are a parent yourself,
challenge yourself to start asking if
there is an unlocked gun where your
child plays when you arrange playdates and other visits.
VUJEVICH DERMATOLOGY ASSOCIATES
IS PLEASED TO ANNOUNCE THE ADDITION TO OUR PRACTICE OF
DR. DIANE INSERRA
Dr. Diane Inserra earned her Doctor of Medicine degree from Rutgers
New Jersey Medical School. She completed her internship in internal medicine
at Cornell University, training at Memorial Sloan Kettering Cancer Center and
New York Hospital. Dr. Inserra returned to Western Pennsylvania to complete
her dermatology residency at the University of Pittsburgh Medical Center.
Dr. Inserra is board-certified by the American Board of Dermatology.
For 24 years, Dr. Inserra has built her reputation as one of Pittsburgh’s
most respected dermatologists. She specializes in medical dermatology,
dermatological surgery and cosmetic dermatology.
For an appointment please call:
Vujevich Dermatology Associates
100 North Wren Drive, Pittsburgh, PA 15243
95 West Beau Street, Washington, PA 15301
412-429-2570 / www.vucare.com
Bulletin / May 2014
195
Materia Medica
Considerations for antipsychotic use
in agitation and aggression of dementia
Nadia Kudla, PharmD
Amy Haver, PharmD, BCPS
Heather Sakely, PharmD, BCPS
T
he medical management of patients with dementia often
involves minimizing behavioral issues precipitated by
the disease, also known as behavioral and psychological
symptoms of dementia (BPSD) or neuropsychiatric symptoms. Over the course of the disease, these symptoms can
progress and negatively impact the patient’s quality of life as
well as that of the caregiver. During a 5-year period, more
than 90 percent of patients with dementia will develop at
least one BPSD, and it is often the development of BPSD
that precipitates a patient’s transfer from living at home or
with family to institutional care.1
There are a variety of syndromes associated with BPSD,
the most common being agitation, psychosis and mood
disorders.1 Agitation, along with aggression, are estimated
to be seen in up to 80 percent of patients with Alzheimer’s
dementia.2 The definition of agitation is not clearly defined;
the behavioral disturbances in dementia often are termed
agitation, and the term is often applied to a heterogeneous
group of patient actions.3 Generally, agitation encompasses broad increases in verbal and motor activity, including
restlessness, anxiety and tension.4 Aggression includes
cursing, threats and destructive behavior toward objects or
people.4
A thorough assessment is necessary to evaluate the
need to treat, the duration of treatment and the effect of
treatment on behavior.3 Scales are useful not only to assess
improvement in agitated or aggressive behaviors, but also
for changes in cognitive function, sedation and quality of
life.3
There are several scales that aid in assessing BPSD,
monitoring progress and adverse effects with treatment. The
Neuropsychiatric Inventory (NPI) assesses the frequency,
severity and distress of the behavior, which aides in determination of treatment necessity.5 The Cohen-Mansfield
196
Agitation Inventory (CMAI) is a one-page assessment that
systematically evaluates the frequency of a range of behaviors, including hitting, pushing, making sexual advances, disrobing, aimless wandering and hiding things.6 The
Behavior Pathology in Alzheimer’s Disease Rating Scale
(BEHAVE-AD) uses 25 items and a 4-point scale of increasing severity to assess seven different groups of behavior:
paranoid/delusional ideation; aggressiveness; hallucinations; activity symptoms; diurnal rhythm symptoms; affective
symptoms; and anxieties and phobias. The aggressiveness
subscale score assesses an additional three symptoms: verbal outbursts, physical threats or violence, or both, and other
kinds of agitation like wandering and thrashing.7 These tools
are effective in both gauging the severity of the behavior, as
well as tracking quantitative improvement.
The decision to treat a behavior is a careful balance of
severity and frequency of symptoms and the benefits and
adverse effects of medication. The specific scale used to
monitor patients is not as important, as long as there is
consistency in assessment. If BPSD is not addressed and
properly monitored, a patient’s quality of life can be impacted and functional decline may progress.8
When treatment is warranted, based on the patient
putting himself or others in danger or if the behavior causes
the patient persistent distress, significant decline in function, difficulty receiving needed care, or to be inconsolable,
antipsychotics are preferentially used, despite lack of FDA
approval for treatment of BPSD and risks associated with
adverse effects.7, 9, 10 Choosing an antipsychotic for specific treatment of agitation is guided by limited research in
patients with dementia. Atypical antipsychotics are usually
chosen as they are associated with less extrapyramidal side
effects (EPS) and tardive dyskinesias in dementia patients.9
Before initiating drug therapy, however, non-pharmacologic
approaches should be exhausted and conversations about
the benefits and risks of treatment should take place with the
patient’s family. Topics to discuss include the serious risks of
increased cerebrovascular events and mortality with the use
of these agents.9 Tailoring a discussion to encourage shared
decision making will ensure that the patient’s and family’s
Bulletin / May 2014
Materia Medica
based on the progression or resolution of these specific
goals of care are included in the decision to treat.9
symptoms is helpful to determine whether therapy should
Of the atypical antipsychotics, risperidone and olanzapbe continued. For instance, if a patient is forcefully kicking
ine have both been shown to have the greatest effect on
7,10
others, one of the behaviors noted on the CMAI, this action
treatment of aggression in dementia. Aripiprazole, quetiapine and the typical antipsychotic haloperidol have modest should be specifically monitored and observed for frequency,
supporting evidence for use in BPSD as well. Risperidone’s time of day, intensity and potential triggers.
Another approach used in conjunction with targeting the
effect on aggression using the CMAI scale and BEHAVE-AD
specific
symptom is choosing an agent based on side effect
scale has been shown to have a significant effect compared
11
profiles. If a patient is overweight or has dyslipidemia, olanto placebo at doses of 1.0 and 2.0mg/day. Olanzapine was
zapine
may be avoided.10 Quetiapine could be considered in
shown to have a beneficial effect versus placebo when using
patients with Parkinson’s Disease, but it is associated with
the NPI-NH aggression scale, but dropout rates due to ad10
7
verse events were higher in the treatment group. Even with the most sedating effects.
When therapy is used to target a specific symptom, it
the use of these antipsychotics, one review found effect siz11
should
be started at the lowest possible doses and titrated
es with olanzapine of only up to 8 points on the NPI scale.
to the lowest effective dose. Reassessment should routinely
Suggested dosing for use in dementia are listed in Table 1.
occur for both effectiveness and adverse events like EPS,
tardive dyskinesia, blood pressure and metabolic effects.9,
9, 10
Table 1: Suggested Dosing for Antipsychotics in Dementia
10, 11
Antipsychotic use even over a short period can cause
Antipsychotic
Dose
harm, including mortality. It has been estimated that for
Risperidone
0.25-2 mg/day
every 100 persons treated with an atypical antipsychotic for
Olanzapine
2.5-10 mg/day
more than 10 to 12 weeks, there is one death due to use of
an atypical antipsychotic drug.9 While these statistics can
Aripiprazole
2-12 mg/day
vary based on the literature, it is still important to minimize
Quetiapine
12.5-200 mg/day
use. Expert opinion and evidence from randomized conHaloperidol
0.25-2mg/day
trolled trials has determined patients’ symptoms tend to
improve within 2 to 4 weeks.9 At this time, a taper can be
Using antipsychotics in dementia patients, regardless of
the agent chosen, requires targeting a specific symptom and instituted to minimize abrupt withdrawal symptoms. If sympchoosing the antipsychotic based on that symptom.10,11 Only toms return and further use is warranted, periodic gradual
dose reductions should still be attempted, at least twice per
describing the indication as agitation or aggression can be
year, or more ideally every 12 weeks. It is recommended
very broad and make assessing efficacy of treatment difficult, especially when the patient is observed by a number of to try decreasing the antipsychotic by 25 percent every 4
Continued on Page 198
various caregivers. Objectively assessing for effectiveness
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Bulletin / May 2014
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12/18/13 10:47 AM
197
Materia Medica
From Page 197
to 6 weeks as a general guideline.10 However, if no effects
are seen within the first few weeks of starting therapy, it is
preferred to stop use and possibly switch to a different agent
or focus more on nonpharmacological therapies.9, 10
The treatment of BPSD is important for both patients
and caregivers. Careful thought must be given to assessing
both the targeted behavior and the positive and negative
effects of treatment. Clinicians should consistently employ
one of the validated assessment scales, such as the NPI,
CMAI and BEHAVE-AD, to assess BPSD and treatment
effects. Further, the decision to use atypical antipsychotics
must accompany a plan for adverse effect monitoring, BPSD
monitoring, duration and subsequent tapering. Incorporating
References
1. Ballard CG, Gauthier S, Cummings JL et al. Management of
agitation and aggression associated with Alzheimer disease. Nat
Rev Neurol. 2009 May;5(5):245-55.
2. A Guide to Dementia Diagnosis and Treatment. American
Geriatrics Society. <http://dementia.americangeriatrics.org/#Nonpharmacologic_Approaches> accessed 12 Sept 2013.
3. Müller-Spahn F. Behavioral disturbances in dementia.
Dialogues Clin Neurosci. 2003 Mar;5(1):49-59.
4. Zagaria ME. Agitation and Aggression in the Elderly. US
Pharm. 2006;11:20-28.
5. Cummings JL. Neuropsychiatric Inventory. Dementia Collaborative Research Centres. <http://www.dementia-assessment.
com.au/behavioural/NPI.pdf>.
6. Cohen-Mansfield Agitation Inventory (CMAI). Dementia Collaborative Research Centres. < http://www.dementia-assessment.
com.au/symptoms/CMAI_Scale.pdf>
7. Ballard CG, Waite J, Birks J. Atypical antipsychotics for
this plan into the patient’s goals of care allows the patient
and caregivers to minimize harm from behavior symptoms
of dementia. With a comprehensive plan for treating the agitation and aggression symptoms of dementia, both patient’s
and family’s wishes can be maintained and respected.
Amy Haver, PharmD, BCPS, is a PGY2 Geriatric Pharmacy resident at UPMC St. Margaret and can be reached
at haverae2@upmc.edu. Nadia Kudla is a PGY1 Pharmacy resident at UPMC St. Margaret and can be reached at
kudlana@upmc.edu. Heather Sakely is the director, PGY2
Geriatric Pharmacy Residency, and director, Geriatric Pharmacotherapy at UPMC St. Margaret, and can be reached at
sakelyh@upmc.edu.
aggression and psychosis in Alzheimer’s disease. Cochrane Database of Systematic Reviews 2006, Issue 1. Art. No.: CD003476.
DOI: 10.1002/14651858.CD003476.pub2.
8. Managing behavioral and psychological symptoms of
dementia (BPSD). Alzheimer’s Association 2013. < http://www.
alz.org/documents_custom/hcp_md_bpsd.pdf> accessed 12 Oct
2013.
9. Jeste DV, Blazer D, Casey D et al. ACNP White Paper:
update on use of antipsychotic drugs in elderly persons with
dementia. Neuropsychopharmacology. 2008 Apr;33(5):957-70.
10. Carnahan R. “Improving Antipsychotic Appropriateness
in Dementia Patients. Introduction to the IA-ADAPT Project.” The
University of Iowa College of Public Health. <http://www.americangeriatrics.org/files/documents/annual_meeting/2013/handouts/
saturday/S1230-5410_Ryan_M._Carnahan.pdf>
11. Sink KM, Holden KF, Yaffe K. Pharmacological Treatment
of Neuropsychiatric Symptoms of Dementia: A Review of the
Evidence. JAMA 2005:293(5): 596-608.
Serving the legal needs of health
care practioners and facilities
BETH
ANNE
JACKSON
Esq. LLC
4050 Washington Road
Suite 3N
McMurray, PA 15317
• Regulatory - Stark, Anti-Kickback,
HIPAA, EMTALA
• Compliance
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Phone: 724 941-1902
Fax: 724 941-1929
bjackson-law@verizon.net
• Joint ventures and other
business transactions
• Reimbursement issues and
payor audits
• Operational issues and policies
198
Bulletin / May 2014
Legal Summary
Security risk assessments
and HIPAA audits
Prepare now for round 2 of the ‘HIPAA police’
Beth Anne Jackson, Esq.
On Feb. 24, 2014, the Office of Civil Rights (OCR), which is the Department of Health
and Human Services (HHS) HIPAA enforcement arm, published an information collection request notice in the Federal Register titled the “HIPAA Covered Entity and Business Associate
Pre-Audit Survey.” OCR plans to survey up to 1,200 covered entities and business associates regarding such things as recent data about the number of patient visits or insured lives,
use of electronic information, revenue and business locations in order to assess the entities’
suitability for a HIPAA audit.1
This information collection request was followed by the March 28, 2014, release of a
HIPAA Security Risk Assessment Tool (the SRA Tool). A result of collaboration between
the HHS Office of the National Coordinator for Health Information Technology (ONC) and
OCR, this free resource is designed to assist small- and medium-sized covered entities in
performing a security risk assessment. Although risk assessment remains a time-consuming
process, the SRA Tool has a more user-friendly interface and simpler questions than previously available toolkits.
Import – The HIPAA security rule requires that covered entities and their business associates “conduct an accurate and thorough assessment of the potential risks and vulnerabilities to the confidentiality, integrity, and availability of electronic protected health information
held by the covered entity or business associate.” The risk assessment is central to achieving compliance with the entirety of the security rule. In spite of this importance, two-thirds
of entities audited as part of the 2011-12 HIPAA audit program did not have a complete and
accurate risk assessment. OCR’s development of the SRA Tool is the result of its efforts to
create technical assistance based on its audit findings.
Therefore, the SRA Tool’s release just a month after OCR announced its intention to
collect information for its next HIPAA audit program is a strong signal that OCR will be
taking a very close look at entities’ risk assessments in the next round of audits. Keep in
mind, however, that formal audit programs are not the only opportunities that OCR have to
examine your security risk assessment: OCR can review security rule compliance as part of
its investigation of breaches and complaints.
Postscript – If the specter of the “HIPAA police” doesn’t concern you, how about a hit
to your bottom line? Risk assessment also is required for compliance with both Stage 1 and
Stage 2 of the EHR Incentive Program (Meaningful Use). Meaningful Use compliance also
will be audited.
Ms. Jackson is the sole member of Beth Anne Jackson, Esq. LLC, a law
firm that serves the legal needs of health care practitioners and facilities in
southwestern and central Pennsylvania. She can be reached at (724) 9411902 or bjackson-law@verizon.net. Her website is www.jacksonhealthlaw.
com.
Bulletin / May 2014
Writers
Wanted
Please don’t
pass up the
opportunity
to have your
voice be heard.
To submit
a writing sample
or for more
information,
contact Bulletin
Managing Editor
Meagan Welling,
(412) 321-5030,
ext. 105, or email
mwelling@acms.org.
Reference
1. The tool is available for both Windows operating systems and iOS iPads.
Download the Windows version at http://
www.HealthIT.gov/security-risk-assessment. The iOS iPad version is available
from the Apple App Store (search under
“HHS SRA tool”). The National Institute of
Standards and Technology (“NIST”) issued
a security risk assessment toolkit in 2011,
but it was considered to be very complex
and too long (809 questions) to be a good
resource for smaller health care entities. It
is available at: http://scap.nist.gov/hipaa/.
199
Practice Management
Staff recruitment and retention
M
ost medical managers with whom
I have spoken seem to have
two common problems. They have a
difficult time finding and hiring staff
members, and once they have hired
an adequate number of employees,
they have a difficult time keeping them.
These issues seem to be ongoing as
well as universal. From large hospital-based medical practices to small
independent medical offices, the issues
of staff recruitment and retention seem
to be the cause of headache and heartache alike. So how can a manager
take control of these issues? Let’s take
a look at these individually.
Where can I find potential candidates to hire? This question has
puzzled many medical managers and
administrators for some time. There
is something to be said for the good
“old fashioned” word-of-mouth method.
First off, it doesn’t cost anything. Ask
other managers at multiple locations if
they keep résumés on file and if they
wouldn’t mind sharing them with you.
Of course, there is a trap located within
this method. Why haven’t they hired
them? It could just be that there were
several good candidates for only one
open position or it could be that these
were lackluster, mediocre candidates.
Either way, they should be wellscreened and vetted.
The Internet is a wonderful tool;
Craigslist is a very inexpensive means
of advertising for an open position.
Monster also is a great way to go, albeit a more expensive way. Occasionally,
I find the need to use the local newspaper’s want ads. This is most often
the most expensive method to utilize.
200
Kenneth
E. Hogue
Personally, I use the newspapers
specifically when looking for mid-level
providers.
The most overlooked method of
recruitment is your area’s technical
schools. These schools usually have
large numbers of students who will
be graduating soon and who will be
beginning their job searches. Medical
assistants, X-ray technicians, billers
and coders, and many other health
care personnel can be found here.
Technical schools are graded on what
is called the completion-to-placement
ratio. This is defined as the ratio of
students who graduate versus those
who actually found employment in their
chosen field. Career services departments will be more than happy to help
you find candidates.
I know what most managers will say
about new graduates: They lack experience. Personally, I have found then if
you hire a recent graduate, you can
mold them into what you need. If you
have the means, then I suggest participating in externship programs through
technical schools. This method can get
you a new graduate who has actually
been in your practice for a length of
time, will be familiar with your policies
and should be much easier to train.
Of course once you find a pool of
candidates, you need to properly interview and follow up with past employ-
Employee retention,
especially in health care,
can be a huge issue. We all
know that when we have
a number of high-quality
employees, we want to keep
them. ers, schools, and personal or business
references. Background checks, credit
checks and other tools may prove very
useful. My preferred way of conducting
an interview consists of three parts.
First, a phone interview. If I like what
I hear, we move on to a face-to-face
interview. Once I have chosen three or
four good candidates, I schedule second face-to-face interviews. This allows
me time to think about each candidate
and decide if I need to ask further
questions. It also allows the potential
hire to think of additional questions to
ask of me. I actually expect and am
impressed when a candidate asks me
additional, relevant questions during
the second interview!
Ok, so now you’ve hired and have
the proper number of high-quality employees to staff your medical practice.
They are properly trained, friendly and
knowledgeable – just what you were
looking for! Now, the big question: How
do you keep them?
Employee retention, especially in
health care, can be a huge issue. We
all know that when we have a number
of high-quality employees, we want
to keep them. We pay them as well
Continued on Page 214
Bulletin / May 2014
q
Allegheny County
MediCAl SoCiety
Leadership and Advocacy for Patients and Physicians
ACMS selects vendors for quality and
value. Contact our Endorsed Vendors
for special pricing.
Banking and
Financial Services
Practice Financing,
Revenue Cycle Management
Physician Only Mortgage
Program
Private Banking
Fifth Third Bank
Robert Foley, 412.291.5401
robert.foley@53.com
Banking, Financial
and Leasing
Services
Medical Banking,
Office VISA/MC Service
PNC Bank
Brian Wozniak, 412.779.1692
brian.wozniak@pnc.com
What does ACMS
membership
do for me?
Bulletin / May 2014
Group Insurance
Programs
Medical, Disability, Property
and Casualty
USI Affinity
Bob Cagna, 412.851-5202
bob.cagna@usiaffinity.com
Printing Services
and Professional
Announcements
Service for New Associates,
Offices and Address Changes
Allegheny County Medical
Society
Professional Liability Susan Brown, 412.321.5030
sbrown@acms.org
Insurance
PMSLIC
Laurie Bush, 800-445-1212,
ext. 5558; lbush@pmslic.com
Medical and Surgical
Supplies
Allegheny Medcare
Michael Gomber, 412.580.7900
michael.gomber@henryschein.
com
Auto and Home
Insurance
Liberty Mutual
Kathy Smith, 412.859.6605,
ext. 51911;
kathy.smith@libertymutual.com
Member Resources
BMI Charts,
Where-to-Turn cards
Allegheny County Medical
Life Insurance
Society
Malachy Whalen & Co.
412.321.5030
Malachy Whalen, 412.281.4050 acms@acms.org
mw@malachy.com
201
INTRODUCING
OUR NEWEST DOCTORS
UPMC is pleased to welcome our newest
neurologists to our offices in Aspinwall,
McKeesport, and West Mifflin.
Edward Mistler, DO
Board-Certified in Neurology
Dr. Mistler specializes in electrodiagnostic
medicine and provides general neurology
consultations, nerve conduction studies /
electromyography, electroencephalogram
interpretation, and chemodenervation
(botulinum toxin).
Stuart Silverman, MD, MS, FAAN
Board-Certified in Neurology
Dr. Silverman is a Fellow of the American
Academy of Neurology. He has more than
25 years of experience in providing
general neurology consultations and
treatments, as well as treating multiple
sclerosis and spinal diseases. He also
specializes in neuroimaging.
To schedule an appointment, or for more
information, call 412-784-5600 or
visit UPMC.com.
UPMC St. Margaret, Medical Arts Building
100 Delafield Road., Ste. 101
Pittsburgh, PA 15215
UPMC McKeesport, Painter Building
500 Hospital Way
McKeesport, PA 15132
Our multi-million-dollar,
state-of-the-art healthcare facility.
UPMC West Mifflin
1907 Lebanon Church Road.
West Mifflin, PA 15122
Every day, we provide healthcare to more families in their homes than
just about anyone. Whether you’re recovering from surgery, disabled
or just need a little help to maintain your independence, our trained,
experienced caregivers will come to your house and take care of you.
On a part-time, full-time or live-in basis. We’re Interim HealthCare®,
and we provide healthcare for the people you love. Give us a call.
Affiliated with the University of Pittsburgh School of Medicine, UPMC is ranked among the nation’s best hospitals by U.S. News & World Report
1789 S Braddock Ave.
Pittsburgh, PA
(412) 436-2200
202
2843-5_bw_3.625x9.75.indd 1
5/9/14 10:53 AM
www.interimhealthcare.com
Bulletin / May 2014
Special Report
Emergency medicine chairs
respond to ACEP report card
O
n Jan. 16, the American College
of Emergency Physicians (ACEP)
issued a news release on Pennsylvania’s ranking 6th in the nation in the
2014 ACEP report card on America’s
emergency care environment.
Charles Barbera, MD, FACEP, chair
of Emergency Medicine at Reading
Health System and Pennsylvania
ACEP chapter president; Donald
Yealy, MD, chair, Department of Emergency Medicine, University of Pittsburgh/University of Pittsburgh Physicians, vice president, UPMC Physician
Services Division; and professor of
Emergency Medicine, Medicine and
Clinical and Translational Sciences,
University of Pittsburgh School of
Medicine; and Thomas Campbell, MD,
MPH, system chairman Emergency
Medicine, Allegheny Health Network,
and associate professor of Emergency
Medicine at Allegheny General Hospital, all provided comments on the
release below.
Pennsylvania ranks 6th in the
nation for policies that support
emergency patients
WASHINGTON – Pennsylvania
ranked sixth in the nation with a
C+ in the 2014 American College
of Emergency Physicians’ (ACEP)
state-by-state report card on America’s
emergency care environment (“Report
Card”). The state has made significant improvements in the category of
Bulletin / May 2014
“
Even though our national ranking improved, overall, we are at a
stalemate. With patient visits increasing as the baby boom generation ages, a growing number of elderly patients with complicated
health problems, the expected increase in Medicaid patient visits
with the implementation of the Affordable Care Act, the shortage
of primary care and specialist physicians, all coinciding with a decrease in
the number of EDs, hospital beds and treatment centers, our emergency
care system is severely stressed and operates in a near-continuous state of
crisis.
“These day-to-day factors have contributed to emergency department
crowding and its subsequent effect on the boarding of admitted emergency
patients, long wait times, ambulance diversion and costs.
“As the demand for emergency care grows, we have concerns that with
the ever present threat of epidemics, such as pandemic flu or environmental
disaster or a terrorist event such as the Boston Marathon bombing that we
will be able to provide life- and limb-saving care on a timely basis.”
Charles Barbera, MD, FACEP,
Chair of Emergency Medicine,
Reading Health System
Access to Emergency Care, which contributed to the ranking, despite declines
in three out of five other categories
since 2009.
“Pennsylvania’s high ranking for
Access to Emergency Care reflects
dedication and hard work on the part of
our state’s policymakers and medical
workforce,” said Dr. Barbera.
“However, our state has seen
decreases in the number of emergency
departments, staffed inpatient beds
and psychiatric care beds. These
losses have led to increased crowding in Pennsylvania’s emergency
departments, which is detrimental to
patients.”
Continued on Page 204
203
Special Report
“
From Page 203
Pennsylvania, ranked 23rd with a
C- in the 2009 Report Card, this year
earned a B+ and came in second in the
nation for Access to Emergency Care.
The state has below-average shortages of health care providers and rates
of underinsurance for both adults and
children. The state also has a relatively
low proportion of adults with an unmet
need for substance abuse treatment.
On the negative side, Pennsylvania
should adopt a statewide psychiatric
bed registry to help cope with the decrease in psychiatric care beds.
The state’s best grade, an A and 3rd
place ranking for Quality and Patient
Safety Environment, is attributed to
statewide systems and policies in place
for heart attack, stroke and trauma
patients. It also supports the fourth
highest rate of emergency medicine
residents in the country.
Pennsylvania earned a C- for Public
Health and Injury Prevention because
of high infant mortality rates and unintentional poisoning deaths. Above-average rates of smoking among adults
We agree that Pennsylvania has emergency services – starting with
EMTs and paramedics through ED physicians and nurses – that
lead the nation. No matter what ‘grade’ is assigned, opportunity to
improve exists. In the UPMC system, we monitor care daily, and we
work to improve the timeliness and quality of care from first contact
through the ED, creating a high performance noted in a recent Medicare
assessment.”
Donald Yealy, MD,
Chair, Department of
Emergency Medicine,
University of Pittsburgh/
University of Pittsburgh Physicians
indicates a need to strengthen the
current smoking ban in restaurants and
bars.
Pennsylvania’s Disaster Preparedness ranking suffered a significant
decline from the 2009 Report Card,
dropping from 4th place with an A to
17th place with a C+. The grade was
impacted by declines in bed surge
Category:
capacity, intensive care unit beds,
burn unit beds and the proportion of
nurses who reported receiving disaster
preparedness training since 2009.
Pennsylvania earned an F for
Medical Liability Environment, in part
because it lacks additional protections
for lifesaving care mandated by the
Emergency Medical Treatment and
Grade:
National Rank:
Access to Emergency Care
B+
2
Quality & Patient Safety Environment
A
3
Medical Liability Environment
F
43
Public Health & Injury Prevention
C-
21
Disaster Preparedness
C+
17
204
Bulletin / May 2014
Special Report
Active Labor Act. The state’s mandated phase-out of its liability insurance
program, MCARE, could require
physicians and hospitals to assume the
program’s $1.3 billion unfunded liability.
Pennsylvania must work to adopt a
clear and convincing standard for
EMTALA-related care to improve the
Medical Liability Environment.
“The problems Pennsylvania has
with liability protections for physicians
who provide emergency care, as required by law, cast a dark cloud,” said
Dr. Barbera. “We want Pennsylvania to
continue to attract and retain the best
and the brightest medical providers, so
we must create a liability environment
that will do that.”
“America’s Emergency Care Environment: A State-by-State Report Card
– 2014” evaluates conditions under
which emergency care is being delivered, not the quality of care provided
by hospitals and emergency providers.
It has 136 measures in five categories:
access to emergency care (30 percent of the grade), quality and patient
safety (20 percent), medical liability
environment (20 percent), public health
and injury prevention (15 percent) and
disaster preparedness (15 percent).
While America earned an overall mediocre grade of C- on the Report Card
issued in 2009, this year the country
received a near-failing grade of D+.
Retiring?
New Address?
“
Our overall ranking was a C+. Pennsylvania ranked highly in:
1. Quality and Patient Safety Environment: which is a tribute
to our state’s policies on stroke, cardiac and trauma patients. It is
also a reflection of the adverse event reporting requirements and
the conversion to electronic medical records and physician order
entry. However, we have some strides to make for real-time accessible
information for prescription monitoring programs to improve our ranking and
patient safety. The state also ranked well in:
2. Access to Emergency Care: with a relatively low rate of underinsurance for adults and children, and a relatively low rate of health professional
shortages. Despite this good ranking, we have a shortage of inpatient beds,
especially psychiatric beds and drug and alcohol acute treatment center
beds. This has led to emergency department crowding which is keeping our
scores below the top. The areas that did not fare well were:
3. Medical Liability Environment: Where PA has some of the highest medical liability insurance premiums in the nation, PA also lacks some protections for mandated care of the EMTALA that other states provide. Finally, the
eventual phase out of the MCARE liability insurance program helped give
our state an F grade.
4. Public Health and Injury Prevention: Our challenge is evident by higher
infant mortality rates and unintentional poisonings. There is also a higher
rate of smoking in our state.
5. Disaster Preparedness: PA rating fell due to a decline in bed surge
capacity, intensive care unit beds, burn unit beds and smaller proportion of
nurses that reported disaster preparedness training.”
Thomas Campbell, MD, MPH
System Chairman Emergency Medicine,
Allegheny Health Network
ACMS Members:
New Partner?
Congratulatory
message?
Professional announcement advertisements
are available to ACMS members at our lowest prices.
Contact Meagan Welling, managing editor, at mwelling@acms.org.
Bulletin / May 2014
205
Special Report
A
Still much to learn
about asthma
t this time of year, and especially
as we emerge from the winter of
2013-14, most are ready to welcome
spring with open arms, but for many
of us and our patients, spring also
signifies the onset of itching, sneezing
and wheezing. Appropriately, May is
Allergy/Asthma Awareness Month,
as designated by the United States
Department of Health and Human
Services (HHS) and sponsored by
the Asthma and Allergy Foundation of
America.
Unfortunately, asthma continues to
be a major public health concern both
in our region and nationally. An estimated 25.9 million people in the United
States, including about 7.1 million children, have asthma, which continues to
be the most common chronic childhood
disease.1 Asthma remains a leading
cause of childhood hospitalizations and
school absenteeism, with about 10.5
million school days missed each year
due to asthma.2 The annual economic cost of asthma, including indirect
costs due to missed school and work
days, amounts to more than $56 billion
per year.3 The prevalence of lifetime
asthma among Pennsylvania school
students increased almost 52 percent
from 1999-2000 to 2010-11, from
160,700 to 228,800 students in grades
kindergarten through 12.4 The Allegheny County student prevalence rate has
been estimated at 12.1 percent.3
In caring for young children who
wheeze, one challenge lies in deter206
Todd
Green, MD
Allyson
Larkin, MD
mining which of these children will
have asthma by the time they reach
school age. While approximately 40
percent of all young children will experience at least one episode of wheezing, coughing or dyspnea, and about
80 percent of asthmatics manifest
the disease in the first years of life,
only about 30 percent of preschoolers
with recurrent wheeze will continue to
have asthma at age 6.5 The Asthma
Predictive Index was developed from
the longitudinal Tucson Children’s
Respiratory Study, and demonstrates
the importance of assessing for
other atopic disease in children with a
history of multiple wheezing episodes.
Those with a positive API are more
at risk for asthma, and treating these
patients aggressively may help to
prevent progression of disease and
development of persistent lung function abnormalities.6,7,8
Increasingly, physicians are aware
of the fact that our one word, asth-
ma, does not adequately describe its
multiple phenotypes, and it may be
more helpful to think of asthma not as
one disease but as a group of conditions that can present with overlapping
clinical presentations.9
Approaching asthma in this way
can help guide our evaluation and
management of patients. This approach
may help to explain, for example, why
recent studies have suggested that one
of our oldest and most reliable asthma
therapies, oral corticosteroids, may
not always be effective in reducing the
severity of wheezing illnesses in young
children.10,11
Efforts to better understand asthma
phenotypes have highlighted the study
of biomarkers. These have become an
important focus due to the need for improved individualized treatment plans
for asthma care. Although their clinical
use is still under investigation, two
biomarkers that characterize inflammation have recently been noteworthy:
blood eosinophils and exhaled nitric
oxide. After a recent study published by
Malinovschi, et al.,12 suggested these
markers offer independent information
regarding the prevalence of wheeze,
asthma diagnosis and asthma-related
events, Pavord and Bafadhel13 suggested that these biomarkers could be
viewed as complementary, each associating with different clinical events and
treatment responses within a specific
pattern of airway inflammation.
Ultimately, we hope that as bioBulletin / May 2014
Special Report
markers and phenotypes are better understood, there will be
more individualized treatment options for asthma patients
providing very specialized and effective care. As an example, Wenzel, et al.,14 recently demonstrated that dupilumab,
a monoclonal antibody to the alpha subunit of the interleukin-4 receptor, when used in persistent, moderate to severe
asthma patients with elevated eosinophil counts (blood or
sputum) was associated with fewer exacerbations when
maintenance therapy was withdrawn as well as improved
lung function and reduced levels of TH2 associated inflammatory markers.
Allergy/Asthma Awareness month is a perfect time to
highlight the importance of the continued need to better
understand this common, complex and at times catastrophic
disease. The diverse clinical presentations in both children
and adults are moving the science toward more individualReferences
1. National Health Interview Survey
(NHIS) Data, 2011 http://www.cdc.gov/asthma/nhis/2011/data.htm
2. National Surveillance of Asthma: United States, 2001-2010 http://www.cdc.gov/
nchs/data/series/sr_03/sr03_035.pdf
3. Centers for Disease Control and
Prevention, Asthma in the U.S.- Vital Signs
http://www.cdc.gov/vitalsigns/asthma
4. Pennsylvania Department of Health
2013 Pennsylvania State Health Assessment
http://www.portal.state.pa.us/portal/server.pt/
community/healthy_schools,_businesses_
and_communities/11601/state_health_assessment_page/1533419
5. Castro-Rodriguez JA,. The necessity
of having asthma predictive scores in children. J Allergy Clin Immunol 2013;132:13113.
ized assessments of disease (biomarkers/phenotypes) that
will hopefully result in a more comprehensive and focused
treatment approach that in the future may highlight steroid
sparing therapy. We look forward to continuing this exciting
and evolving journey with our patients.
Dr. Green is an allergist/immunologist at Children’s Hospital of Pittsburgh of UPMC. He is an assistant professor of
Pediatrics; directs the UPMC fellowship program in allergy/
immunology; and is president-elect of the Pennsylvania
Allergy & Asthma Association. He can be reached at (412)
692-7885.
Dr. Larkin is assistant professor of the Pediatrics Division
of Allergy and Immunology at Children’s Hospital of Pittsburgh of UPMC. She can be reached at (412) 692-7885.
6. Castro-Rodriguez JA, Holberg CJ,
Wright AL, Martinez FD. A clinical index to
define risk of asthma in young children with
recurrent wheezing. Am J Respir Crit Care
Med. 2000;162(4 pt 1): 1403-1406.
7. Guilbert TW, Morgan WJ, Zeiger RS,
et al. Long-term inhaled corticosteroids in
preschool children at high risk for asthma. N
Engl J Med. 2006;354:1985-1007.
8. Huffaker MF, Phipatanakul W. Utility
of the asthma predictive index in predicting
childhood asthma and identifying disease-modifying interventions. Ann Allergy
Asthma Immunol 2014;112:188-190.
9. Borish L, Culp JA. Asthma: a
syndrome composed of heterogeneous
diseases. Ann Allergy Asthma Immunol
2008;101(1):1-8.
10. Beigelman A, King TS, Mauger D, et
al. Do oral corticosteroids reduce the severi-
ty of acute lower respiratory tract illnesses in
preschool children with recurrent wheezing?
J Allergy Clin Immunol 2013;131:1518-1525.
11. Panickar J, Lakhanpaul M, Lambert
PC, et al. Oral prednisolone for preschool
children with acute virus-induced wheezing.
N Engl J Med 2009;360:329-338.
12. Malinovschi A., et al. Exhaled nitric
oxide levels and blood eosinophil counts
independently associate with wheeze and
asthma events in National Health and Nutrition Examination Survey subjects. J Allergy
Clinical Immunology 2013;132:821-7.
13. Pavord ID, Bafadhel M. Exhaled nitric
oxide and blood eosinophilia: independent
markers of preventable risk. J Allergy Clinical
Immunology 2013; 132:828-9.
14. Wenzel, S., et al. Dupilumab in
persistent asthma with elevated eosinophil
levels. NEJM 2013; 368:2455-66.
Allegheny County Medical Society
Leadership and Advocacy
for Patients and Physicians
Bulletin / May 2014
207
Care is Your Business, Change is Ours
The healthcare environment is changing. Physicians must focus on providing the highest quality care with intense
competition for their time. Medical practices face increased challenges tied to changes to regulation, insurance protocols,
cost-management and revenue management.
Houston Harbaugh has over 30 years of experience in helping physicians and medical practices manage change through
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Every challenge a medical practice can face, we have seen. We have helped practices of all size and structure meet
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208
Bulletin / May 2014
Bulletin / May 2014
209
Special Report
Gluten-free fad diet …
D
rew Brees, Chelsea Clinton, Mariel
Hemingway, Scarlett Johansson,
Novak Djokovic, Keith Olbermann
and Lady Gaga. Add to that list, me,
Dr. David Limauro. What do I have in
common with these “A listers?” Actually, the same diet is about the only thing
I have in common with these famously
gluten-free people. As a practicing
gastroenterologist, it’s ironic that I was
diagnosed with celiac disease approximately 10 years ago. Everywhere you
look these days, it seems people are
eating a wheat/barley/rye-free diet. According to one market research group,
the sales of gluten-free foods reached
$2.64 billion in 2010 and have been
climbing steadily each year.
Celiac disease, wheat allergy and
gluten sensitivity or gluten intolerance
are all reasons that a person might be
following a gluten-free diet. Approximately 1 in 133 people in the United
States have celiac disease, and some
resources state the non-celiac gluten
sensitivity or gluten intolerance may
affect as many as 5 percent of the
population.
Many incorrectly call celiac disease
a wheat allergy; however, this is not
the case. Celiac disease is an autoimmune disease. The gluten (complex
of proteins found in wheat, rye and
barley) binds with intestinal proteins
and provokes a powerful, misdirected
overreaction from the patient’s own
immune system toward their own intestine. This immune response is directed
against the microscopic villi that line
the small intestine and that are responsible for normal absorption of nutri210
David
Limauro,
MD
ents, vitamins and minerals. In a patient with celiac disease, when the villi
are damaged by the immune response
to gluten, symptoms such as abdominal pain, gas, bloating and diarrhea
commonly occur.
True wheat allergy, on the other
hand, is a very rare condition caused
by a wheat-specific antibody, an IgE
type antibody. This antibody, when
it binds to wheat protein, can cause
immediate symptoms including hives,
sneezing, wheezing and anaphylaxis.
This also is called baker’s asthma and
can be difficult to diagnose because
blood tests for IgE (called RAST tests)
can be unreliable. It is much more
common in children than adults, and
fortunately very rare.
The last group of people following
the gluten-free diet are those with
non-celiac gluten sensitivity (or gluten intolerance). Gluten sensitivity is
a very hard to define condition, as
there are absolutely no reliable blood
tests or other medical tests to make
this diagnosis. Frequently, these are
simply people who are self-diagnosed
because they feel better, or may have
less headaches, GI upset, anxiety,
brain fog, or other symptoms when
they exclude wheat from their diets. A
dietary intolerance generally means the
food “doesn’t agree with me.”
At one time, finding gluten-free
food could be extremely challenging.
Crumbling bread, cookies that tasted
like rocks and foul-tasting corn pasta
were the norm. I found that eating
out at restaurants could be especially
challenging and confusing. It was very
unusual to get a food server who was
familiar at all with the term “gluten-free
diet.” Awkwardness in social situations
like parties or special occasions when
everyone else is eating cake or other
gluten-containing goodies was common. I gave up taking communion at
my church, and wondered if people
who saw me only taking the wine were
thinking I might have a drinking problem!
In addition to the person eating
the gluten-free diet, the food preparer
is really the critical person who also
has to understand the intricacies of
the gluten-free diet. In my case, this
falls on a very understanding and
thoughtful wife. I am lucky that I have
someone who has learned all about
cooking without gluten both by reading
and experimenting through the years.
Not only does the cook have to work
with new and sometimes very brittle
ingredients, but he/she also must avoid
cross contamination. This can occur
when gluten-containing foods that
other family members may be eating
come in contact with gluten-free foods.
The cook also must read labels and
ingredient lists diligently so as to avoid
serving hidden gluten.
It’s been approximately 10 years
from the time I was diagnosed with
celiac disease, and the changes have
been extraordinary. Many restauBulletin / May 2014
Special Report
rants now have dedicated gluten-free
menus. Large food manufacturers are
offering products including cereals,
special mix non-wheat flours, and even
beers which are gluten free. Many
smaller bakeries and food vendors
also have their own varieties of gluten-free products which have become
popular. Gluten-free foods also can
easily be purchased online, in smaller
food stores, and increasingly in larger
grocery stores as well. This has been
a tremendous boon for me and most
people following the gluten-free diet.
Nevertheless, I have developed
conflicting feelings about the popularization of the gluten-free diet. I
do believe that true celiac disease is
underdiagnosed and the publicity of
the diet has raised awareness of celiac
disease. The popular press attention
has likely led to proper diagnosis in
patients who may not have otherwise been found to have true celiac
disease. On the other hand, I think
that non-celiac gluten intolerance is
likely overdiagnosed, frequently by the
patients themselves after browsing
Bulletin / May 2014
the Internet and possibly questionable
websites. I worry that the gluten-free
diet has become a fad diet for people
with unrealistic expectations for its effects. The gluten-free diet is expensive
and generally best undertaken with the
instruction of a dietician or nutritionist
with experience in counseling the diet.
The fiber content of the gluten-free diet
also can be low and the fat content
high which can contribute to other
medical and gastrointestinal issues.
There can be deficiencies in vitamins,
minerals and micronutrients not present in gluten-free foods, but that are
found in fortified whole grain breads
and other products no longer being
eaten by those on a strict gluten-free
diet.
Although being diagnosed with
celiac disease can be a shock, it is a
disease that is treatable by following
a strict gluten-free diet. Those of us
with celiac disease or severe gluten
intolerance can’t understand why
anyone else would voluntarily take on
this challenging diet. Though I suspect
the attraction to this diet may fade, I’m
appreciative that it has raised awareness and created a lot of improved
food choices.
Dr. Limauro is a board-certified
gastroenterologist in private practice
serving patients in the South Hills and
city of Pittsburgh, including St. Clair
and UPMC Mercy Hospitals and South
Hills Endoscopy Center in Upper St.
Clair. Dr. Limauro and his family reside
in the North Hills.
References
Catassi C, Fasano A. Celiac disease
diagnosis: simple rules are better than
complicated algorithms. Am J Med.
2010;123:691-3.
Lee AR, Zivin J, Green PH. Economic burden of a gluten-free diet. J Hum
Nutr Diet 2007;20:423-30.
Biesiekierski JR, Peters SL, Newnham ED, et al. No effects of gluten in
patients with self-reported non-celiac
gluten sensitivity after dietary reduction
of fermentable, poorly absorbed, shortchain carbohydrates. Gastroenterology
2013;145:320-328.
211
Special Report
Helping to ensure your patients
take the medications you prescribe
S
ince many visits to the doctor’s
office end with the physician
writing a prescription for the patient,
what happens next is critical: ensuring
the patient takes the medications as
prescribed by the doctor. All too often,
that is not happening, and as the
statistics reflect, problems with medication adherence can have a significant
negative impact. Consider:
• Approximately 75 percent of adults
fail to adhere to prescribed medications.
• The financial impact of non-adherence is approximately $300 billion
annually.
• Non-adherence contributes to up
to 69 percent of medication-related
hospital admissions per year.
• Non-adherence causes approximately 125,000 deaths in the United
States each year.
So, what can you as health care
providers do to keep your patients from
becoming part of those statistics? What
follows is a prescription that, if adhered
to, should do wonders for your patients’
ability to properly take their prescribed
medications.
For starters, add a fifth vital sign
to the checklist. After checking your
patients’ temperature, pulse rate,
blood pressure and respiratory rate,
it’s time to check something else: Are
they taking their medications as prescribed? Use a risk-assessment tool
and check for signs that your patients
are not taking their medications. Are
212
Anne M.
Jacques,
PharmD
they picking up their prescriptions in
the first place? On follow-up visits, do
their symptoms persist? Are their lab
readings failing to move in the right
direction? All of these are signs that
adherence is an issue.
In maintaining an open, direct
dialogue that is a two-way communication with your patients, perhaps the
most important thing you can do is to
engage them. Make them an active
participant in this health care discussion. But talk to them in a way that encourages them to open up to you. For
instance, ask blame-free, open-ended
questions such as, “I know it must be
difficult to take all of your medications
regularly. How often do you miss taking
them?” This opens the door for a
truthful conversation and allows you to
work with them to better position your
patients to be successful at medication
adherence.
Ways to achieve this could include
having your patients maintain a daily
diary to help them keep track of when
they take their pills. When prescribing
drugs, consider simplifying the dosing
regimen – perhaps choosing a once-aday medication over a more frequently
dosed drug. And work with them on
Your patients also need to
become educated about
their prescription drug
benefits, which vary from
health plan to health plan. ...
You should encourage your
patients to take advantage
of the information that is
available to them.
using modern technology that will help
them remember to take their medications. This could include a smartphone
application or a reminder text-messaging service.
Health care providers also need to
keep in mind that the reason their patients are not taking medications may
come down to finances. Simply put,
they can’t afford to take them. Highmark is working to educate physicians
to be straightforward with their patients
about the oftentimes difficult and uncomfortable money question. Ask them,
“Are you unable to afford all of your
medications?” and “Have you ever had
to choose between buying food, paying
bills or buying your medication?” If the
answer is yes to either question, then
you need to work with your patients to
get them prescriptions that fit into their
budgets.
Nearly 90 percent of the time in
Pennsylvania, brand-name drugs
Bulletin / May 2014
We will reduce your
medical office and
supply costs.
Special Report
prescribed by physicians end up being substituted by
pharmacists for a generic alternative. Knowing this, doctors
should use generic medications whenever possible. Also,
help your patients to find free or low-cost medications or, if
necessary, a patient assistance program.
Your patients also need to become educated about their
prescription drug benefits, which vary from health plan to
health plan. While doctors cannot be expected to know
the ins and outs of every patient’s health insurance, you
should encourage your patients to take advantage of the
information that is available to them. This includes health
insurance member websites, where they can see which
drugs are included on their drug formularies. They also can
see the difference that buying brand or generic as well as
getting their prescriptions filled via home delivery or at a
retail location can have on their cost-sharing. For example,
a 90-day mail-order prescription may be more cost effective
than a 30-day retail supply that will likely need to be refilled
multiple times. The price of medications can even fluctuate
from one retail location to another.
Keep in mind that, although you write prescriptions
near the end of your time with a patient, that should not
signal the end of the appointment. In fact, for patients to
have the best chance of successfully taking their medications – and, thus, the best chance of improving their health
outcome – the moment you write that prescription is when
the physician-patient conversation needs to be at its best
and clearest.
Don’t leave it up to the pharmacist to explain when or
how the drug should be taken, or what kind of side effects
it may cause. Instead, provide the patient with understandable, written instructions – and insist on having the patient
read them and ask questions about them before leaving
your office. Use the teach-back method so you know that
your patients understand what they need to do. The pharmacist can then reinforce that message when the prescription is filled.
Dr. Jacques is the vice president of Pharmacy Markets
at Highmark Inc., where she also has served as director
of Clinical Pharmacy Services and a clinical pharmacy
specialist in geriatrics. She previously held positions with
HealthAmerica of Pennsylvania and Novartis. She has
been a member of the Academy of Managed Care Pharmacy since 1993 and is a past president of the Phi Lamdba
Sigma Pharmacy Leadership Society.
Bulletin / May 2014
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Practice Management
From Page 200
as we can, provide benefits such as
affordable health care insurance,
paid vacation time, sick leave, retirement plans, profit sharing and so on.
I know it seems strange to say, but
often this is not enough. Employees
most often expect more. Simple
things such as a good work environment and the proper resources to
do the job they were hired for are a
good start. I also like to provide ongoing staff education once a month,
bringing in qualified educators to address the staff. Hands-on education
is even better! I have never paid for
an educator to train our employees.
There are many resources that will
provide this at no cost!
I have found that two common
causes of poor employee retention
are a lack of giving the employee
credit when it is due and lack of
self-empowerment in the workplace.
When an employee does a good
job, tell them. If you have given a
staff member an additional assignment, give them a bonus in their pay
or a gift card of some type. Recognize accomplishments such as an
employee receiving a certification in
a new procedure or completing an
educational program.
A birthday card and cake go a
long way in showing an employee
that you think about them as a
person. Listen to your employees.
Take heed of suggestions that they
might make. Walk among them and
be accessible. Empower them and
give them a feeling of value. I like to
use protocols regarding patient care
in our practice. The staff members
need to think about these protocols
and when to utilize them. This makes
them feel that they are not just
“another employee,” but rather that
they are an integral and necessary
component of the health care team.
So now you have the staff you
need, want and are happy with. Be
sure to utilize the three F’s of staff
management. Work should be FUN,
but management needs to be FIRM
yet FAIR. I actually want our employees to enjoy coming to work in the
morning. I know it’s cliché, but I truly
believe that a good employee is a
happy employee, but I also believe
that this type of employee leads
to the best thing of all – a happy
manager!
Mr. Hogue is practice director at
Singh & Dayalan Medical Associates, a division of Genesis Medical
Associates. He can be reached at
khogue@genesismedical.org.
Classifieds
HELP WANTED
HOSPITALIST Medical Director for
Hospitalist Program in America’s Most
Livable City.
Excellent Hospitalist Medical
Director opportunity for a Hospitalist
Program in Western PA. Candidates
should be BC in Internal Medicine, or
BC in Family Practice with appropriate
inpatient experience. Outstanding
salary and benefit package. Interested
candidates please forward CV to ermicareers@upmc.edu or call our ERMI
recruiters at 412-432-7400.
PITTSBURGH/Western Pennsylvania – Emergency Medicine opportunities throughout Pittsburgh/Western
Pennsylvania. Pittsburgh offers a great
lifestyle with a low cost of living, great
schools, plentiful outdoor activities, and
easily accessible amenities. Physician
friendly scheduling and work environment averaging <2 patients/hour. We
offer an outstanding compensation/
benefit package including paid occurrence malpractice insurance, employer-funded retirement plan, paid health
insurance, CME allowance, and more.
Call our ERMI recruiters at 412-4327400, toll-free 888-647-9077, or email
at ermicareers@upmc.edu
Free classified ad online
Place a classified advertisement in the Bulletin, and
your ad will appear online FOR FREE on the ACMS website,
www.acms.org, for the duration of your advertisement.
For information, call Meagan Welling at (412) 321-5030, ext. 105.
214
Bulletin / May 2014
ExclusivEly sponsorEd by thE AllEghEny county MEdicAl sociEty
PMSLIC is committed to its physician-policyholders, therefore
we promise to treat your individual needs as our own. You
can expect caring and personal service, as you are our
first priority. For more information contact your agent, or
call Laurie Bush at PMSLIC at 800-445-1212, ext. 5558
or email lbush@pmslic.com. Or visit www.pmslic.com/start
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