RHODE ISLAND M EDICAl J ournal
SPECIAL SECTION Transitions/End-of-life Care in RI
Guest Editor RenÉe R. shield, PhD
APRIL 2015 VOLUME 98 • NUMBER 4 ISSN 2327-2228 Your records are secure.
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14 Journeys in Long-Term Care Renée R. Shield, PhD Guest Editor t e s y o f renée r. S h ie l d, P
R. Shield, PhD C o ur The cover image is a painting by Stanley M. Aronson, MD.
15 Healthcare Transitions of Older Adults: An Overview for the General Practitioner Lidia Vognar, MD; Nadia Mujahid, MD
19 Health Care Transitions: Perceptions from L. Vognar, MD Older Patients in Rhode Island Renée R. Shield, PhD; Kali S. Thomas, MA, PhD; Rachel Ratchford, ScB
23 The Goals of Care Conversation: A tool to improve patient care in the E. Martin, MD nursing home at the end of life Edward W. Martin, MD, MPH
29 Hospice and Palliative Care in Nursing Homes: Challenges and Opportunities for Enhanced Access Susan C. Miller, PhD
S. Miller, PhD RHODE ISLAND M EDICAl J ournal
8 COMMENTARY Brain Warfare: Primates To Humans? Yawning: Monkey see, monkey do Joseph H. Friedman, MD
11 RIMJ around the world we are read everywhere: Sausalito, San Diego, Austin
52 RIMS NEWS Medical Student event working for You why You Should Join RIMS
70 BOOKS new Book Explores Acceptance and Mindfulness Therapy for Psychosis
72 heritage 100 Years Ago: First EKG Machine Arrives in RI Mary Korr RHODE ISLAND M EDICAl J ournal
In the news
Nicole Alexander-scott, MD 56 58 kent Hospital named Director of the RI approved to perform angioplasty Department of Health 60 Bradley Hospital RI Hospital 56 awarded $168K to support offers RI’s first medical residency training fellowship in Addiction Medicine 60 Care New England VPs selected for National Fellows Program Richard Axel, MD 57 delivers keynote at 63 Alpert Medical School Brown’s Brain Day students celebrate Match Day
people
Thomas Drew, MD 65 68 Renee Eger, MD honored with named Medical Director of Hamolsky Award Women’s Primary Care Center
Star Hampton, MD 65 68 Michael Stanchina, MD brings specialty care named Medical Director of RWMC’s to women in Rwanda Sleep Disorders Center
Ziya Gokaslan, MD 66 68 Kate Lally, MD named Chief of Neurosurgery named Inspirational Leader at RIH, Miriam; Neurosurgery in Hospice and Palliative Chair at Alpert Medical School Medicine April 2015 VOLUME 98 • NUMBER 4 RHODE ISLAND Rhode Island Medical Society R I Med J (2013) 2327-2228 M EDICAl J ournal 98 publisher Rhode Island Medical Society 4 president 2014 Peter Karczmar, MD
April president-elect 1 RUSSELL A. SEttipane, MD vice president Sarah J. fessler, MD ContributionS secretary Bradley J. Collins, MD 30 Comparison of Substance-Use Prevalence among Rhode Island
treasurer and The Miriam Hospital Emergency Department Patients to Jose r. Polanco, MD State and National General Population Prevalence Estimates immediate past president Vera L. Bernardino, BSc, RN; Janette R. Baird, PhD; Tao Liu, PhD; Elaine C. Jones, MD Roland C. Merchant, MD, MPH, ScD Executive Director Newell E. warde, PhD 35 Training Family Medicine Residents to Build and Remodel a Patient Centered Medical Home in Rhode Island: Editor-in-Chief Joseph H. Friedman, MD A Team Based Approach to PCMH Education Rabin Chandran, MD; Christopher Furey, MD; Arnold Goldberg, MD; associate editor Sun Ho Ahn, MD David Ashley, MD; Gowri Anandarajah, MD
Publication Staff managing editor Mary Korr EMERGENCY MEDICINE RESIDENCY CPC [email protected] 42 Too Weak to Move graphic designer Wendy H. Wong, MD; Nathan Hudepohl, MD; Marianne Migliori Bruce Becker, MD; William Binder, MD advertising Steven DeToy Sarah Stevens [email protected] PUBLIC HEALTH
Editorial board 46 Health by Numbers John J. Cronan, MD Uninsurance is only half the problem: James P. Crowley, MD Edward R. Feller, MD Underinsurance and healthcare-related financial burden in RI John P. Fulton, PhD Dora Dumont, PhD, MPH; Tara Cooper, MPH; Yongwen Jiang, PhD Peter A. Hollmann, MD Kenneth S. Korr, MD 50 Vital Statistics Marguerite A. Neill, MD Frank J. Schaberg, Jr., MD Colleen A. Fontana, State Registrar Lawrence W. Vernaglia, JD, MPH Newell E. Warde, PhD
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Brain Warfare: Primates To Humans? Yawning: Monkey see, monkey do
Joseph H. Friedman, MD 8 [email protected] 9 EN
Many readers probably One can imagine that The chimp saw a yawn and the brain are familiar with the persistent yawning may said, “boring,” and so another yawn was surprising observation provoke a reaction from born. But the experiment did not include published recently show- the other chimps that blind or blindfolded primates. And why ing that young chimpan- could possibly lead to should a chimp, which spends 8 hours zees, but not juveniles, embarrassment, possi- eating and 16 hours sleeping, get bored were immune from the bly ostracism. Was this by a yawn? No blind or blindfolded contagious form of yawn- protocol sensitive to the chimps were tested. Perhaps there are ing (Madsen EA.) Chim- needs of its subjects? brain waves or exhaled particles which panzees show a develop- One must also consider communicate yawning. We also do mental increase in sus- the other aspects of this not learn from this project whether a ceptibility to contagious protocol. What if “gap- yawning chimp, caged by itself, will yawning: a test of ontogeny and emo- ing” was contagious? How stigmatizing continue to yawn, or whether it lessens tional closeness on yawn contagion. is it to be a gaping chimp? Would gaping (PLoS One 2013;8(10)e76266). In a interfere with socialization? Might a Imagine how hard life surprise development, a study of 33 gaping chimp provoke antagonism, orphaned chimps showed that juveniles especially if it was also yawning? Imag- might be for a chimp which only “caught” yawning when a human ine how hard life might be for a chimp not only was yawning but yawned, but that young chimps did not. which not only was yawning but was was gaping? I’ve seen Moveover, there was something special gaping? I’ve seen chimps suffer for lesser chimps suffer for lesser about yawning, in contrast to certain social miscues than these. social miscues than these. other stereotypic behaviors. Juveniles I suspect contagious nose wiping didn’t develop contagious gaping or might pose different and lesser prob- contagious nose wiping, stereotypes lems. Nose wiping, especially in chimps, or increases. Can the yawn be con- in chimps. Equally interesting was the which probably were not given tissues trolled? Does contagious yawning have observation that the strength of the or handkerchiefs, probably looks like a half-life? contagion didn’t matter if the yawning scratching an itch to another chimp, and Most importantly, can this be used by model, ie, the yawner, was their adoptive not necessarily a reflection of boredom, the state department to undermine our human mother or an unknown human. stupidity or dumfounded-ness. Other foreign opponents by putting yawning I was surprised that the IRB had chimps might not react so badly to a people in prominent advertisements approved a plan that didn’t include chimp which spent a lot of time rubbing to encourage yawning? Might there be a description of how the researchers its nose. They might steer clear though a “critical mass” for yawning, so that were going to deal with the chimps if they interpreted the behavior as a sign after a number of chimps, or people, which were caught yawning. Is there of an infestation of nose mites. develop contagious yawning, most of the treatment for yawning? It’s presum- I have not addressed the issue of con- chimp/human colony become yawners? ably not life threatening but could it tagion. The authors assumed, of course, At this point, the shoe may shift to the be? Is there a cure? Once present can it as you, the reader did as well, that the other foot so that the chimps which are worsen? Does it lead to other problems? contagion was based on observation. immune from the contagion become the
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outliers, possibly with severe repercus- mitigates the contagion of yawning. brain stimulation suggests that prop- sions that we can only guess at. Parkinson disease patients, who have erly calibrated stimulation effectively Can one die from yawing? Might a dopamine deficiency, also yawn more stifles yawns, whether contagious or gaping be contagious in adults? than others, although distinguishing a not. But much work needs to be done In humans yawning, even contagious yawn from routine mouth opening may to determine long-term outcome, and yawning, appears to die out over time. be challenging. Apomorphine induces what target will be best if gaping or nose We don’t know this yet for chimps. But yawning in people with Parkinson’s wiping become epidemic in our rapidly what if occasional people who developed disease. Of course, it also induces nausea aging population. April fool. v contagious yawning continued to yawn? and vomiting, so that what looks like a What if it worsened over time? And yawn may be a partially suppressed act Author what if they also developed contagious of vomiting. So dopamine agonism may Joseph H. Friedman, MD, is Editor-in- gaping and nose wiping? be one approach to treat, or perhaps, chief of the Rhode Island Medical Journal, I think there are several possible prevent the contagion of yawning, but Professor and the Chief of the Division approaches. Yawning undoubtedly what about refractory contagious yawn- of Movement Disorders, Department of involves dopamine. We know that ing? Basic neurophysiology teaches us Neurology at the Alpert Medical School of schizophrenics on drugs that block that the “yawning center,” a poorly Brown University, chief of Butler Hospital’s dopamine receptors are more apt to defined collection of small, spindly, Movement Disorders Program and first “catch” yawning than schizophrenics dull-spiny neurons in the pars inter- recipient of the Stanley Aronson Chair in who are untreated. So, blocking a dopa- galactica, is hyperactive within 15 ms Neurodegenerative Disorders. mine receptor, presumably D2, which is of yawn commencement, then hypo- blocked by all the antipsychotic drugs, active. Early experiments with deep Disclosures on website
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San diego, California Ken and Mary Korr also checked out the Wells Fargo museum in Old Town, San Diego. This red and gold overland express coach was in use in 1867, carrying passengers and mail, and is similar to the one Mark Twain wrote about in an account of his stagecoach adventure from Missouri to Nevada in Roughing It. Average speed: 5 mph, stop- ping every 12 miles for a change of horses or mules.
Sausalito, California Dr. Barbara Roberts, director of The Women’s Cardiac Center at The Miriam Hospital, read RIMJ’s tribute to Dr. Stanley M. Aronson while staying on the S.S. Maggie in Sausalito, CA.
San diego, California Dr. Ken Korr of Barrington at the Old Point Loma lighthouse (1855) within the Cabrillo Na- tional Monument, checks the March issue of RIMJ. He is stand- ing in front of a historic Fresnel lens, in use from 1891. The lens relies on catoptrics (reflection) and dioptrics (refraction) to col- lect, redirect and intensify light. Divided into panels with a bull’s eye in the center, surrounded by both prisms, a rotating lens creates a flash pattern as it turns. The lighthouse was restored by the National Park Service in 2003.
Wherever your travels take you, be sure to check the latest edition of RIMJ on your mobile device and send us a photo: [email protected].
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Austin, Texas Andreas Nicholas, (above) filmmaker/partner at AnderImage LLC viewed the March issue while attending the South by Southwest® Conference and Festival (SXSW®). Founded in 1987, SXSW now attracts 28,000 visitors annually as a showcase for independent films, music, and emerging technologies.
Andrew Migliori, (left) filmmaker/partner at AnderImage LLC (and RIMS’ Bicentennial filmmaker) viewed the March “We Are Read Everywhere” that featured his grandparents in Barcelona, before visiting the Texas State Capitol in downtown Austin. The Capitol, completed in 1888 and constructed of red granite, is at 308 feet in height, taller than the US Capitol building in Washington, DC.
Wherever your travels take you, be sure to check the latest edition of RIMJ on your mobile device and send us a photo: [email protected].
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Journeys in Long-Term Care
Renée R. Shield, PhD Guest Editor
14 14 EN
I introduce this second themed issue on the subject of long- highlight how the transitions as seen from the patients’ point term care in Rhode Island (RI) by noting that it is again of view can be frightening and challenging; the patients also dedicated to the memory of Dr. Stanley M. Aronson, offer advice to physicians about how these moves could be an ardent and longtime champion of humane health care managed better. in general and the enlightened medical approach in par- The final two articles discuss the role of hospice and ticular for the care of older adults. The platform of being palliative care in the long-term care institution. Miller guest editor allows me to speak once more for the values describes how hospice and palliative care can best be uti- Dr. Aronson held dear about how competent and excellent lized in this setting and how these approaches can effec- care must be based fundamentally in the unique needs, life tively alleviate patients’ pain and suffering. Physicians are story and preferences of the individual patient. His emphasis themselves sometimes the barrier to patients and their fam- on respect for the person and superb medical competence ilies accessing adequate relief for their conditions. Martin were instrumental values that led to his initiating hospice next addresses how physicians can talk with patients and care to RI (Home and Hospice Care of RI, founded in 1974), families in “goals-of-care” conversations about end-of-life Interfaith Health Care Ministries (founded in1975) as well choices in a realistic and comforting way. He offers a blue- as embedding interdisciplinary approaches to medical care print of a clear approach to clarifying patient goals and pref- in the Brown Program in Medicine (now The Warren Alpert erences physicians can use to effectively implement these Medical School of Brown University). dialogues into their clinical practice. The papers in the March 2015 issue of RIMJ (http://rimed.org/ Dr. Aronson intimately understood the inherent brevity rimedicaljournal/2015/03/2015-14-ltc-complete.pdf) provided and finality of our transient lives. His life is an example of an overview of the evolving medical landscape of long-term how to enrich the limited time we have to maintain and care in RI and offered first-hand experiences of those directly heighten the preciousness of life itself. Older patients are involved in providing long-term care: the medical director, at the end of long, complex and intensely unique lives. His the nursing home administrator and the long-term care nurse. painting featured on the cover speaks to a lengthy journey This issue focuses on the journey in long-term care, spe- into a vast unknown. When we care for older patients, we cifically transitions and end of life. Medical care for older need to respect their individuality and honor the specific adults is often marked by frequent transitions in sites of experience of who each of them is. We thank Dr. Aronson care, moves that are fraught with difficulty as physicians for reminding us of the compassionate view of age and mor- and other caregivers rush to move the patient from site to tality and for helping us finding a practical and informed site, too often without adequate preparation and sufficient way to care for patients in the best ways possible. In con- information to ensure that the move is accomplished well tinuing the spirit and example of Stan Aronson, I sincerely and safely. hope the articles in this issue convey the message of how Vognar and Mujahid describe how transitions between to better care for older adults as they approach the ends of hospital and nursing home challenge the provision of the their lives. most effective care; they provide practical advice about how to manage transitions in a smoother and safer way. The arti- cle by Shield, Thomas and Ratchford takes the perspective Guest Editor of patients who have actually undergone these transitions. Renée R. Shield, PhD, is Professor of Health Services, Policy and They focus on how patients recalled their journeys from Practice (Clinical) at the Center for Gerontology and Healthcare home to hospital to nursing home for rehabilitation. They Research, Brown University School of Public Health.
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Healthcare Transitions of Older Adults: An Overview for the General Practitioner
Lidia Vognar, MD; Nadia Mujahid, MD
15 18 EN
ABSTRACT Advancing age and more complex disease are associated Healthcare transition refers to the care “hand-off” of a with frequent care transitions because of the increased like- patient among providers and treatment settings. Older lihood of co-morbidities, cognitive impairment, increased adults experience more frequent care transitions than dependence and polypharmacy; a variety of providers is younger patients due to the presence of co-morbidities, needed to address the complex needs, which in turn can cognitive impairment, increased dependence and medi- result in fragmented care, exposure to adverse events, and cation use. Hospitalization and subsequent readmission increased hospital readmissions.5 Seventy-four percent (73.7) after discharge to a nursing home represents a unique of older adults with dementia have a care transition from care transition situation. It is estimated that as many as hospital to NH: the re-hospitalization rate is 23% annually.6 60% of readmissions from nursing homes can be avoided. A review of more than 25,000 admissions of Medicare bene- Poor communication between hospital and nursing home ficiaries in Rhode Island revealed that patients with demen- staff; delayed, inaccurate, or missing discharge summa- tia were 20% more likely to be readmitted within 30 days of ries; lack of accurate medication reconciliation; pending discharge than those without cognitive impairment.7 test results; inappropriate follow-up; and poor education Care transitions are expected to rise in frequency and of patient and families all contribute to poor care transi- complexity as the adult population ages3 and as older adults tion quality, and increase the probability of rehospitaliza- increasingly use SNF for the recovery of independence.4 The tion. Interventions for improved care transitions are sug- care transition to and from SNF is supported by appropri- gested. They focus on patient and family-centered care ate communication of health information between these effectiveness, minimizing adverse events, and increasing healthcare settings.8 timely, accurate and complete communication. KEYWORDS: Healthcare transitions, nursing home CARE TRANSITIONS residents, hospital readmission rates Care transitions are generally preceded by a change in an individual’s condition that triggers an evaluation for possi- ble transfer of care to another setting. The OPTIC (Older Persons’ Transitions In Care) study demonstrated that the INTRODUCTION most common trigger events in the NH setting were falls A healthcare transition occurs when a patient moves among with injury (30.9%), changes in physical condition (14.7%), providers or treatment settings coincident with a change in and gastrointestinal distress (11.8%).4 a patient’s condition or health care needs. These care set- Essential elements of effective care transitions that are tings include hospitals, nursing facilities (NFs), rehabilita- vital to ensuring quality include providers’ communications tion centers, and home.1 Effective and safe care transitions regarding discharge planning, preparation of the patient and depend upon a set of actions designed to ensure the coordi- family for the transition of care, reconciliation of medica- nation and continuation of healthcare as patients transfer tions, a follow-up care plan, patient education regarding between locations and levels of care.2 Optimal care tran- self-management3, and the involvement of patient and fam- sitions should include pre-hospital discharge activities, ily.5 Poorly executed care transitions can result in adverse immediate post hospital discharge follow up at the next care outcomes or events2, such as fragmented medical care, setting, and should be part of a broader, integrated, multidis- delayed diagnosis and treatment, medication errors, unnec- ciplinary care plan.3 essary utilization of emergency room and hospital services, The annual incidence of care transitions from nursing and duplication of testing.1 Fear, confusion, and anxiety are homes (NHs) to emergency departments (EDs) range from often experienced by patients and families, which lead to 23-60% in the U.S.4 Adults aged 65 years and above account poor patient satisfaction. The risk for potentially prevent- for more than 400 ambulatory visits, 300 ED visits, 200 hos- able adverse events should be identified at each care tran- pital admission, 46 admissions to SNFs, and 106 home care sition point and be actively addressed whenever possible to admissions per 1000 persons in 2000.1 ensure the likelihood of a quality care transition.3
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OUTCOMES OF POOR QUALITY CARE TRANSITIONS Poor communication between hospital and NH staff, Readmissions delayed, inaccurate, or missing discharge summaries on It is known that one in five Medicare beneficiaries dis- discharge, lack of medication reconciliation, pending test charged from hospitals will be readmitted within 30 days, results, lack of a follow-up care plan, and poor education at a cost of $26 billion annually.9 Several performance mea- of patient and family regarding expectations at the next sures aimed at reducing avoidable hospitalizations have care setting are the most common reasons contributing to been proposed by the Centers for Medicare and Medicaid AE occurrences during care transitions. Patients with low Services (CMS).10,11 In 2010, the Patient Protection and health literacy, non-English language speakers (or English as Affordable Care Act imposed penalties related to hospital a second language), who have cognitive impairment, limited readmission rates. Penalties reduce Medicare payments to social support, and a lack of resources, further contribute to hospitals with higher than average rates of rehospitalization the likelihood of an AE occurrence. Healthcare system-spe- within 30 days of discharge when the hospitalization is for cific barriers, such as specialty care provided in silos, create acute myocardial infarction, pneumonia, or congestive heart further ambiguity about who is responsible for the patient; failure. Penalties are scheduled to increase and the list of these factors lead to fragmented care and also possibly conditions to expand in fiscal year 2015.7 It is estimated that increase AE occurrence.17,19 avoiding 5.2% of preventable Medicare readmissions could save approximately $5 billion annually.12 Hospitalization of NH residents and hospital readmis- INTERVENTIONS TO IMPROVE CARE sions of patients sent to SNFs for acute rehabilitation rep- TRANSITIONS: NATIONAL resent a unique care transition that is affected by many Interventions to improve care transitions often focus on read- different factors, including both facility and patient spe- mission rates and cost containment for inpatient services, cific characteristics.10 Readmissions from the NH happen but there are domains in which beneficial interventions, most frequently due to infections, fractures, cardiovascular, such as care effectiveness, minimizing AE, reducing stress and gastrointestinal disorders.13,14 One study reported that of residents, families, and staff4, timeliness, and patient- and infections accounted for 25% of NH readmissions. Facility family-centered care3 could improve care transitions.9 Inter- characteristics, such as nursing staff patterns, NH size, and ventions include profession-oriented interventions, organi- percentage of Medicaid and Medicare reimbursed days also zational interventions, and patient-family interventions.5 influence NH residents’ risk of hospitalization.13 To aid in the development of profession-oriented inter- Sixty percent of hospital readmissions from NHs were ventions, the Transitions of Care Consensus Conference identified as potentially avoidable.15 Medication errors, (TOCCC), which aimed to create successful care transitions, infections, and injuries represented the majority of poten- developed standards for the transition of care.16 TOCCC stan- tially avoidable hospitalizations, indicating that measures dards include coordinating clinicians, providing a care plan/ aimed at infection control, falls, medication reconciliation, transition record, having standard communication formats, improved inter-provider communication, timely discharge accounting for transition responsibility, timeliness, commu- summaries, follow-up plans, and patient and family educa- nity standards, and including patients and their families in tion on care transitions 5 may help reduce readmission rates.15 the transition process.16 The TOCCC standards insist that clinician communication happen whenever patients are at Adverse Events a transition of care. The standards list a minimal set of data An adverse event (AE) is defined as harm resulting from elements that should be part of the transition record or dis- medical management rather than from the disease process.16 charge summary, including the principal diagnosis, problem About one in five17 patients discharged from hospitals will list and medication list, the name of the transferring physi- experience an AE within 3 weeks of discharge.16 More than cian, the patient’s cognitive status and all pending tests.16,19 half of post discharge AEs occur because of poor commu- It is important to realize that discharge summaries may be nication among providers, most commonly regarding med- the only information regarding hospital events, medication ications and test follow-up errors.18 Test follow-up errors, changes, follow-up appointments, and pending tests that a defined as having a test result noted as pending at the time of provider in the community or NH has about a discharged discharge in the inpatient medical record but not acknowl- patient. However, 75% of primary care physicians have not edged in the outpatient chart, have come to the attention of received a discharge summary by the first post-hospitaliza- the Agency for Healthcare Research and Quality, as well as tion visit, and often discharge summaries are incomplete or to large malpractice insurers.18 It has been shown that 41% inaccurate, leaving providers at a total loss.19 of discharged patients had pending test results, and that a The Community–based Care Transitions Program (CCTP) test follow-up error occurred in 8% of discharged patients.18 is an organizational intervention created by the Affordable Fifty-four percent of patients experienced one or more medi- Care Act to improve quality of care and reduce readmis- cation error on admission to hospitals, with 39-45% of these sion rates for high-risk Medicare beneficiaries.9 Commu- considered dangerous to the patient.17 nity involvement is encouraged through formation of
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community-based organizations (CBOs) that will use care over the last 3 years.20 In addition, RI has a mandated con- transition services to manage Medicare patients’ transitions tinuity of care form that has led to dramatic improvement and improve the overall quality of care.9 in cross-setting communication since inception in 2009, Patient-family interventions are also of high value, as and our readmission rates have been dropping rapidly (20% these individuals often wish for more education and a coor- decline in the last three years). dinated approach to care transitions.2 Patients and families 2 are often left uninformed about what to expect , often feel CONCLUSION that transfer was initiated too early and note a lack of pre- Poorly executed care transitions have been associated with paredness for the transition from total care at the acute care increased hospital readmission rates, increased AEs, poor site to near self-care at the NH.2 patient satisfaction, and negative overall patient health out- comes. Older adults, and NH residents, in particular, are RHODE ISLAND identified as especially vulnerable, and at risk for increased Healthcentric Advisors (the Medicare Quality Improvement health care transitions, hospital readmissions, and AEs. In Organization for Rhode Island) developed Safe Transitions RI, patients with dementia, who account for the majority Best Practice Measures for improving care transitions of of NH residents, are responsible for 20% of 30-day readmis- NH residents.20 This project created statewide standards for sions. Interventions aimed at improving care transitions cross-setting care transitions, resulting in sustainable sys- should be implemented at every care transition point, and tems change and overall improved patient safety.20 These should follow the standards set out by the Transitions of standards have been widely accepted and incorporated into Care Consensus Conference (TOCCC). Adherence to these health plans across multiple care settings. They have con- standards will result in improved coordination and commu- tributed to a decrease in the readmission rate of 8.7 per nication of clinicians, comprehensive discharge summaries, 1000 Medicare beneficiaries, reflecting 1086 fewer patients timeliness, as well as education and inclusion of patients admitted to RI hospitals with a $10.4 million cost avoidance and their families in the transition process.
Table 1. Safe Transitions Best Practice Measures, Rhode Island
Best Practice #1 Interventions implemented for residents at highest risk for unplanned transfer These interventions are targeted at residents with depression, falls, and > 2 hospitalizations in the last 12 months.
Best Practice #2 Clinical information sent with emergency department (ED) referrals Information should include the resident’s baseline status, reason for referral, medications, advance directives, and phone num- ber connecting the ED to nursing home (NH) staff who can address questions about resident Best Practice #3 Real time verbal information provided to ED or hospital clinicians Clinical or clerical NH staff should be readily available to address the ED or hospital clinicians’ specific questions regarding the transferred resident. Best Practice #4 Medication reconciliation completed after ED or hospital discharge Medication reconciliation includes the review of the patient’s discharge medication regimen, comparing the discharge medica- tion regimen to the prior medication regimen to identify and resolve any discrepancies. Best Practice #5 Structured communication used for clinical questions to physicians A framework for inter-provider discussions is recommended to ensure high urgency concerns are addressed efficiently. Best Practice #6 End-of-Life care discussed with residents Conversations should take place regarding end -of -life topics such as comfort care, do not hospitalize, hospice, general goals of care. Best Practice #7 Effective education provided to residents prior to NH discharge Education should incorporate the testing of resident’s understanding, and should include the reason for the NH stay; also includes medication changes, recommended follow up appointments and tests, and condition-specific “red flags” to prompt the resident to seek attention. Best Practice #8 Written discharge instructions provided to residents prior to NH discharge This instruction should include the reason for the NH stay, all medication changes, recommended follow-up appointments, pending test results, and condition-specific “red flags” to prompt the resident to seek attention. Best Practice #9 Follow-up appointment scheduled prior to NH discharge The appointment should indicate the date, time, location, and contact info for any questions. Best Practice #10 Summary clinical information provided to outpatient physicians at discharge This information should include a contact number to connect the NH staff to outpatient physicians for questions. Best Practice #11 Residents have access to medication after NH discharge Residents must receive enough medications after NH discharge until the end of the intended treatment course or until the first outpatient follow-up.
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Acknowledgments 16. Snow V, Beck D, Budnitz T, Miller D, Potter J, Wears R, Weiss Stefan Gravenstein, MD, MPH, Professor of Medicine; Inter- K, Williams M. Transitions of Care Consensus Policy Statement American College of Physicians-Society of General Internal im Chief, Division of Geriatrics and Palliative Care, Center for Medicine- Society of hospital Medicine- American Geriatrics Geriatrics and Palliative Care, Case Medical Center for his expert Society- American College of Emergency Physicians-Society of opinion and edits. Academic emergency Medicine. J Gen Intern Med. 2009; 24(8): Richard Besdine, MD, Professor of Medicine; Director, Division 971-976. of Geriatrics and Palliative Medicine; Greer Professor of Geriatric 17. Kripalani S, Jackson A, Schnipper J, Coleman E. Promoting ef- Medicine, Alpert Medical School of Brown University; Professor fective transitions of care at hospital discharge: a review of key Health Services Policy and Practice; Director, Center for Gerontol- issues for hospitals. Journal of Hospital Medicine. 2007; 2:314- ogy and Health Care Research, Brown University School of Public 323. Health, also provided helpful editorial comments. 18. Roy C, Poon E, Karson A, Ladak-Merchart Z, Johnson R, Ma- viglia S, Gandhi T. Patient safety concerns arising from the Disclaimer results that return after hospital discharge. Improving patient The views expressed herein are those of the authors and do not care. 2005. necessarily reflect the views of any other party. 19. Alper E, O’ Malley T, Greenwald J. Hospital discharge and readmission UpToDate, www.uptodate.com, last accessed References 8/25/2014. 1. Coleman E. Falling Through the cracks: challenges and opportu- 20. Chase L, Butler K. Safe transitions best practice measures for nities for improving transitional care for persons with continu- nursing homes. Healthcenric Advisors, Quality Improvement ous complex care needs. JAGS. 2003;51:549-555. Organizations, Centers for Medicare and Medicaid Services Re- 2. Jeffs L, Kitto S, Merkley J, Lyons R, Bell C. Safety threats and port, 2014. opportunities to improve interfacility care transitions: insights from patients and family members. Patient prefer Adherence. Authors 2012;6:711-718. Lidia Vognar, MD, Staff Geriatrician at Providence VAMC, 3. Allen, J, Hutchinson A, Brown R, Livingston P. Quality care out- Assistant Professor of Medicine, Division of Geriatrics comes following transitional care interventions for older people and Palliative Medicine, Alpert Medical School of Brown from hospital to home: a systematic review. BMC Health Ser- University. vices Research. 2014;14:346. Nadia Mujahid, MD, Assistant Professor of Medicine, Division of 4. Reid R, Cummings G, Cooper S, Abel S, Bissell L, Estabrooks Geriatrics and Palliative Medicine, Alpert Medical School of C, Rowe B, Wagg A, Norton P, Ertel M, Cummings G. The older Brown University. persons’ transitions in care (OPTIC) study: pilot testing of tran- sition tracking tool. BMC Health Serv Res. 2013;13:515. Disclosures 5. Storm M, Siemsen M, Laugaland K, Dyrstad D, Aase K. Quality None in transitional care of the elderly: Key challenges and relevant improvement measures. Int J Integr Care. 2014. Correspondence 6. Callahan C, Arling G, Tu W, Rosenman M, Counsell S, Stump Lidia Vognar, MD T, Hendrie H. Transitions in care among older adults with and without dementia. JAGS. 2012;60(5):813-820. Providence VAMC 7. Rhode Island Hospital. Rhode Island Hospital Study Finds Medi- 830 Chalkstone Ave care Patients with Dementia Nearly 20 Percent More Likely Providence RI 02908 To Be Readmitted Within 30 Days of Discharge. Newsroom, 310-619-0127 www.rhodeuslandhospital.org/Newsroom/News. Last accessed [email protected], [email protected] 8/27/2014. 8. AAse K, Laugaland K, Dyrstad D, Storm M. Quality and safety in transitional care of elderly: the study protocol of a case study research design (phase 1). BMJ Open. 2013; 3(8). 9. Centers for Medicare and Medicaid Services. Community- Based Transitions Program. www.cms.gov. Last accessed 8/27/2014. 10. O’Malley J, Caudry D, Grabowski D. Predictors of nursing home residents’ time to hospitalization. Health Serv Res. 2011;46(1 Pt 1):82-104. 11. Ogunneye O, Rothberg M, Friderici J, Slawsky M, Gadiraju V, Stefan M. The association between skilled nursing facility care quality and 30-day readmission rates after hospitalization for heart failure. American journal of medical quality. 2014. 12. O’Connor M, Hanlon A, Bowels K. Impact of frontloading of skilled nursing visits on the incidence of 30-day hospital read- mission. Geriatric Nursing. 2014. 13. Carter M, Porell F. Variations in hospitalization rates among nursing home residents: the role of facility and market attri- butes. The Gerontologist. 2003; 175-191. 14. Kruger K, Jansen K, Grimsmo A, Eide G, Geitung J. Hospital admissions from nursing homes: rates and reasons. Nurs Res Pract. 2011; 2011: 247623. 15. Spector W, Limcangco R, Williams C, Rhodes W, Hurd D. Poten- tially avoidable hospitalizations for elderly long- stay residents in nursing homes. Medical Care. 2013;51(8):673-681.
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Health Care Transitions: Perceptions from Older Patients in Rhode Island
Renée R. Shield, PhD; Kali S. Thomas, MA, PhD; Rachel Ratchford, ScB
19 22 EN
ABSTRACT transitions; however, these priorities are challenged after Health care transitions are often dangerous for older pa- medical school by the exigencies of hospital routines and tients. Interviews with older adults about their health care requirements.11-13 The purpose of the research was to use the moves in Rhode Island (RI) were conducted to develop an patient perceptions of their transition experiences to develop Internal Medicine (IM) curriculum designed to provide a 3-hour curriculum with Internal Medicine (IM) interns on IM interns with insights about the impact of transitions the impact of these transitions. on patients. This paper describes some ways patients talk This paper describes these recollections, focuses on how about their transitional experiences. Following pilot in- patients perceived what happened to them and includes some terviews, 10 nursing home residents were interviewed ways patients would like physicians to speak with them. about their care transitions, conversations with physi- A separate paper, forthcoming, describes the development cians, and advice to doctors beginning their careers. The of the IM curriculum. interviews were analyzed to identify themes. Patients described multiple moves, often did not know what to expect, appreciated help from a family member and de- METHODS sired effective communications with physicians. Learn- Three nursing homes (NH) in RI agreed to participate in ing about patient experiences may help new physicians this project. The administrator, director of social work (SW) appreciate the experiences of transitions on patients. and director of nurses (DoN) of each facility helped iden- KEYWORDS: transitions of care, patient experiences, tify NH residents who might be willing to participate. Six nursing homes pilot interviews were conducted with recently hospitalized NH residents who the SW or DoN of the NH determined to be cognitively intact; these were followed by interviews with 10 community-dwelling older adults undergoing reha- bilitation in a skilled nursing facility (SNF) following a hos- INTRODUCTION pitalization. The project was explained to all respondents Problematic transitions plague the experience of older adults through an informed consent process. The respondents were in health care. Our rapidly aging population is at risk from a asked to recall the reason for hospitalization and to relate fragmented system of care in which transitions among sites events regarding transfers to and care in the emergency of care are poorly conducted, and experiences of older adults room (ER), hospital, skilled nursing facility (SNF) and any can be of secondary consideration.1 Transitions among sites conversations they remembered having with physicians. of care, even when appropriate, are linked to increased inci- Interviews were audio-recorded and transcribed, then ana- dence of delirium, hospital-acquired infections and falls, and lyzed for themes. The research was reviewed by the Brown the exacerbation of pre-existing chronic conditions.2-4 Recent University Research Protections Office and determined to literature indicates that more research is needed about these be exempt. transfers, and that improved communication and education among and by providers is key.5,6 There is increased interest in measuring patient satisfac- RESULTS tion with hospital care during hospitalizations;7-9 however, After the pilot interviews were completed, we decided to since little is known about the patient perspective regarding conduct subsequent interviews with community-dwell- transitions in sites of care, experiences of older adults must ing individuals who had recently been hospitalized and be better understood. Interviews can be effective in revealing were now undergoing rehabilitation in a SNF. Of these, one aspects of health care that are otherwise difficult to quan- respondent was 61 years old, three were in their 70s, and tify.7,10 During medical school, students may be exposed to 6 were in their 80s. All but two respondents were female. principles of patient-centered care, the importance of com- A few prominent themes from the interviews are discussed munication, and in some cases, the dangers inherent in care below with illustrative quotes from the respondents.
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Respondents describe multiple moves floor…[to]…get my food tray…It’s busy…they still have Multiple moves were common occurrences related in inter- to clean the bed, wash, wipe the bed down, change views. Some respondents had transfers beyond those from the linens’…so it wasn’t until about 7 o’clock when home to the ER, admission to the hospital, and eventual I came up here.” transition to the SNF. For example, one went to a local urgent care facility, then a hospital ER before admission to Respondents often did not know what to expect the hospital and transfer to the SNF. Three went to two hos- Confusion and/or not knowing what to expect was another pitals after the ER. One was admitted to the hospital, then refrain heard in these interviews. One respondent said, “I went to the intensive care unit and then back to a hospital really didn’t know. I was just in ‘blah’, and I was kept think- floor before entering the SNF. After admission to the SNF, ing, where am I gonna go?” Another similarly recalled what a few then experienced moves within the SNF. The follow- may have been delirium: ing excerpts are examples of recollections of ER and hospital “I had a really scary experience of not knowing what I experiences. This respondent had positive memories: was, who I was, or what was going on. It was scary fright- “[All I] remember is the fast ride, sirens going and feeling ening…I kind of went into la la land…It was really weird, this blood coming out of my legs you know. It just seemed and then they assured me that this …happens because of like one big drama, personal drama anyway. And I don’t the pain medication…it was this terrible experience I had of know, I wasn’t worried about it…They were so friendly… being somewhere else, me being someone else. Just disori- and they weren’t the least bit afraid [of] this bleeding ented…I felt very much alone…” patient…I realized this is not a big thing to those who are Some wanted more information than they remembered taking care of me…because they were so relaxed…I began was given. One respondent said, “They didn’t explain hardly to relax.” anything…I did have questions but they never asked me An 87-year-old participant described caring ambulance about questions.” drivers: “Their personality and the way they treated you, Another recalled, “What really irritated the hell out of you know. Like you wasn’t just a nothing and they treated me” was that his wife knew about his upcoming hospital you with compassion and very nice.” In the ER, discharge shortly before he did. “The team of people just…started hooking you up to IVs [The case manager] said, “Mr. [patient name], you know …And there was a lady doctor, very very nice… they had to you’re going to a rehab center?” I said, “Yeah I know. My take all these tests and x-rays. [The doctors] didn’t have too wife told me. You didn’t have the decency to come down much to say. They were just asking the same questions like, and tell me first? You went around my back?” “Well,” she ‘What happened?’ ” said, “we were very busy…there was so much paperwork.” However, another who recalled being in a great deal of pain said she was given a call bell to use in the ER. “They Family members could be very helpful kept saying, ‘It’ll just be a minute.’ This was obviously a lie; The assistance of a family member figured in these inter- it wasn’t just a minute. But nobody would pay attention to views. A few respondents said they did not involve them- the fact that I was uncomfortable.” She noted that despite selves in decisions about the moves or the care because a the staff’s “Ooey gooey speech” designed to be reassuring, daughter was performing this role. For example, one daugh- [they] “really didn’t care and I was just part of the problem… ter asked the respondent about the choice of SNF, and the I called, but nobody answered the call bell.” respondent said, “Just do it.” The daughter retrieved the Two respondents moved from one hospital to another. respondent’s belongings from the hospital and made sure One’s daughter was instrumental in this decision. The the medications were correct. “My daughter took care of 78-year-old respondent said, “I went to the doctor, they bring everything.” Another recalled crying much of the time and me to the hospital over here, they bring me to the other hos- relying on her daughter for decisions because she became pital. Then they bring me back to here. And they bring me confused. When asked whether doctors or other providers back and forth, I guess.” explained the care, this 87-year-old respondent answered: Moves within SNFs can be a common part of the patient’s “Yes, they did explain. But…you’re not really listening experience, too. Roommate problems sometimes resulted in for them. My daughter…really listened to them all…She room changes. A 72-year-old respondent described his frus- said, ‘Mom, this is the best place for you because how else tration in being admitted to the second floor of a NH for can you manage?…until we get to the bottom of [this]…you hours before his third-floor room was ready: have to be at the hospital.’ ” “I get in here [at 5 PM]…they move me up to the third A 78-year-old respondent asked her daughter, “You under- floor…[the] patient’s still in [his] room…So I have to go stand that?”… She said, ‘Yeah, okay Ma.’ And so I just forget back down to my original room…it’s like 6:30… I am hun- about it because I get confused if you get more [information].” gry, I am tired and the nurse…said, ‘I called up to the third
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Communication with physicians was described can be markedly different.7 Individuals in these accounts as uneven described the variety of transfers they endured and their feel- Communication with physicians was reported to range in ings of disorientation and confusion. Respondents had differ- quality and was connected to the advice respondents offered. ent needs for information and seemed reassured by a family One enjoyed being the object of concern by her providers: member’s assistance in decisions and advocacy. Their advice “I loved it. I like to talk about myself. And they were to physicians about how they would like to be talked with is interested. A couple of them even had good suggestions. a vivid reminder that their perception of communication is a And I felt as if we were moving forward, that something vital element in competent and compassionate care in diffi- was being done.” cult transitions. Attention to their stories can help improve their care at these vulnerable times. Another said: “The doctors…were very nice talking to me…they were just proper...I liked them…they made you feel at home… Acknowledgments They made me sit down, and then they sat down.” The corresponding author gratefully acknowledges the support On the other hand, one was frightened by what she of the Picker Institute, Inc. and the Arnold P. Gold Foundation recalled was a too-forceful manner in one physician’s in conducting this project. recommendation: “ ‘If you don’t do this, you will die.’ That really got References me…scared the hebegeebees right out of me. It didn’t 1. Coleman EA, Berenson RA. Lost in transition: challenges and help matters. It really shook me up.” opportunities for improving the quality of transitional care. Ann Intern Med. Oct 5 2004;141(7):533-536. 2. Priority Areas for National Action:Transforming Health Care Advice for physicians Quality: The National Academies Press; 2003. This respondent wanted the physician to “Put it a differ- 3. Bodenheimer T. Coordinating Care — A Perilous Journey ent way, you know. Sit my family down and say ‘Look, the through the Health Care System. New England Journal of Med- icine. 2008;358(10):1064-1071. blood work is this, this and that.’ But he didn’t do that.” 4. Jencks SF, Williams MV, Coleman EA. Rehospitalizations Her advice was to, “Give [patients] the opportunity to talk. among Patients in the Medicare Fee-for-Service Program. New Be patient… they’re not hearing everybody, you know?” An England Journal of Medicine. 2009;360(14):1418-1428. 86-year-old woman said simply, “Treat them like they were 5. Naylor MD, Kurtzman ET, Pauly MV. Transitions of Elders Be- tween Long-Term Care and Hospitals. Policy, Politics, & Nurs- their father. You know, be gentle.” A 77-year-old respondent ing Practice. August 1, 2009 2009;10(3):187-194. said, “They need to be reassuring and not be the master of 6. LaMantia MA, Scheunemann LP, Viera AJ, Busby-Whitehead everything… people have their own way of thinking and J, Hanson LC. Interventions to Improve Transitional Care Be- organizing themselves. And it’s up to the doctor to pick up tween Nursing Homes and Hospitals: A Systematic Review. Journal of the American Geriatrics Society. 2010;58(4):777-782. on that.” An 83-year-old respondent had this specific advice 7. Coughlin C. An ethnographic study of main events during hos- for physicians: pitalisation: perceptions of nurses and patients. Journal of Clin- ical Nursing. 2013;22(15-16):2327-2337. “Slow down. Just remember we have some physical diffi- 8. Goldstein E, Farquhar M, Crofton C, Darby C, Garfinkel S. Mea- culty…I think I am more with it than most of the patients suring Hospital Care from the Patients’ Perspective: An Over- here. And even I am exhausted by them. The people stand view of the CAHPS® Hospital Survey Development Process. over me too close; if they move too fast, I get out of breath. Health Services Research. 2005;40(6p2):1977-1995. And I am just physically wiped out. And I am perfectly 9. Bowling A, Rowe G, Lambert N, et al. The measurement of pa- tients’ expectations for health care: a review and psychometric capable of having a party with a team of doctors, but testing of a measure of patients’ expectations. Health Technol they’ve got to do it at my pace a little bit…It would be nice Assess. Jul 2012;16(30):i-xii, 1-509. if they talked a little bit about our particular backgrounds. 10. Pope C, Mays N. Reaching the parts other methods cannot reach: an introduction to qualitative methods in health and …Many doctors make us feel that we’re cute and precious health services research. BMJ. Jul 1 1995;311(6996):42-45. and gee just doing well. But, they don’t think of us as real 11. Shield R, Tong, I, Tomas, M, Besdine, R. Teaching communi- human beings.” cation and compassionate care skills: An innovative curric- ulum for pre-clerkship medical students. Medical Teacher 2010;33(8):e408-416. 12. Yedidia MJ, Gillespie CC, Kachur E, et al. Effect of commu- CONCLUSION nications training on medical student performance. JAMA This small sample of interviews reveals how some older : the journal of the American Medical Association. Sep 3 2003;290(9):1157-1165. patients in RI experienced their care transfers among hos- 13. Pedersen R. Empathy development in medical education – A pitals and SNFs. Their stories reflect patient vulnerability critical review. Medical Teacher. 2010;32(7):593-600. after a hospitalization with disruptions in sleep and other 14. Krumholz HM. Post-hospital syndrome--an acquired, tran- routines and when pain is common.14 The quotes remind sient condition of generalized risk. N Engl J Med. Jan 10 2013;368(2):100-102. us that patient and provider perceptions of medical events
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Authors Correspondence Renée R. Shield, PhD, is Professor of Health Services, Policy Renée R. Shield, PhD and Practice (Clinical) at the Center for Gerontology and Center for Gerontology and Healthcare Research Healthcare Research, Brown University School of Public Health. School of Public Health Kali Thomas, PhD, is a Research Health Science Specialist at Box G-121 (6) the Providence VA Medical Center and Assistant Professor Brown University (Research) of Health Services, Policy, and Practice, Brown 121 South Main Street University School of Public Health. Providence, RI 02912 Rachel Ratchford, ScB, completed her degree in Human Biology at 401-863-9958 Brown University in 2013 and is now a Business Analyst at the René[email protected] Public Consulting Group.
Disclaimer The views expressed in this paper are solely those of the authors.
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The Goals of Care Conversation: A tool to improve patient care in the nursing home at the end of life
Edward W. Martin, MD, MPH
23 25 EN
ABSTRACT and independence. As an illness progresses, the goal may Patients residing in nursing homes may undergo burden- then shift to maintaining or improving quality of life and some transitions in care during the final months of life. then finally to having a peaceful death.D iscussion of goals They may get care they do not want and are unlikely to of care should be held on admission to the nursing home and benefit from. Patients and families may not understand then repeated at regular intervals, particularly when there prognosis or the potential benefits of treatment. A “goals are changes in health status. of care” conversation can be the critical first step in iden- Before establishing goals of care, it is important that tifying a patient’s wishes and then developing a plan of patient and family understand where the patient is in his/ care that honors those wishes. When the goal of care is her illness. Goals may change significantly as the prognosis to focus on comfort, hospice can be accessed. Hospice is better understood. Research has shown that many patients can help ensure that the patient’s final time is spent in are unaware of their prognosis. Many patients with heart comfort and that the family’s needs are attended to both failure, for example, did not understand that their heart dis- before and after the patient dies. ease would limit their life expectancy.2 Patients with renal KEYWORDS: end of life, hospice, communication, advance disease on dialysis were much more optimistic about their 3 care planning prognosis than their physicians. Those patients who under- stood they had a poorer prognosis were less likely to want potentially life prolonging care. Families may not under- stand that dementia is a terminal illness.4 Honest discussion about prognosis can begin to address some of these misun- INTRODUCTION derstandings. It is important when outlining prognosis that Patients residing in nursing homes often undergo burden- jargon be avoided. Also vague and evasive comments about some transitions in the final weeks and months of life.1 prognosis like “only God knows” or “I don’t have a crystal Patients may return to the hospital for care they did not ball” are not helpful, especially when it is clear the patient want and were not likely to benefit from. Identifying the has a limited life expectancy and is seeking information to patient’s goals, values and preferences and then developing inform decision-making. a plan of care based on these can help to improve care in the Concerns are sometimes raised by family or nursing home final weeks of life. A goals of care discussion is the critical staff that discussing these issues may be upsetting to the first step in determining what care is most likely to benefit patients. However, it has been shown that patients who the patient in achieving their goals, what care is not con- have conversations about the kind of care they want at the sistent with their goals, and what options, such as hospice, end of life are not more likely to develop depression than would help meet their goals. Common goals of care include: those who do not engage in these types of conversations.5 curing disease, avoiding premature death, maintaining or They are, however, less likely to get aggressive care at the improving function, prolonging life, relieving pain, enhanc- end of life. ing comfort, maintaining or improving function, and dying peacefully. DECISION-MAKING CAPACITY AND GOALS OF CARE GOALS OF CARE MAY NOT BE STATIC In the nursing home, many patients have dementia and it The goals of care will typically change as an illness pro- will be important to assess decision- making capacity. The gresses. A patient in the nursing home may have experi- patient must be able to understand the clinical information, enced a lifetime of medical care with goals that focused on use the information to make a decision and understand the curing illness and prolonging survival. Patients may have consequences of the decision. If the patient is not able to endured discomfort and, at times, suffering to achieve these make medical decisions, the surrogate named in the advance goals. They may come to a point where cure is not possible directive will need to be consulted. If a surrogate has not and the goals of care may change to maintaining function been designated, the family can assist in determining goals
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and making decisions. In speaking to families it is import- practitioner input in developing the plan of care is critical. ant that they understand the role of surrogate. The family One error that is sometimes made in discussing the plan should not be asked what they want done for the patient of care is to focus solely on what will not be done (e.g., no but instead they should be asked to assist in determining intubation, no CPR, no hospitalization). This may leave the what the patient wanted. This clarification can be critical to patient and family wondering what will happen as they are alleviate some of the burden that the family may feel. Some dying. They will need to be informed how pain, dyspnea, and may feel that they are being asked to “play God” if they are suffering will be effectively managed and be reassured that solely responsible for the decision making process. care will not be withdrawn. When the patient is unable to participate in the discussion, Patients and families may still have misconceptions about the family or others will need to assist in identifying the the benefits of various interventions. CPR in particular may goals and values of the patient. Ideally the patient has left an be misunderstood. Patients and families may vastly overes- advance directive. This serves two purposes. The document timate the success of CPR and may make decisions based can identify the person the patient has designated to speak on that misinformation. Learning about the futility of this for them when they are unable to speak for themselves. It intervention in certain settings and conditions may change can also help in describing preferences for care in the setting the likelihood of requesting it.6 Benefits of dialysis for nurs- of an advanced illness. The Rhode Island Durable Power of ing home patients may also be misunderstood. It has been Attorney for Health Care form helps patients to note these shown that most patients residing in a nursing home who preferences. The form presents three scenarios, one when begin dialysis will die or have a significant decline in function actively dying, the second describing a persistent vegetative in the year following initiation of dialysis.7 Patients receiv- state and the third advanced dementia. Given those scenar- ing chemotherapy or radiation for advanced cancer often do ios, patients are asked to note if they would want a feeding not understand that the treatment is not likely to cure their tube or life support. Patients also have the opportunity to cancer.8,9 Many families may assume that the placement of describe other wishes or limits they want. This information a feeding tube will benefit a patient with advanced dementia can be very helpful in guiding the discussion. whose dietary intake has declined. Research has shown that The medical history may also provide some clues as to the placement of a percutaneous endoscopic gastrostomy what the patient might want. Family history in many cases tube does not prolong survival.10 It is important to assess simply reads “noncontributory.” It is certainly true that patient and family understanding of the benefits or the treat- the cause of death of parents of the terminally ill patient is ment options they are considering, or they may be opting for very unlikely to impact the care of the patient. How they interventions that are unlikely to help them. died however, often provides important insight into what Patients, families, and nursing home staff may not under- the patient might have wanted as their death is approach- stand the benefits of antibiotics in a dementia patient with ing. If, for example, a parent died after a prolonged hospital pneumonia. Antibiotics are often viewed as a comfort mea- stay with multiple unwanted interventions, the patient may sure by the staff; however, research has shown this is not have commented on the kinds of things they wouldn’t have the case. Patients with dementia who were given antibiotics wanted in that situation. If a parent died at home among were actually found to be more uncomfortable than patients family and friends, this may also have elicited some com- who did not receive antibiotics.11 Antibiotics did however ments by the patient. prolong survival of patients with advanced dementia and The social history may also have some important infor- pneumonia. Again, it is critical to determine what the goals mation. The number of cigarettes smoked and the amount of of care are at that point. alcohol consumed is unlikely to be of great benefit in estab- lishing goals of care. Instead, an appreciation of the kinds of activities that brought quality to the patient’s life can be THE ROLE OF HOSPICE extremely helpful. The clinician may learn if the patient If it is determined that quality of life and comfort are the was someone who valued independence or if they were quite goals of care, then hospice may be helpful in achieving those satisfied with a more sedentary and dependent role; these goals. Research has shown that nursing home residents who are clues that may help direct the discussion about patient receive hospice care are less likely to be hospitalized.12 It goals and preferences. has also been shown that management of pain is better for nursing home resident residents enrolled in hospice than for those not receiving hospice care.13 Many nursing home resi- DEVELOPING A PLAN OF CARE dents do access hospice care which can improve the quality Once the patient’s goals and values have been elicited, a of life. Unfortunately for many residents, it is only accessed plan of care can be developed. When the goal is to have com- for the final days of life, often after multiple hospitalizations. fort for the final weeks of life, the plan of care will be very Some dying patients may leave the hospital and go to the different than when the goal is prolonged survival, even if nursing home as skilled patients so that Medicare will pay it requires burdensome interventions. Strong physician or for the room and board. If they go to the nursing home with
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hospice care at the routine level, the family will be required References to pay the daily room and board rate which can be up to 1. Gozalo, P., et al., End-of-life transitions among nursing home $300 a day or more. Medicaid may cover this cost for those residents with cognitive issues. N Engl J Med, 2011. 365(13): p. 1212-21. patients who meet eligibility guidelines and established in 2. Allen, L.A., et al., Discordance between patient-predicted and that state. This creates a disincentive for patients to access model-predicted life expectancy among ambulatory patients their Medicare hospice benefit following a hospitalization. with heart failure. JAMA, 2008. 299(21): p. 2533-42. Research has shown that patients who receive skilled care 3. Wachterman, M.W., et al., Relationship between the prognostic expectations of seriously ill patients undergoing hemodialysis are less likely to use hospice and are more likely to have and their nephrologists. JAMA Intern Med, 2013. 173(13): p. a short hospice stay, and those patients without hospice in 1206-14. place are much more likely to return to the hospital.14 4. Mitchell, S.L., et al., The clinical course of advanced dementia. If decisions have been made to limit potentially life-pro- N Engl J Med, 2009. 361(16): p. 1529-38. 5. Wright, A.A., et al., Associations between end-of-life discus- longing interventions, the Medical Orders for Life Sus- sions, patient mental health, medical care near death, and taining Treatment (MOLST) form can be completed. This caregiver bereavement adjustment. JAMA, 2008. 300(14): p. document ensures that the patient’s wishes for care will be 1665-73. honored if they leave the nursing home for another setting. 6. Murphy, D.J., et al., The influence of the probability of survival on patients’ preferences regarding cardiopulmonary resuscita- It includes preferences for CPR, comfort care, feeding tubes, tion. N Engl J Med, 1994. 330(8): p. 545-9. and hospitalization. 7. Kurella Tamura, M., et al., Functional status of elderly adults For many patients in the final weeks and months of life before and after initiation of dialysis. N Engl J Med, 2009. hospice can provide tremendous benefit not just to the 361(16): p. 1539-47. 8. Weeks, J.C., et al., Patients’ expectations about effects of che- patient but to the patient’s family and caregivers. Hospice motherapy for advanced cancer. N Engl J Med, 2012. 367(17): can help ensure that the patient final time is spent in com- p. 1616-25. fort and that the family’s needs are attended to both before 9. Chen, A.B., et al., Expectations about the effectiveness of radia- and after the patient dies. tion therapy among patients with incurable lung cancer. J Clin Oncol, 2013. 31(21): p. 2730-5. 10. Teno, J.M., et al., Does feeding tube insertion and its timing improve survival? J Am Geriatr Soc, 2012. 60(10): p. 1918-21. 11. Givens, J.L., et al., Survival and comfort after treatment of pneumonia in advanced dementia. Arch Intern Med, 2010. 170(13): p. 1102-7. 12. Gozalo, P.L. and S.C. Miller, Hospice enrollment and evaluation of its causal effect on hospitalization of dying nursing home patients. Health Serv Res, 2007. 42(2): p. 587-610. 13. Miller, S.C., et al., Does receipt of hospice care in nursing homes improve the management of pain at the end of life? J Am Geri- atr Soc, 2002. 50(3): p. 507-15. 14. Miller, S.C., et al., Dying in U.S. nursing homes with advanced dementia: how does health care use differ for residents with, versus without, end-of-life Medicare skilled nursing facility care? J Palliat Med, 2012. 15(1): p. 43-50.
Author Edward Martin, MD, MPH, is Chief Medical Officer at Home and Hospice Care of Rhode Island and Clinical Associate Professor of Medicine at the Alpert Medical School of Brown University.
Disclaimer The views expressed herein are those of the author alone.
Correspondence Edward Martin, MD, MPH Home and Hospice Care of Rhode Island 1085 North Main Street Providence, RI 02904 401-415-4204 [email protected]
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Hospice and Palliative Care in Nursing Homes: Challenges and Opportunities for Enhanced Access
Susan C. Miller, PhD
26 29 EN
ABSTRACT are difficult) and the use of Medicare Part A Skilled Nursing The use of hospice care in nursing homes (NHs) has Facility (SNF) care by terminally ill (often dying) residents grown exponentially, but an increasing concern is the who cannot simultaneously choose hospice. lack of access to resident and family-centered palliative care when residents do not elect hospice, and in time pe- riods prior to election. This concern is amplified by the CONTEXT OF HOSPICE AND PALLIATIVE CARE high magnitude of palliative care needs present for NH USE IN THE NH residents (and their families) when the NH will be their Sixty-three percent of hospice enrollees in 2012 had non-can- final residence; and, it is amplified because of short hos- cer diagnoses,7 but the proportion was closer to 80% in NHs. pice stays, half of which are 22 days or less. This manu- Also, 67% of older adults dying with dementia die in NHs.8 script describes the use of the Medicare hospice care in To be enrolled in Medicare hospice, physicians must certify NHs and discusses the policy, staff and physician barriers that patients have a six-month terminal prognosis (if the dis- to timely hospice referral. It also describes the challeng- ease runs its normal course). For NH residents with chronic es NHs face in expanding residents’ access to palliative terminal illnesses, and in particular with dementia, the care. Opportunities and approaches for increasing palli- determination of a six-month prognosis is imprecise in prac- ative care expertise and practice in NHs are presented. tice; research attempting to predict mortality has had only 9 KEYWORDS: Hospice, palliative care, nursing homes, limited success. Given this difficulty and the high preva- Medicare lence of chronical terminal illness in NHs, hospice NH resi- dents have high proportions of both very short and very long hospice stays. In 2012, for example, the median length of hospice stays was 27 days for patients receiving home hos- pice compared to 22 days for NH hospice. Still, while 50% INTRODUCTION of NH hospice patients had stays of 22 days of less, 10% had This manuscript discusses the barriers to timely hospice stays of 335 days or longer, resulting in an average hospice care for nursing home (NH) residents and the associated length of stay of 112 days in NHs compared to 90 days for need for expansion of nonhospice palliative care in NHs. home hospice.10 Hospice care provided in NHs is now common. While In addition to the above, the admission or readmission 14% of dying NH residents nationally received hospice in 1999, in the first six months of 2010, Figure 1. Growth in Nursing Homes Hospice Use – 1999 through 2010. this proportion rose to 40% (see Figure 1); and, in 2010 it was 68% in Rhode Island. This growth 45 39.8 in hospice use is believed to be beneficial to 38.6 40 37.0 NH residents, given the substantial research 35.4 showing hospice enrollment to be associated 35 32.6 29.3 with lower end-of-life hospital use, lower use 30 27.0 of aggressive end-of-life treatments (e.g., tube 25 23.7 feeding, intravenous fluids, other), higher-qual- 21.0 18.3 ity symptom management, and family reports 20 15.3 1-6 of superior care. However, there are concerns 15 13.4 regarding the high rates of short hospice stays 10 and thus the limited exposure to palliative care expertise by residents and their families. In NHs, Percent of Decedents Accessing Hospice 5 major barriers to timely referral are the high 0 proportion of residents with chronic terminal 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 illnesses (for which determination of prognoses Year
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Transitions/End-of-life Care in RI
of NH residents to Medicare Part A SNF care when they without SNF care. Additionally, 14% of residents with end- are near death or actively dying has a profound impact on of-life SNF care died in a hospital compared to 9% of those Medicare hospice use since Medicare disallows simulta- without SNF care.12 neous hospice and SNF care (if SNF care is related to the While hospice eligibility guidelines and Medicare payment terminal condition). Still, 12% of Medicare SNF residents restrictions challenge timely hospital referral, other referral die within 90 days of admission.11 Residents admitted or challenges exist as well. NH staff practices and knowledge returning to NHs from (3-day) hospital stays qualify for also influence the timing of hospice referral. Through inter- NH SNF care when skilled observation and assessment views conducted in RI, we found earlier hospice referral was are required or when they receive therapy or complex ser- facilitated when NH staff was able to recognize the familiar vices (e.g., intravenous feeding, intramuscular injections, signs of terminal decline, took initiative in raising and dis- other). There are financial incentives for choosing Medi- cussing the option of hospice with physicians, residents and care SNF care instead of private-pay or Medicaid NH care, families, and when staff believed hospice added value and and thus there is concern about its inappropriate use. For was not only for the “very end.”13 Also, at the time of our private-pay residents/families, with SNF enrollment, a sub- study none of the study NHs had written procedures regard- stantial Medicare co-payment is received and out-of-pocket ing assessment of residents’ prognoses or eligibility for hos- expenditures are substantially reduced. For NHs, admission pice, or for communicating with physicians, residents and of Medicare/Medicaid (dually) enrolled residents to SNF families regarding such outcomes. However, according to care translates into NHs receiving the substantially higher new CMS surveyor interpretive guidelines,14 surveyors are Medicare per diem payment instead of the lower Medicaid instructed to assess whether NHs have practices in place to payment. Research on NH decedents with advanced demen- regularly assess whether residents are “approaching end-of- tia (i.e., moderately severe to severe dementia) found 40% life;” and surveyors are instructed to look for evidence that received Medicare SNF care in the 90 days prior to death. interdisciplinary teams have addressed the discussions and Of these, 30% received hospice compared to 46% of those considerations regarding advance care planning needed to without SNF care; and, 40% of hospice enrollees (post-SNF) clarify residents’ goals and care preferences.14 had short hospice stays (≤ 7 days) compared to 19% of those
Figure 2. “Pocket Care” Information on When to Consider Palliative or Hospice End-of-Life Care
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HOW PHYSICIANS AFFECT HOSPICE REFERRAL with end-of-life care decision making. There are no progno- Ultimately, residents and their families (and NH staff) rely sis requirements associated with receipt of palliative care on physicians for information regarding prognosis, and for consults, and they can be provided to residents enrolled in referral to hospice. Thus, physician behavior is a key deter- Medicare SNF care. Anecdotal findings show the efficacy of minant in enabling hospice access. However, several phy- palliative care consults in NHs to be promising,18 but there sician-related barriers to timely hospice referral have been has been little comparative research of their benefits.H ow- found, including lack of knowledge about hospice, negative ever, one NH with a NH-staffed consult program found res- perceptions of hospice, discomfort communicating poor idents with consults had greater reductions in depression prognoses, fear of losing control of the patient, and delay- and in emergency room visits, compared to its matched res- ing the discussion of hospice until the patient was actively idents without consults.19 Also, preliminary findings from dying.15,16 To assist physicians with determining when our ongoing longitudinal research show that when NHs palliative or hospice care should be considered, “pocket introduce palliative care consults, their residents’ rates of card” information has been developed (see Figure 2). Also, end-of-life hospital use decrease, compared to rates of NHs the American Medical Directors Association (AMDA) has who have not yet introduced consults.20 developed a palliative care took kit to assist physicians in providing optimal care to long-term care residents with EDUCATION AND TRAINING EFFORTS chronic and progressive illnesses.17 In particular, this tool kit Selective staff recruitment and staff and medical director addresses how “all members of the interdisciplinary team education and training are other ways for NHs to increase can help physicians become more proficient in the assess- the presence of palliative care expertise. In recent interviews ment and relief of suffering.”17 As discussed below, surveyor of NH administrators, most cited hospice alone as their only interpretive guidelines address the expected care practices resource for providing staff with palliative care education.21 when residents are assessed to be approaching end of life. However, other resources for education and training are For NH residents approaching end of life, the Medicare/ available but are certainly not in abundance. Through the Medicaid surveyor interpretive guidelines ask surveyors to End-of-Life Nursing Education Consortium (ELNEC) project determine whether care is driven by resident preferences a train-the-trainer education program in palliative care was and is palliative – patient and family-centered care that opti- developed, and there is palliative care geriatric curriculum.22 mizes quality of life by anticipating, preventing and treating NHs can send a nurse for ELNEC training, and when they physical or psychological suffering.14 This surveyor guideline return, they can convey this information to other NH nurses pertains to all residents regardless of their hospice status; and aides. Attendees also have the opportunity to become thus, it intensifies the need for NHs to increase the avail- certified in hospice and palliative care. Also, in addition ability of palliative care expertise to enable assessment and to AMDA’s palliative care tool kit discussed earlier, other management of residents’ physical and psychosocial needs. relevant clinical guidelines are available.23 For example, Since many RI NHs through their “culture change” efforts guidelines on pain management and on managing an “acute have adopted practices and environments enabling patient change of condition” are available. and family-centered care, they are well-equipped to meet In addition to the above, quality improvement organiza- this aspect of the guideline. However, these and other NHs tions (QIO) or culture change coalitions in some states have may lack the palliative care expertise needed to ameliorate led initiatives to assist in improving NH staff’s palliative intractable symptoms such as persistent pain or dyspnea or care knowledge and practice. 23-25 In Rhode Island, for exam- the staffing or expertise to address residents’ (and families’) ple, the QIO (Healthcentric Advisors) recently conducted a psychosocial and spiritual needs. NHs can gain this expertise NH palliative care collaborative with staff from 16 facilities. internally through education and training efforts or through Staff-initiated improvement efforts focused on one of six hall- selected recruitment; and, it can be obtained externally as marks of palliative care: identifying proxy decision-makers, discussed below. advance care planning, pain assessment, discussion of resi- Medicare hospice expands the availability of palliative dent prognosis, discussion of resident goals, and assessment care expertise to NH residents, but for residents unable or and access to spiritual care. The palliative care collaborative unwilling to access hospice and prior to hospice enrollment, facilitated improvement through staff sharing of informa- other approaches are needed. One approach for expanding tion on their change efforts and resulting achievements.24 In access to palliative care expertise is the use of palliative addition, other PC education was provided to staff; and 20 care consults. These consults may be provided by internal NH nurses were funded to attend ELNEC training. A prod- NH experts but are also often available to NH residents by uct of this RI initiative is a palliative care toolkit that is external providers (most often through hospice-affiliated available for free on Healthcentric Advisors’ website.25 This organizations).18 Physicians order palliative care consults tool kit contains a wealth of information including guidance (often at the suggestion of NH staff) to assist in managing on assessing pain and having resident/family discussions intractable physical symptoms or to assist in addressing res- regarding prognoses and goals of care. It also contains links ident/family psychosocial needs, including the need for help to numerous palliative care organizations and guidelines.
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CONCLUSION 17. American Directors Medical Association: Palliative Care Tool- kit. 2014; http://www.amda.com/resources/ltcis.cfm#LTCPC1. While there has been a large increase in hospice use in Accessed December 4, 2014. NHs, many residents still do not access hospice or access it 18. Carlson MD, Lim B, Meier DE: Strategies and innovative mod- only weeks prior to death. To adequately care for residents els for delivering palliative care in nursing homes. J Am Med Dir with chronic and progressive illnesses, an increase in the Assoc. 2011;12(2):91-98. presence of palliative care expertise within NHs is needed. 19. Comart J, Mahler A, Schreiber R, et al.: Palliative care for long- term care residents: effect on clinical outcomes. Gerontologist. This increase can be achieved through earlier hospice refer- 2013;53(5):874-880. ral, use of external palliative care expertise, selected staff 20. Miller SC, Lima J, Dahal R, et al.: The Provision of Palliative recruitment, or by investing in the training and education Care Consultations in Nursing Homes and End of Life Hospital- izations. Paper presented at: Poster session presented at: Mak- of staff and physicians. Resources are available to assist in ing Connections From Cells to Societies. 67th Annual meeting this effort. of the Gerontological Society of America; November 5-9, 2014; New Orleans, LA. 21. Tyler DA, Shield RR, Miller SC: Diffusion of Palliative Care in References Nursing Homes: Lessons from the Culture Change Movement. 1. Miller SC, Mor V, Teno J: Hospice enrollment and pain assess- Journal of pain and symptom management. 2014. ment and management in nursing homes. J Pain Symptom Man- 22. American Association of Colleges of Nursing (AACN): End-of- age. 2003;26(3):791-799. Life Nursing Education Consortium (ELNEC) Fact Sheet. 2014; 2. Teno JM, Clarridge BR, Casey V, et al.: Family perspectives on http://www.aacn.nche.edu/elnec/about/fact-sheet. Accessed end-of-life care at the last place of care. JAMA. 2004;291(1):88- November 25, 2014. 93. 23. American Medical Directors Association: Clinical Practice 3. Gozalo PL, Miller SC: Hospice enrollment and evaluation of its Guidelines in the Long-Term Care Setting. 2012; http://www. causal effect on hospitalization of dying nursing home patients. amda.com/tools/guidelines.cfm. Accessed December 4, 2014. Health Serv Res. 2007;42(2):587-610. 24. Healthcentric Advisors: Nursing Home Palliative Care Collabo- 4. Baer WM, Hanson LC: Families’ perception of the added value of rative. 2014; http://www.healthcentricadvisors.org/nhpcc.html. hospice in the nursing home. J Am Geriatr Soc. 2000;48(8):879- Accessed November 25, 2014. 882. 25. Healthcentric Advisors: Nursing Home Palliative Care Tool Kit. 5. Miller SC, Mor V, Wu N, et al.: Does receipt of hospice care in 2014; http://www.healthcentricadvisors.org/resources/alphain- nursing homes improve the management of pain at the end of dex/resources/n.html. Accessed November 25, 2014. life? J Am Geriatr Soc. 2002;50(3):507-515. 6. Kiely DK, Givens JL, Shaffer ML, et al.: Hospice use and out- Author comes in nursing home residents with advanced dementia. jour- Susan C. Miller, PhD, is a Professor of Health Services, Practice nal of the American Geriatrics Society. 2010;58(12):2284-2291. and Policy (Research) at the Center for Gerontology and 7. National Hospice and Palliative Care Organization: NHP- Healthcare Research, Brown University School of Public CO’s Facts and Figures: Hospice Care in America. Alexandria, Health. VA2014. 8. Mitchell SL, Teno JM, Miller SC, et al.: A national study of the Disclaimer location of death for older persons with dementia. J Am Geriatr The author has no conflicts of interest to report Soc. 2005;53(2):299-305. 9. Mitchell SL, Miller SC, Teno JM, et al.: Prediction of 6-month Correspondence survival of nursing home residents with advanced demen- Susan C. Miller, PhD tia using ADEPT vs hospice eligibility guidelines. JAMA. Center for Gerontology and Healthcare Research 2010;304(17):1929-1935. Brown University School of Public Health 10. MedPac: Report to the Congress: Medicare and the Health Care Delivery System. Washington DC: Medicare Payment Advisory 121 South Main Street Commission; 2013, pp. 117-142. Providence, RI 02912 11. Magaziner J, Zimmerman S, Gruber-Baldini AL, et al.: Mor- 401-863-9216 tality and adverse health events in newly admitted nursing Fax 401-863-9219 home residents with and without dementia. J Am Geriatr Soc. [email protected] 2005;53(11):1858-1866. 12. Miller SC, Lima JC, Mitchell SL: Influence of hospice on nurs- ing home residents with advanced dementia who received Medi- care-skilled nursing facility care near the end of life. J Am Geri- atr Soc. 2012;60(11):2035-2041. 13. Welch LC, Miller SC, Martin EW, et al.: Referral and timing of referral to hospice care in nursing homes: the significant role of staff members. Gerontologist. 2008;48(4):477-484. 14. Center for Medicare & Medicaid Services: CMS Manual System Pub. 100-07 State Operations Provider Certification. Appendix PP/F tag 309. Quality of Care- Advance Copy. Baltimore, MD: Department of Health and Human Services; 2012. 15. Shield R: Physicians’ perspectives on end-of-life care: a qualita- tive inquiry. Med Health R I. 2007;90(12):391-392. 16. McGorty EK, Bornstein BH: Barriers to physicians’ decisions to discuss hospice: insights gained from the United States hospice model. J Eval Clin Pract. 2003;9(3):363-372.
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Comparison of Substance-Use Prevalence among Rhode Island and The Miriam Hospital Emergency Department Patients to State and National General Population Prevalence Estimates
Vera L. Bernardino, BSc, RN; Janette R. Baird, PhD; Tao Liu, PhD; Roland C. Merchant, MD, MPH, ScD 30 34 EN
Abstract The specific aims of this study were to: (1) compare the Objectives: Compare the prevalence of recent alcohol, prevalence of alcohol, tobacco and recent (past one to three tobacco, and drug use among patients from two Rhode Is- months) drug use/misuse among Rhode Island and The land emergency departments (EDs) to Rhode Island state Miriam Hospital ED patients to Rhode Island state and US and United States national general population estimates national general population estimates; (2) examine trends between 2010 and 2012. in substance misuse over time and age groups among these ED patients, as compared to national general population Methods: Secondary analysis of ED patient data and estimates. the National Survey of Drug Use and Health. Results: Alcohol was the most commonly reported substance, and prevalence of its use was higher among Methods ED patients than those in the national, but not the Rhode Study design Island, general population. Drug use was higher among This investigation involved a secondary analysis of data from ED patients than in the state and national general popu- the National Survey on Drug Use and Health (NSDUH), lation. For ED patients, tobacco and opioid use was high- which is an annual nationwide survey that provides national est among 26–34 year-olds, alcohol and marijuana high- and state-level estimates on the use of tobacco products, est among 18–25 years-olds, and cocaine highest among alcohol, and illicit drugs (including non-medical use of 35–49 years-olds. prescription drugs).8 We used NSDUH national and Rhode Conclusion: Rhode Island Hospital and The Miriam Island State level data from the years 2010 to 2012. To com- Hospital ED patients report a greater prevalence of sub- pare the prevalence of substance misuse in the US and the stance use than the national population and in many State of Rhode Island to that of the Rhode Island Hospital cases the state general population. and The Miriam Hospital ED patients, we compiled data from two federally funded studies: Increasing Viral Testing in the ED (InVITED) and Brief Intervention for Drug Misuse in the ED (BIDMED). InVITED and BIDMED were random- Introduction ized, controlled trials conducted from July 2010 to Decem- Substance use and misuse has been associated with increased ber 2012. The hospital Institutional Review Board approved risk for economic, legal, physical, and psychosocial negative the InVITED and BIDMED studies. consequences.1,2 The emergency department (ED) is often the health resource utilized by individuals who use and Database Descriptions misuse substances.3 In 2011, an estimated 2.5 million visits NSDUH to EDs in the United States (US) involved drug misuse or NSDUH participants are randomly selected to obtain a rep- abuse, which is equivalent to 790 visits per 100,000 people resentative cross-sectional sample of individuals 12 years- in the US.4 Between 2009 and 2011, US ED visits involving old or older residing in the US.8 Respondents are interviewed illicit drugs increased 29%.4 in their home (or another place denoted as their residence), Research suggests that screening ED patients for substance and following a face-to-face screening interview with a use, providing access to interventions, and if needed, refer- NSDUH representative, answer questions on substance use ring patients to treatment while in the ED may reduce sub- and mental health using a computer-based survey. Using stance misuse and health-related negative consequences.5 an audio computer-assisted self-interviewer (ACASI), the Determining the extent of substance misuse as well as the NSDUH asks participants about their frequency of tobacco, type of substances misused among the ED patients in Rhode alcohol and illicit drug use (marijuana/hashish, cocaine/ Island, and understanding how their prevalence compares to crack, heroin, hallucinogens, and inhalant use) and nonmed- national and state estimates, may better direct efforts address- ical use of prescription drugs (analgesic opioids, stimulants, ing the need for interventions to reduce harmful substance tranquilizers, and sedatives) during the past 30 days. The misuse among ED patients. NSDUH provides data on alcohol, tobacco, and marijuana
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use individually, but combines illicit and prescription drug were estimated and stratified by year and age group from the use into one drug use category. Data on specific drugs used national NSDUH data and from the BIDMED and InVITED only are available on a national and not a state level, and studies. Statistical comparisons of prevalence were made prevalence data are stratified for state level data in two age using 95% CIs. Non-overlapping 95% CIs indicate two prev- groups: 18–25 year-olds and ≥ 26year-olds. National data are alence estimates that are different at an α=0.05 level. available in five age groups (12–17, 18–25, 26–24, 35–49 and 50+ year-olds). Results BIDMED/InVITED Substance use/misuse prevalence by age group Also using an ACASI system, participants in the BIDMED and population and InVITED studies at the Rhode Island Hospital and The Table 1 shows the comparison of substance use/misuse prev- Miriam Hospital EDs answered questions about their past alence by age group between the NSDUH and the BIDMED/ 90 days substance use and misuse using the Alcohol, Smok- InVITED studies. Alcohol was the most commonly used sub- ing, and Substance Involvement Screening Test (ASSIST, stance across all three populations, with the ED and Rhode Version 3).9 Data on demographic characteristics also were Island state populations reporting more alcohol use than the obtained. For purposes of direct comparisons to the NSDUH national population. Among those 26 years-old or older, the state and national prevalence estimates, the baseline data Rhode Island state population reported significantly more (before randomization) from the BIDMED and InVITED alcohol use than the national and ED populations. Tobacco, studies were combined as a one dataset, and data on drug marijuana and illicit drug use was generally greater among misuse except for marijuana use were collapsed into a single the ED than the other two populations for both age groups. category. These two studies included ED patients who were 18–64-year-old Spanish or English speakers who did not have Specific substance use/misuse prevalence trends a critical illness or injury, were not mentally or physically by year and age groups unable to participate in the study, intoxicated or in the ED Figure 1 depicts trends in specific substance use/misuse for acute psychiatric illness care. between 2010 and 2012 by age groups from the NSDUH national and ED data. For tobacco and all drugs, the ED pop- Data analysis ulation reported more use of these substances than those in Prevalence of recent substance misuse was estimated by the US population across all years and age groups. There was year and by substance misuse category (alcohol, tobacco, a trend towards greater alcohol use among the ED population marijuana, and other drugs) for the NSDUH state and as well. Among the ED population, tobacco and opioid anal- national and BIDMED/InVITED databases along with 95% gesic use tended to be highest among 26–34 year-olds, alco- confidence intervals (CIs). Prevalence estimates were strati- hol and marijuana were highest among 18–25 year-olds, and fied by age groups (18–25 year-olds and≥ 26 year-olds). Prev- cocaine was highest among 35–49 year-olds, as compared to alence of specific substances used recently (tobacco, alcohol, other age groups. In general, prevalence of substance use was marijuana, cocaine, opioid analgesics, and illicit opioid use) stable across the three years of data.
Table 1. Recency of substance use from NSDUH national and Rhode Island State data and RIH/TMH ED data for the years 2010, 2011, and 2012
United States* State of Rhode Island* RIH/TMH ED** n=206,222 n=2,768 n=6,432 18–25 years-old 26+ years-old 18–25 years-old 26+ years-old 18–25 years-old 26–64 years-old Substances % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI)
Tobacco 39.3 (38.8-39.8) 26.8 (26.3-27.3) 41.6 (38.5-44.8) 27.8 (25.0-30.8) 45.0 (42.6-47.5) 43.3 (42.0-44.7)
Alcohol 60.6 (60.0-61.3) 55.1 (54.5-55.7) 72.1 (69.1-74.9) 66.3 (62.8-69.7) 71.0 (68.7-73.2) 58.5 (57.2-60.0)
Marijuana 18.7 (18.3-19.2) 4.9 (4.7-5.2) 30.7 (27.9-33.7) 9.2 (7.5-11.3) 43.3 (40.8-45.8) 21.2 (20.1-22.4)
Illicit drugs including marijuana 21.4 (20.8-21.9) 6.6 (6.4-6.9) 33.4 (30.4-36.5) 11.9 (9.9-14.2) 45.9 (43.4-48.4) 26.8 (25.6-28.1)
Illicit drugs excluding marijuana 7.3 (7.0-7.6)ǂ 2.6 (2.4-2.7)ǂ 9.9 (8.2-11.9)ǂ 4.0 (2.9-5.4)ǂ 14.2 (12.5-16.0)ǂǂ 12.3 (11.3-13.2)ǂǂ
*= sample interviewed ages > 12 years-old; **=sample included ages 18-64 years-old; ǂ = marijuana/hashish, cocaine (including crack), heroin, hallucinogens, inhalants, or prescription-type psychotherapeutics (pain relievers, tranquilizers, stimulants, and sedatives) used non-medically; ǂǂ =marijuana, cocaine (including coke, crack), metham- phetamines (crank, crystal methamphetamine, ecstasy or 3,4-methylenediozymethamphetamine (MDMA), tweak), Inhalants, hallucinogens, illicit opioids (heroin or opium), gama-Hydroxybutyric acid, Amphetamines, benzodiazepines, barbiturates, methadone, prescription opioids Key: NSDUH= National Survey on Drug Use and Health; RIH=Rhode Island Hospital; TMH=The Miriam Hospital; ED=Emergency Department
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Figure 1. Trends in specific substance use between 2010 and 2012 by age groups from the NSDUH national and RIH/TMH ED data
Key: NSDUH= National Survey on Drug Use and Health; RIH=Rhode Island Hospital; TMH=The Miriam Hospital; ED=Emergency Department
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Discussion Grants This investigation highlights many concerning findings This research was supported by grants from the National Institute about substance misuse among Rhode Island residents and on Drug Abuse (R01 DA026066, R21 DA28645) and the Lifespan/ Tufts/Brown Centers for AIDS Research (P30 AI042853). Clinical- in particular those who receive medical care at the two Trials.gov identifiers: NCT01419899, NCT01124591. Rhode Island EDs. As noted, substance misuse among these populations is higher than the general population across the Acknowledgment rest of the US, which indicates the need for action to reduce The research team gratefully acknowledges the assistance of the burden of misuse in our community. Of particular con- Wentao Guan in preparing this publication. cern is the consistent trend from 2010 to 2012 of high sub- References stance misuse among younger ED patients (18–25 year-olds). 1. Brewer RD, MH S. Binge drinking and violence. JAMA. 2005;294 Screening brief intervention and referral for treatment (5):616-618. (SBIRT) is an approach to identify individuals who might 2. Lipsky S, Caetano R, Field CA, Larkin GL. Psychosocial and benefit from interventions for their substance misuse.11 substance-use risk factors for intimate partner violence. Drug Alcohol Depend. 2005;78(1):39-47. This approach has been used in primary care as well as ED 3. D’Onofrio G, Becker B, Woolard RH. The impact of alcohol, to- settings for tobacco, alcohol and other substance misuse.12 bacco, and other drug use and abuse in the emergency depart- Our data suggests that the ED is a health care setting where ment. Emerg Med Clin North Am. 2006;24(4):925-967. many individuals who misuse substances could be identified 4. Substance Abuse and Mental Health Services Administration. as the first step to receiving appropriate treatment. We also The DAWN Report: Highlights of the 2011 Drug Abuse Warn- found that age is an important factor in identifying where ED ing Network (DAWN) Findings on Drug-Related Emergency De- SBIRT resources might be directed. Our analyses showed that partment Visits. Rockville, MD. 2013. younger ED patients (18–25 years-old) are using substances 5. D’Onofrio G, Degutis LC. Integrating Project ASSERT: a screen- ing, intervention, and referral to treatment program for un- such as alcohol and illicit drugs at greater frequency than healthy alcohol and drug use into an urban emergency depart- older ED patients or those of the same age in the national ment. Acad Emerg Med. Aug 2010;17(8):903-911. and state population samples. Research suggests that early 6. Levi J, Segal LM, Fuchs MA. Prescription Drug Abuse: Strate- initiation of drug use is associated with an increased risk of gies to Stop the Epidemic, 2013. Robert Wood Johnson Founda- a more negative drug use trajectory including an increased tion; 2013. risk of injection drug use13, as well as alcohol and drug 7. Sanjuan P, SL R, K W, Mandler R, C C, MP B. Alcohol, tobacco, dependence.14,15 Our finding suggests that secondary preven- and drug use among emergency department patients. Drug Al- cohol Depen. 2014;138:32-38. tive interventions targeted for younger adults (18–25 years) 8. Substance Abuse and Mental Health Services Administration. who present for care at our EDs are needed. National Survey on Drug Use and Health: About the survey. 2012; There were several limitations to this investigation. We https://nsduhweb.rti.org/respweb/project_description.html. were unable to separate past month and past three-month Accessed October 10th, 2014. prevalence because recency of use was estimated differently 9. Merchant RC, Baird JR, Liu T, Taylor LE, Montague BT, Niren- for the NSDUH than the BIDMED/InVITED studies. Past berg TD. Brief intervention to increase emergency department three-month prevalence, which encompasses past-month uptake of combined rapid human immunodeficiency virus and hepatitis C screening among a drug misusing population. Acad prevalence, was in many cases higher for the ED popula- Emerg Med. Jul 2014;21(7):752-767. tions. Also, since data for both the NSDUH and BIDMED/ 10. Dawson D. Methodological issues in measuring alcohol use. InVITED was based on self-report, there may be inaccuracies Bethesda, MD: National Institute on Alcohol Abuse and Alco- because reporting might have been influenced by memory holism. 2003. error and social desirability, leading to underreporting of use. 11. Bien, T. H., Miller, W. R., & Tonigan, J. S. (1993). Brief inter- vention for alcohol problems: A review. Addiction. 88, 315–335. 12. Madras BK, Compton WM, Avula D et al. Screening, brief inter- Conclusion ventions, referral to treatment (SBIRT) for illicit drug and alco- hol use at multiple healthcare sites: Comparison at intake and Compared to a national and state survey data on recent drug six months later. Drug Alcohol Depen. 2009;280–295. use, Rhode Island Hospital and The Miriam Hospital ED 13. Trenz RC, Scherer M, Harrell P, Zur J, Sinha A, Latimer W. Early patients report a greater prevalence of use of tobacco, alcohol, onset drug and polysubstance use as predictors of injection drug prescribed and illicit substances than the national popula- use among adult drug users. Addic Behav. 2012;367-372. tion and in many cases the Rhode Island general population. 14. Grant JD, Lynskey MT, Scherer JF, Agrawai A, Heath AC, Bu- Misuse was generally stable and higher among ED patients cholz KK. A cotwin-control analysis of drug use and abuse/de- pendence risk associated with early-onset marijuana use. Addic than the national general population across the three years Behav. 2010;35-41. of data. As demonstrated in this study, these EDs are set- 15. Wagner FA, Anthony JC. From fist use to drug dependence: De- tings with high prevalence of patients who could be screened velopmental periods of risk for dependence upon marijuana, co- for substance misuse and offered intervention services. caine, and alcohol. Neuropsychopharmaco. 2002;479-488.
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Authors Correspondence Vera L. Bernardino, BSc, RN, Department of Emergency Medicine, Roland C. Merchant, MD, MPH, ScD Alpert Medical School, Brown University. Department of Emergency Medicine Janette R. Baird, PhD, Department of Emergency Medicine, Alpert Rhode Island Hospital Medical School, Brown University. 593 Eddy Street, Claverick Building Tao Liu, PhD, Department of Biostatistics, Center for Statistical Providence, RI 02903 Sciences, School of Public Health, Brown University. [email protected] Roland C. Merchant, MD, MPH, ScD, Department of Emergency Medicine, Alpert Medical School, Brown University; Department of Epidemiology, School of Public Health, Brown University.
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Training Family Medicine Residents to Build and Remodel a Patient Centered Medical Home in Rhode Island: A Team Based Approach to PCMH Education
Rabin Chandran, MD; Christopher Furey, MD; Arnold Goldberg, MD; David Ashley, MD; Gowri Anandarajah, MD 35 41 EN
ABSTRACT bodies, such as the National Committee for Quality Assur- Primary Care practices in the United States are under- ance (NCQA), began offering certification of PCMHs. going rapid transformation into Patient Centered Medi- The PCMH model may be best understood as a state-of- cal Homes (PCMHs), prompting a need to train resident the-art approach to primary care focusing on coordination physicians in this new model of primary care. However, of care, working in highly effective teams, and iterative few PCMH curricula are described or evaluated in the improvement of systems to improve healthcare delivery literature. We describe the development and implemen- to a population of patients. Thus the PCMH enhances the tation of an innovative, month-long, team-based, block care provided during one-on-one doctor-patient encounters, rotation, integrated into the Brown Family Medicine Res- using a variety of team and system-based techniques which idency Program, within the context of statewide PCMH improve quality and outcomes for both the individual patient practice transformation in Rhode Island. The PCMH res- and the population of patients served by a physician or prac- ident team (first-, second- and third-year residents) gain tice. This approach is especially effective for such things PCMH skills, with progressive levels of responsibility as chronic disease management, prevention measures, and through residency. In addition to traditional supervised monitoring and management of high-risk patients within a direct outpatient care, learning activities include: active practice (eg., severely ill, geriatric, adolescent, pregnant, or participation in PCMH transformation projects, popula- substance abusing patients). tion health level patient management, quality improve- Despite a widespread movement towards the PCMH as ment activities, interdisciplinary teamwork, chronic a new model for primary care delivery, there remain many disease management (including leading group medical questions regarding the exact form this model will take both visits), and PCMH specific didactics paired with weekly in Rhode Island and the country as a whole. Additionally, projects. This new clinical block rotation and team holds educators are only just beginning to explore the training that promise as a model to train residents for future PCMH will be necessary for primary care physicians to optimally primary care practices. 3 Keywords: primary care, PCMH, patient centered List 1. Joint Principles of the PCMH List 2. Acronyms and Abbreviations medical home, residency training Enhanced access to care FCC Family Care Center Care continuity (the Brown Family Practice-based team care Medicine’s resident/faculty practice) Comprehensive care GMV Group Medical Visit Introduction Coordinated care (an emerging method Population management The national drive to provide patient care within Patient for chronic disease Centered Medical Homes (PCMHs) makes it is essential that Patient self-management management) Health information technology we prepare the next generation of primary care providers with HRSA Health Resources Services the skills to successfully build and remodel these “homes.” Evidenced-based care Administration The term “medical home” was first used in publication Care plans NCQA National Committee in 1967 by subspecialty pediatricians.1 However, in recent Patient-centered care for Quality Assurance years, the PCMH model has rapidly evolved and has been Shared decision-making (accrediting body increasingly recognized as a future model for primary care, Cultural competency for PCMHs) with the potential to improve the health outcomes of both Quality measurement and PCMH Patient Centered Medical individual patients and populations of patients. In 2004, the improvement Home American Academy of Family Physician’s Future of Family Patient feedback Medicine report called for every patient to have “a personal PDSA Plan-Do-Study-Act Quality Improvement Cycles medical home,”2 and by 2007 key primary care organiza- New payment systems
tions had defined 16 essential components of a Patient Cen- (from Berenson’s summary of “Joint Principles of the PCMH” tered Medical Home (List 1).3 Soon afterwards accrediting and Guidelines for PCMH and Accreditation Programs”)3
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function within new PCMHs and take leadership Table 1. Objectives for the first-year residents (PGY-1) roles in further development of the PCMH model. ACGME By the end of the first year rotation, the resident will be able to: In this article we describe the development of Competency a month-long, team-based, PCMH rotation for General PCMH Brown family medicine residents, which was cre- • Help represent the interdisciplinary team and coordinate with SBP 1 ated within the context of a rapid transformation both the local FCC Operations Committee and PCMH Transfor- of our own resident-faculty practice into a PCMH. mation Committee. The overarching goals of this training program are • Effectively communicate with staff and providers by collaborat- SBP4 to prepare residents to (1) practice within a PCMH, ing with administrative support personnel to update PCMH bul- letin board, newsletter, and “Tabletop Tips” in preceptor rooms. (2) actively participate in population health activi- • Compare and contrast the implementation of the PCMH in at SBP2 ties in the PCMH, and (3) assume leadership roles least one health center, one private/group practice site, and in the ongoing evolution of the PCMH. the FCC. • Be familiar with the most recent rendition of the three levels of SBP2 NCQA recognition and newest meaningful use guidelines for Growth of the PCMH model the electronic health record. • Articulate the principles of the open access delivery system and SBP4 in Rhode Island the telephone coverage system in the FCC and its application to While several components of the PCMH model meet the goals of the PCMH have been embraced by Rhode Island primary • Actively participate in daily interdisciplinary “PCMH Morning PC 8 care practices for many years, a key step in the Rounds” movement towards a statewide recognition of Chronic Disease Management/Population Health PCMH occurred in 1999 with the chronic disease • Articulate the key elements of the Chronic Care Model. SBP 2; management collaborative sponsored by the RI • Facilitate at least one interdisciplinary Group Medical Visit by PC 1 & 8 Department of Health.4 Another major milestone helping prepare the pre-visit data, being present and supportive during the GMV, and assisting with documentation after the occurred in 2008 with the creation of Chronic visit. Care Sustainability Initiative (CSI), a program • Synthesize and present current article related to chronic disease PBLI 5 bringing together several major stakeholders in management during didactics. primary care: providers, insurers, state govern- Quality Improvement and Monitoring ment, and patients. In 2008 the CSI provided fund- • Demonstrate teamwork in the completion/dissemination of one PBLI 1; PC 8 ing to support early adoption of the PCMH model brief PDSA (Plan-Do-Study-Act) cycle that assists the medical in five RI practices. The funding subsequently director with Quality Improvement in the FCC. expanded in 2010, 2012 and 2013 adding eight, • Review their own Chronic Disease Dashboard(s) and the FCC PBLI 1 three and twenty practices, respectively. In 2014, chronic disease registries, and articulate the targets for their own practice improvement. the CSI initiative, now called the Care Transfor- mation Collaborative, comprised practices caring Practice Management for over 260,000 patients.5 Several national initia- • Apply the correct CPT Evaluation and Management code to SBP 2 tives have also helped shape the development of each of 4 outpatient FCC encounters on a standardized exercise. • Present and provide a one page word document on an am- PBLI 2,4,5 PCMH in RI. These include the Beacon Collab- bulatory case vignette, a key teaching point (or points), and a orative (a federally funded PCMH incentive pro- reference(s) in outpatient morning report. gram), Connect Care (the local Regional Health Information Organization for electronic health Care of Complex/Vulnerable Patients/Safety • Assist the PGY-3 in providing coordinated care on two Nursing PC 8 record interconnectivity), and the Meaningful Use Home/home bound patient encounters. electronic health record implementation initia- • Work with the Pharm D student to conduct a medication review PC8; PBLI 4; tives from Medicare and Medicaid. for one geriatric patient (preferably a home bound patient) from MK 2 the PCMH PGY-3 resident panel and review with the PGY-3. • Help facilitate coordinated care for a Centering Pregnancy PC 7& 8 PCMH at the Brown Family Group Medical Visit Medicine Residency Program Provide Patient Care within a PCMH The Brown Family Medicine Residency Program • Utilize PCMH resources appropriately for the care of their own PC 8 has focused on training primary care physicians patients in the FCC • See their own continuity patients in the FCC, appropriately PC 8;SBP 2,4 since its inception in 1975. The main faculty/res- utilizing PCMH resources, 2 to 3 sessions per week. ident practice is the Family Care Center (FCC), at Memorial Hospital of Rhode Island, which serves Legend. ACGME: Accreditation Council for Graduate Medical Education; FCC:Family Care Cen- a primarily urban underserved community from ter; MK: Medical Knowledge; PBLI: Problem Based Learning and Improvement; PC: Patient Care; Pawtucket and Central Falls. The FCC covers PDSA:Plan Do Study Act; CPT: Current Procedural Terminology; SBP: Systems Based Practice; 9,000 primary care patients and has over 25,000 PGY: Post Graduate Year
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patient visits per year. It is the primary continuity Table 2. Objectives for the second-year residents (PGY-2) practice site for 39 residents and 14 faculty family ACGME By the end of the second year rotation, the resident will be able to: physicians. Physicians follow their patients in mul- Competency tiple settings in addition to the FCC, including in General PCMH nursing homes, patients’ homes, and the hospital. • Work collaboratively with the faculty practice leaders to set PBLI 1; SBP 3 The FCC was an early adopter of the PCMH the agenda and run the residency clinic Team Meeting for this model, paralleling early statewide and national month, including presenting an update and distributing individu- trends. Residency faculty and FCC staff partici- al reports on the team’s productivity and PCMH dashboards pated in the RI Department of Health sponsored • Actively participate in daily interdisciplinary “PCMH Morning PC 8 Chronic Disease Collaborative beginning in 2002, Rounds”, assuming co-leader role with faculty physician when PGY3 resident is unavailable. a first step towards PCMH practice transforma- tion. Additional funding in 2005 from the Rob- Chronic Disease Management/Population Health ert Wood Johnson Foundation and Institute for • Review each team’s chronic disease (CSI) Dashboard(s)/Registry PBLI 1 Healthcare Improvement for “improving care by on a rotating schedule and highlight outliers for each team. engaging patients” helped establish many of the • Facilitate and help lead a Group Medical Visit helping provide PC 1,3,8; motivational interviewing to patients during the visit, helping ICS 1,2 principles of the Chronic Care Model and PCMH patients set self management goals, and assisting with the in the FCC practice. Next, in early 2010 the FCC documentation after the visit. was invited to join the RI Chronic Care Sustain- • Jointly care with a PCMH Nurse Care Manger for one chronic PC 8 ability Initiative (CSI) as one of the first resident disease patient. physician PCMH training sites in RI. Later that Quality Improvement and Monitoring year the FCC earned NCQA recognition as a Level • Demonstrate teamwork and leadership in the completion of PBLI 1; PC 8 3 Medical Home, the highest of three possible lev- one brief PDSA (Plan-Do-Study-Act) cycle with the other els of PCMH certification.D uring this time, con- PCMH residents that assists the medical director in Quality sistent with other residency sites in early phases of Improvement in the FCC. PCMH transformation,6,7,8 we primarily used resi- Practice Management dency-wide lectures and workshops, practicing in • Conduct chart audits each on patients of the PCMH PGY-1, SBP 2 a functioning PCMH, and elective PCMH oppor- the PCMH PGY-3, and a PCMH faculty member, to assess tunities to convey PCMH concepts to residents. appropriateness of the Evaluation and Management coding and documentation. • Review and update one office policy and present as a proposal PC 8;PBLI 1; National Trends in PCMH at the FCC Operations Committee. SBP 2 Residency Training • Present and provide a one page word document on an am- PBLI 2,4&5 bulatory case vignette, a key teaching point (or points), and a As the PCMH has became increasingly recog- reference(s) in outpatient morning report. nized as a future model of primary care, leaders in primary care education have began to focus Care of Complex/Vulnerable Patients/Safety on preparing resident physicians for practice and • Work with Nurse Care Manager to identify and track patients PC 8; SBP 3 leadership in this environment.9 Several groups being referred from the FCC, and transitioning out of the inpatient setting. have articulated guidelines for PCMH-specific • Conduct acute coordinated home visits and Nursing Home acute PC 4&8 skills that residents should possess prior to gradu- visits/admissions. ation.10,11,12 Initial curriculum development efforts have focused on transforming residency continu- Provide Patient Care within a PCMH ity clinics into PCMHs,13,14,15 or applying PCMH • Appropriately triage and schedule patients identified from PC 4 overnight calls into an acute visit in her/his schedule after taking transformation principles to specific aspects of sign-out from the on-call resident. This must include the notes care, such as chronic pain, substance abuse and of 4 examples that are reviewed with the PCMH faculty. 16,17,18 prenatal care. Unfortunately, many resi- • Conduct acute home visits and Nursing Home acute visits/ PC 4&8 dency clinics do not meet all PCMH attributes admissions with the geriatric nurse practitioner and/or geriatric and the process of transforming resident clinics physician and jointly manage coordinated care related to that can be challenging.19 Other teaching strategies patient visit, 1 session per week. PC 8; SBP described include: didactic teaching on PCMH • See their own continuity patients in the FCC, appropriately 2,4 utilizing PCMH resources, 4 sessions per week. principles, supervised resident experiences in quality improvement, and individual two- to six- Legend. CSI: Chronic Care Sustainability Initiative; ACGME: Accreditation Council for Graduate week block rotations.6 There is some evidence Medical Education; FCC: Family Care Center; MK: Medical Knowledge; PBLI: Problem Based that incorporating PCMH concepts into residency Learning and Improvement; PC: Patient Care; PDSA:Plan Do Study Act; SBP: Systems Based training can increase residents’ sense of compe- Practice; PGY: Post Graduate Year. tence with and utilization of some important
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PCMH components, such as team-based care, Table 3. Objectives for the third-year residents (PGY-3) 6 access to care, and quality improvement. How- ACGME By the end of the third year rotation, the resident will be able to: ever, literature review does not reveal the opti- Competency mal training model, or support the idea that clinic General PCMH transformation alone will prepare residents for • Represent the interdisciplinary team and coordinate with SBP 1 practice and leadership in the PCMH. the local FCC practice Operations Committee and PCMH Transformation Committee. • Lead the PCMH team in preparing for maintenance of PBLI 1; SBP 2 PCMH Curriculum Development certification for NCQA recognition. at the Brown Family Medicine • Co-lead daily interdisciplinary “PCMH morning rounds” PC 4,8 Residency Program with faculty physician leader We conducted a targeted needs assessment with Chronic Disease Management/Population Health interviews of all third-year residents in 2011, • Lead a Group Medical Visit, including providing educational PC1,3,5,8; after the FCC had achieved Level 3 PCMH recog- topic to patients, helping manage group dynamics, providing ICS1&2 nition. Since family medicine residency is heav- motivational interviewing, helping patients set self management goals, and assisting with documentation and billing after ily focused on preparing physicians for primary the visit. care practice, all residents are required to fol- low a panel of patients for all three years of resi- Quality Improvement and Monitoring dency with a minimum of 1650 continuity clinic • Demonstrate teamwork and leadership in the completion of PBLI1;PC8 encounters during residency. Third year residents one brief PDSA (Plan-Do-Study-Act) cycle with the other at the Brown FM Residency spend 3-5 sessions per PCMH residents that assists the medical director in Quality Improvement in the FCC. week in their FCC continuity clinic during most rotations, allowing for ample immersion in this Practice Management PCMH practice. The needs assessment revealed • Demonstrate an attitude of helping lead change by preparing PC 8; ICS2; that, despite practicing in a certified PCMH, res- the agenda and facilitating the FCC Operations Committee SBP 2 ident education regarding the PCMH model was and PCMH Transformation Committee meetings with the insufficient (manuscript submitted).20 Residents Medical Director • Conduct four chart audits for quality care and documentation SBP 2 did not perceive themselves as integral to PCMH using the residency’s chart audit EValue tool. activities, but rather simply as physicians who • Present and provide a one page word document on an PBLI 2,4,5 happened to practice in a PCMH. Additionally ambulatory case vignette, a key teaching point (or points), our primary teaching methods – residency-wide and a reference(s) in outpatient morning report. Could be didactics and workshops, immersion in a PCMH Morbidity and Mortality (near miss) presentation. practice, and elective PCMH opportunities – did Care of Complex/Vulnerable Patients/Safety not appear to offer adequate education on specific • Facilitate the successful transitions, working with the Nurse PC 4,5,8 PCMH concepts or skills. Care Manager, of patients from the hospital to home/Nurs- SBP 2, 3, 4 In order to improve PCMH training, we con- ing Home/Home Bound Residence including family and team ICS 1 ducted a literature review, drew upon local exper- communication. tise, and obtained funding through a Title VII Provide Patient Care within a PCMH HRSA Primary Care Training Grant. Our initial • Appropriately triage and schedule patients identified from PC 4 premise was that to meet the educational needs of overnight calls into acute visits in her/his schedule after taking family medicine residents in the rapidly changing sign-out from the on-call resident. healthcare environment, it is not sufficient to have • Conduct acute home visits and nursing home acute visits/ PC 4,8; achieved NCQA Level 3 status, to have excellent admissions and provide mentoring/teaching for PGY 1 resident, PBLI 5 PCMH role models within the practice, or to have 4 sessions per week. PCMH didactics. Instead, more in-depth, experi- • See their own continuity patients in the FCC, appropriately PC 8; SBP utilizing PCMH resources and teaching medical students, 2,4 ential, longitudinal training with opportunities for 2 to 3 sessions per week. leadership and teaching was necessary.
Legend. ACGME: Accreditation Council for Graduate Medical Education; FCC: Family Care Center; MK: Medical Knowledge; PBLI: Problem Based Learning and Improvement; PC: Patient Care; The Creation of the PCMH Block PDSA: Plan Do Study Act; SBP: Systems Based Practice; PGY: Post Graduate Year Rotation and Resident Team To meet these educational needs we created a new PCMH block rotation and resident team. We evalu- ated existing residency block rotations, reorganize rotations that already contained PCMH-related
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content, and reclaimed time from rotations which exceeded PCMH Rotation Educational Strategies ACGME family medicine training time requirements for We use multiple educational strategies in this block rota- certain content areas. Specifically, we restructured a first- tion. These include direct patient care (both individual and year ambulatory rotation focused on practice management, in group medical visits), population health experiential a second-year ward medicine rotation (exceeded require- activities, practice management activities, didactics, and ments by 3 months), and a third-year rotation focused on progressive levels of responsibility with opportunities for managing the FCC’s complex nursing home and homebound teaching junior residents and students. The residents on the patients. These changes required significant residency direc- team remain embedded in our primary care practice site and tor leadership (GA). continue to see their own patients several sessions per week. Our goal was for residents to increase the number of indi- However, they are also given time and responsibility for vidual continuity clinic visits they conducted during resi- conducting population health level patient care and quality dency while gaining additional PCMH population health level improvement activities, as well as providing proactive direct expertise. To accomplish this goal, we created an interdisci- care to FCC patients who are acutely ill or particularly com- plinary PCMH team, including a resident from each year of plex or vulnerable. residency. The inclusion of senior residents on the team cre- There is a four-week repeating didactic curriculum with ated a similar leadership structure to that of traditional inpa- twice-weekly, two-hour sessions (see Table 4) that anchor tient ward teams, with senior residents accepting progressive each week on Monday and Friday afternoons, lead by the levels of responsibility, modeling leadership qualities, and curriculum director (RC) or FCC medical director (AG, teaching junior residents (and potentially medical students). DA). Each week also has specific practical projects, such as: The resident and faculty physicians work closely with admin- reviewing patient chronic disease registries and providing istrative staff, pharmacists, social workers, nurse care man- feedback to providers, performing chart audits, and prepar- agers, and other staff in the practice. The primary focus of ing for and leading group medical visits focused on chronic this team is to utilize PCMH and population health principles disease management. Projects are assigned on Mondays, to manage the complex care of primary care patients seen in residents are assigned project time during the work week, the FCC. We developed specific learning objectives based on and projects are reviewed on Fridays. Residents also help our existing PCMH curriculum, literature review regarding the FCC medical director and interdisciplinary PCMH team proposed PCMH competencies, and deficiencies suggested by design and implement least one larger quality improvement our needs assessment. (Tables 1–3). The total curricular time project (PDSA cycle) each month. In addition, specific clin- is 4 weeks per year for a total of 12 weeks during residency. ical content reinforces and helps provide a real life context
Table 4. Overview of Curriculum Content
Didactic themes: • Week 1 - PCMH, NCQA certification, PDSA cycles, registries • Week 2 - Patient Safety, trigger tool audits, root cause analysis • Week 3 - Practice Management, coding/leveling, chart auditing • Week 4 - Group Medical Visits, Chronic Disease Management, interdisciplinary teams
Examples of Clinical Content: Daily Interdisciplinary PCMH Team Meetings (“PCMH Morning Rounds”) • Review of inpatient census – looking for “Hot Spots”21 • Work with nurse care managers and geriatric team with transitions of care • Review overnight phone calls to the practice; triage patients needing acute visits (with ability to schedule patients from PCMH morning rounds) Direct Patient Care • Acute nursing home & home bound patient visits with geriatric interdisciplinary team. • Continuity clinic.
Examples of weekly projects: • Review with medical director and distribute chronic disease quality measures/registries to each resident and faculty provider. • Review safety concerns and present at practice wide monthly team meetings a safety pearl for the whole practice. • Perform chart audits for resident colleagues looking for quality use of the EMR and appropriate documentation. • Prepare for Group Medical Visit (PCMH resident team leads the group medical visit). Interdisciplinary team includes behavioral health, nutrition, pharmacy, nursing, physical therapy.
Examples of Monthly PDSA Cycles: • Improving ordering and documentation of hgbA1c values for diabetics. • Improving the process for ordering and tracking of referrals to consultants. • Improving the evaluation of osteoporosis patients that may need a holiday from bisphosphonate therapy.
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to apply principles related to PCMH (Table 4). Finally, and Acknowledgments importantly, daily morning interdisciplinary PCMH team We thank Melissa Nothnagle, MD, and Patricia Stebbins, MA, for rounds, lead by the PGY3 resident and faculty, anchor the reviewing this manuscript. We also thank all the members of the management of complex FCC patients from a population interdisciplinary teams that make up the family medicine resi- health and case-management perspective, through activities dency faculty and Family Care Center staff, who collectively play such as reviewing and following up on overnight phone calls a critical role in the ongoing success of this program. We thank and reviewing hospital admissions and transitions of care Judith Walker for her organizational support in implementing this of FCC patients. Interdisciplinary team members initially new curriculum, Helen Bryan for her assistance in survey data included: nurse care managers, the geriatrics team, behav- analysis, and Nicola Pallotti for assistance with literature review. ioral health providers, a dietician, and pharmacy students. This work was supported by HRSA Primary Care Residency Training Grant # D58HP20805 (PI – G. Anandarajah)
Early Outcomes References 1. Fisher C, Thompson H. Standards of Child Health Care. Evan- As an early process measure, nine months into implement- ston, IL: American Academy of Pediatrics Council of Pediatric ing the new curriculum, we (CF, RC) conducted an online Practice;1967. survey of the third-year residents who had completed their 2. Martin J. The future of Family Medicine: A collaborative project first PCMH rotation to gather rotation feedback and resident of the Family Medicine community. Ann Fam Med. 2004 Mar- Apr; 2(1):s3-s32. self-assessment of learning. Although residents’ confidence 3. Berenson R, Devers K, Burton R. Will the Patient-Centered to “implement PCMH principles” after this short period of Medical Home Transform the Delivery of Health Care? Time- time remained moderate, there appeared to be an improve- ly Analysis of Immediate Health Policy Issues. 2011 Aug ment in the number of group medical visits (GMVs), chart [cited 2014 Jan 22]. Princeton (NJ): Robert Wood Johnson Foundation. Available from: URL: http://www.urban.org/publi- audits and PDSA cycles completed by residents, as well as cations/412373.html confidence in their ability to incorporate PCMH compo- 4. Rhode Island Department of Health. Rhode Island Chronic Care nents in their practice, compared to reports of comparison Collaborative website. http://www.health.ri.gov/partners/col- laboratives/chroniccare/. Accessed October 11, 2014. residents in the baseline needs assessment. A formal, multi- 5. Beron S. 20 Practices join R.I. Patient Centered Medical Home method curriculum evaluation process is underway including Initiative. Patient Centered Medical Home Rhode Island Rhode qualitative interviews with intervention residents, rotation Island Chronic Care Sustainability Initiative & the Rhode Is- evaluations, and concrete outcome measures. land Quality Institute.[Cited 2014 Feb 1] Available From: URL: http://www.pcmhri.org/node/331 6. Jortberg B, Fernald D, Dickinson M, Coombs L, Deaner N, O’Neill C, deGruy F, Green L, Dickenson P. Curriculum rede- Next Steps sign for teaching the PCMH in Colorado family medicine resi- There is still no clear consensus in the literature on how best dency programs. Fam Med. 2014 Jan;46(1):11-8. 7. Brown KK, Master-Hunter TA, Cooke JM, Wimsatt LA, Green to prepare resident physicians to be leaders in PCMHs. Our LA. Applying health information technology and team-based care preliminary process measures suggest that there is potential to residency education. Fam Med. 2011 Nov-Dec;43(10):726-30. benefit to supplement existing longitudinal direct patient 8. Reid A, Baxley E, Stanek M, Newton W. Practice transformation care experience in a PCMH with a resident team-based block in teaching settings: Lessons from the I3 PCMH Collaborative. Fam Med. 2011 July-Aug;43(7):487-94. rotation. There are currently no similar PCMH educational 9. Rogers J, Heaton C. STFM focuses activities on the Patient-Cen- interventions described in the literature. We are imple- tered Medical Home. AnnFam Med. 2009 Jan-Feb:7(1):88-9. menting additional curricular elements to challenge senior 10. Chang A, Bowen J, Buranosky R, Frankel R, Ghosh N, Rosen- residents as they progress through each year of this longitu- blum M, Thompson S, Green M. Transforming primary care training - Patient-Centered Medical Home entrustable profes- dinal curriculum, and our curriculum evaluation is ongoing. sional activities for internal medicine residents. J Gen Inter Med. 2013 Jun;28(6):801-9. 11. Scherger J. Preparing the personal physician for practice (P4): Es- Conclusion sential skills for new Family Physicians and how residencies may provide them. J Am Board Fam Med. 2007 Jul-Aug;20(4):348-54. The PCMH is emerging as a dominant model for primary 12. Kruse J. The Patient-Centered Medical Home: A brief educa- care delivery in the US, and holds promise to improve quality tional agenda for teachers of family medicine. Fam Med. 2013 of patient care and enhance health care outcomes. Given the Feb;45(2):132-6. rapid healthcare changes happening in Rhode Island and the 13. Carney PA, Eiff MP, Saultz JW, Lindbloom E, Waller E, Jones S, Osborn J, Green L. Assessing the impact of innovative training United States, educators are challenged to train young phy- of family physicians for the patient-centered medical home. J sicians to practice in this new model of care and to lead fur- Grad Med Educ. 2012 Mar;4(1):16-22. ther practice transformation. The PCMH block rotation and 14. David A, Baxley L; ADFM. Education of students and residents team approach described in this article may provide a model in Patient Centered Medical Home (PCMH): preparing the way. Ann Fam Med. 2011 May-Jun;9(3):274-5. for other residency programs working to prepare the next 15. Babbott SF, Beasley BW, Reddy S, Duffy FD, Nadkarni M, Holm- generation of primary care physicians in evolving models boe ES. Ambulatory office organization for internal medicine of care delivery. resident medical education. Acad Med. 2010 Dec;85(12):1880-7.
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16. Evans L, Whitham J, Trotter D, Fitz K. An evaluation of Fam- Authors ily Medicine residents’ attitudes before and after a PCMH in- Rabin Chandran, MD, is an Associate Professor (Clinical) in the novation for patients with chronic pain. Fam Med. 2011 Nov- Department of Family Medicine at the Alpert Medical School Dec;43(10):702-11. of Brown University, RI. 17. Muench J, Jarvis K, Boverman J, Hardman J, Hayes M, Winkle J. Tilling the soil while sowing the seeds: Combining resident ed- Christopher Furey, MD, is an Assistant Professor (Clinical) in the ucation with Medical Home transformation. Substance Abuse. Department of Family Medicine at the Alpert Medical School 2012 Jun;33(3): 282-5. of Brown University, RI. 18. Barr W, Aslam S, Levin M. Evaluation of a group prenatal care- Arnold Goldberg, MD, is an Associate Professor (Clinical) in the based curriculum in a Family Medicine residency. Fam Med. Department of Family Medicine at the Alpert Medical School 2011 Nov-Dec;43(10):712-7. of Brown University, RI and also at the Lehigh Valley Health 19. Fernald DH, Deaner N, O’Neill C, Jortberg BT, degruy FV 3rd, Network/University of South Florida College of Medicine. Dickinson WP. Overcoming early barriers to PCMH practice David Ashley, MD, is an Assistant Professor (Clinical) in the improvement in family medicine residencies. Fam Med. 2011 Jul-Aug;43(7):503-9. Department of Family Medicine at the Alpert Medical School of Brown University, RI. 20. El Rayess F, Anandarajah G, Fury C, Chandran R, Goldman R. PCMH Level-3 is just the first step: A qualitative study of res- Gowri Anandarajah, MD, is Professor (Clinical) and Director of ident and faculty PCMH knowledge and attitudes after NCQA Faculty Development in the Department of Family Medicine certification. Manuscript submitted for publication. at the Alpert Medical School of Brown University, RI. 21. Gawande A. The hot spotters: Can we lower medical costs by giving the neediest patients better care. The New Yorker. Jan Correspondence 24, 2011. http://www.newyorker.com/reporting/2011/01/24/ Rabin Chandran, MD 110124fa_fact_gawande. Accessed April 4, 2014. Department of Family Medicine Memorial Hospital of Rhode Island 111 Brewster Street Pawtucket, RI 02860 401-729-2237 Fax 401-729-2923 [email protected]
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Too Weak to Move
Wendy H. Wong, MD; Nathan Hudepohl, MD; Bruce Becker, MD; William Binder, MD
42 45 EN
From the Case Records of the Alpert Medical School of Dr. Nathan Hudepohl: Her vital signs were most sig- Brown University Residency in Emergency Medicine nificant for hypertension and tachycardia, which could be a response to infection as well as a cause of end-organ dam- age or ischemia. The use of immunosuppressants as well as Dr. Wendy Wong: Today’s case is a 31-year-old woman her report of a UTI prompted us to look for an infectious who presented with generalized weakness which had been etiology. We obtained a cbc, chem 7, troponin, and urinaly- worsening over 2 weeks. She was seen at an outside hospital sis which revealed acute renal failure and proteinuria >500 24 hours prior to her presentation and was diagnosed with units. Her creatinine had increased to 1.99 from a baseline a urinary tract infection (UTI). She was discharged home of 0.86. We also obtained an EKG which revealed sinus but her weakness worsened in severity. Just prior to arrival, tachycardia without evidence of ischemia and a chest X-ray she had been ambulating to the bathroom with a cane but which revealed pulmonary edema. Computed Tomography became so weak that she slid to the ground. She denied loss Angiography (CTA) was negative for PE. of consciousness or any injuries. The patient’s medical history was significant for sys- Dr. Matthew Siket: The patient had a hypertensive emer- temic lupus erythematosus (SLE), hypertension, deep vein gency with evidence of end-organ damage to her kidneys, thrombosis (DVT), and pulmonary embolus (PE) diagnosed brain and lungs. Do you think her signs and symptoms were 3 months ago. She takes prednisone daily, but has missed due to poorly controlled hypertension and non-compliance several doses of rivaroxaban and blood pressure medications with medications? Premature closure is the most common due to nausea. diagnostic error in clinical decision making, and this diag- On review of systems, she reported a migraine head- nosis did not encompass all of the patient’s symptoms.1 Was ache associated with photophobia and blurry vision which there a unifying diagnosis? improved minimally with Fioricet. She noted diffuse abdom- inal discomfort over the past few months associated with Dr. Hudepohl: The patient’s history of SLE and immu- occasional nausea, vomiting, and anorexia. She reported nosuppression, in combination with her severe hyperten- normal bowel movements, denied dysuria, but reported sion and myriad of signs and symptoms led us to consider decreased urinary output. a central nervous system cause of her weakness. Posterior The patient’s vital signs were: blood pressure 219/143 mm Reversible Encephalopathy Syndrome (PRES), a clinico-ra- Hg, pulse 112 beats/min and regular, temperature 98.7F, diologic diagnosis, is associated with autoimmune diseases respirations 18 breaths/min, and oxygen saturation 98% on and use of immunosuppressive medications.2 We confirmed room air. The patient was somnolent but easily arousable. this diagnosis with CT brain and MRI brain imaging (see She was oriented to person, place and time and appeared Figures 1, 2). much older than her stated age. She had symmetric mild weakness of the arms and legs She was able to stand and Dr. David Portelli: What exactly is PRES? How is PRES ambulate with assistance. Reflexes were normal. Sensa- different from RPLS? tion was intact. Her oral mucosa was dry. Her cardiac exam revealed tachycardia without murmurs and her capillary Dr. Wong: PRES is a unique pattern of brain vasogenic refill was brisk. The patient’s lung exam was clear to aus- edema associated with a number of medical conditions cultation. Her abdomen was soft, obese, with normal bowel including hypertension, eclampsia/pre-eclampsia, autoim- sounds but diffusely tender to palpation, without rebound mune disease, use of cytotoxic/immunosuppressant drugs, or guarding. She had severe alopecia but the skin was other- chemotherapeutic agents, bone marrow or solid organ trans- wise unremarkable. plant, sepsis, collagen vascular disease, or renal failure.3 The disorder is a clinico-radiologic syndrome first described in Dr. Elizabeth Nestor: Her complaints were non-specific a cohort of 15 patients with symptoms of altered mental and her physical exam is non-focal. How did you direct your status, headache, seizures, and loss of vision who also had laboratory testing? “prominent white matter abnormalities” on CT consistent
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Figure 1. CT Brain. Multiple areas of hypoattenuation bilaterally. The largest is centered at the right internal capsule and extends inferiorly to the right cerebral peduncle, midbrain and pons. An additional is found at the left periventricular white matter. Involvement at the left cerebellum concerning for underlying mass lesion.
Figure 2. MRI Brain. Scattered areas of T2/FLAIR signal hyper-intensity within the cerebrum, cerebellum, deep gray matter structures and pons, which are most suggestive of posterior reversible encephalopathy syndrome (PRES).
with posterior leukoencephalopathy.4 The symptoms and presentation is white matter edema in the posterior cere- CT abnormalities resolved in all 15 patients after 2 weeks bral hemispheres that does not necessarily follow a vascular of anti-hypertensive medication and withdrawal or reduc- territory.4,7 Accumulation of large amounts of edema occurs tion of immunosuppressive treatment. Originally called in the subcortical white matter because the cortex is more Reversible Posterior Leukoencephalopathy Syndrome resistant to edema as a result of being more tightly packed ( RPLS), the disorder was re-named PRES because the revers- and organized.2,5 The posterior circulation is most affected ible white matter abnormalities did not appear to be true because the vertebrobasilar circulation with its relative lack leukoencephalopathy.5 of sympathetic innervation, is more susceptible to sudden elevations in blood pressure.7-9 Dr. Noah Rosenberg: Clinical findings of PRES include seizures, which this patient did not have. How did you diag- Dr. Jeff Feden: Is it possible to have PRES with a normal nose PRES? CT brain? What is the best imaging modality to diagnose PRES? Is it always reversible? Dr. Wong: PRES is characterized by diminished mental sta- tus, headache, seizure, nausea/vomiting, and visual abnor- Dr. Wong: In a large multi-center retrospective study, 16% malities. Decreased alertness, the most common feature, of patients had a normal CT of the brain.6 Brain MRI with can range from drowsiness to stupor.2,6 Seizures may not be FLAIR sequencing is the most sensitive imaging modal- reported on initial presentation.5 Abnormalities in visual ity and T2 hyper-intense vasogenic edema is noted.5 PRES perception can range from blurry vision to visual neglect is neither always posterior nor reversible. While the pari- or hallucinations.4 On CT brain, the most characteristic etal occipital pattern is the most characteristic, it is only
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Emergency medicine Residency cPC
present solely in that location in 22% of cases.2,10,11 PRES Dr. Eric Goldlust: Is PRES considered a neurologic emer- has been seen to affect other regions of the brain: frontal gency? How do we manage these patients? lobe 77%, temporal lobe 64%, cerebellum 53%, basal gan- glia 34%, brainstem 27%.2 Spinal cord involvement in PRES Dr. Wong: PRES does not reverse spontaneously and delay (PRES-SCI) has also been noted in a recent case report of in the diagnosis and treatment can result in permanent patients with neurologic signs referable to the spinal cord, neurological sequelae.7,14 With prompt treatment, complete MRI lesions that extend to the cervicomedullary junction, reversal of PRES occurs within several days to weeks (range or grade IV hypertensive retinopathy.12 Cerebellar involve- 2-15 days) with radiological improvements lagging behind ment is most commonly associated with autoimmune clinical recovery.7,8 Management includes: 1. discontinuing disease.2,13,14 Although PRES is characterized by reversible the offending agent (ie. removal of cytotoxic/immunosup- symptoms and radiologic abnormalities, it occasionally may pressive drugs), 2. controlling blood pressure with anti- not be as benign or reversible as the name implies.15,16 In hypertensive medications, 3. Treating seizures/status with a retrospective study of 90-day outcomes, the case fatality anti-epileptics.7,8,10 rate was 16%, with 37% of patients experiencing significant functional impairments from secondary complications such Dr. William Binder: Do you stop immunosuppressives as status epilepticus, intracranial hemorrhage, or ischemic when severe hypertension is thought to be due to poor con- infarct.6,16 trol of the underlying autoimmune disorder?
Dr. Otis Warren: What is the pathophysiology of PRES? Dr. Wong: Patients with autoimmune disease pose a unique problem as it can be difficult to ascertain if PRES is Dr. Wong: There are several competing theories, all of caused by hypertension due to poor control of the underlying which involve disruption of the blood brain barrier resulting autoimmune disorder or if the use of immunosuppressive in the development of vasogenic edema. The most widely medications are to blame. Although there are case reports of accepted theory is that severe increases in blood pressure symptom resolution while immunosuppressives are main- cause a failure of cerebral auto-regulation, resulting in vaso- tained, removal of cytotoxic drugs or substitution of another dilation, hyper-perfusion, extravasation and edema.2,4,14 immunosuppressive agent is usually recommended if the Control of hypertension with anti-hypertensive medication inciting factor is unclear.8 If symptoms are improving with often improves symptoms. However, PRES can develop in control of hypertension and etiology of PRES likely due to normotensive or mildly hypertensive patients and the sever- severe hypertension, it is reasonable to continue immuno- ity of hypertension does not predict the development or suppressives. However, it is not recommended to reintro- severity of PRES.3,5,10,14 Furthermore, PRES patients often do duce agents that were known to induce PRES in a patient as no have a mean arterial pressure high enough to overcome recurrence of PRES has been reported in this setting.8 cerebral auto-regulatory capacity.2,3,13 Angiography of the posterior circulation in PRES reveals Dr. Becker: What are your take-home points from this case? a “string of beads” appearance most consistent with vaso- spasm or arteritis, suggesting that vasoconstriction, vaso- Dr. Wong: Consider PRES in the differential diagnosis of spasm, and resultant hypo-perfusion leads to ischemia and decreased mental status or headache in those with co-mor- vasogenic edema. MR perfusion imaging shows reduction bidities of hypertension, eclampsia/pre-eclampsia, autoim- in the relative cerebral blood volume indicating cerebral mune disease, use of cytotoxic/immunosuppressant drugs, hypo-perfusion rather than hyper-perfusion.3,9 chemotherapy, bone marrow or solid organ transplant, sep- Patients with PRES are often on cytotoxic medications, sis, collagen vascular disease, or renal failure. CT brain may which may have a direct toxic effect on cerebral endothe- be normal and diagnosis may require MRI brain if clinical lium, resulting in vascular leakage.2,17 Symptoms may suspicion is high. Once diagnosed, PRES is a neurologic improve after discontinuing a potentially inciting agent.3 emergency and should be treated promptly with control of However, levels of cytotoxic agents in PRES patients do not blood pressure, removal of inciting drugs, and treatment of correlate with the development or severity of PRES; PRES seizures. Although some case series support continuation of can occur even at therapeutic blood levels.2,4 seizure prophylaxis for 1-3 months, there is no indication Interestingly, renal failure is a common manifestation that PRES patients are at long-term risk for seizure recur- of the conditions associated with PRES such as eclampsia, rence or epilepsy. Anti-epileptics can be safely tapered as hypertension, sepsis, autoimmune disease and use of chemo- symptoms and neuroimaging abnormalities resolve, usually therapeutic agents. Release of Vascular Endothelial Growth after 1-2 weeks.8 Factor (VEGF) from the kidney in response to damage can increase endothelial permeability with resultant cerebral Final Diagnosis: Posterior Reversible Encephalopathy vascular leakage, leading to edema.10 Syndrome (PRES)
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References 11. Bartynski WS, Boardman JF. Distinct imaging patterns and le- 1. Eva KW, Link CL, Lutfey KE, McKinlay JB. Swapping horses sion distribution in posterior reversible encephalopathy syn- midstream: factors related to physicians’ changing the their drome. AJNR Am J Neuroradiol. 2007; 28(7):1320-7. minds about a diagnosis. Acad Med. 2010; 85(7):1112-7. 12. de Havenon A, Joos Z, Longenecker L, Shah L, Ansari S, Digre K. 2. Rykken JB, McKinney AM. Posterior reversible encephalopathy Posterior reversible encephalopathy syndrome with spinal cord syndrome. Semin Ultrasound CT MR. 2014; 35(2):118-35. involvement. Neurology. 2014; 83(22):2002-6. 3. Bartynski WS. Posterior reversible encephalopathy syndrome, 13. Fugate JE, Claassen DO, Cloft HJ, Kallmes DF, Kozak OS, Rabin- part 1: fundamental imaging and clinical features. AJNR Am J stein AA. Posterior reversible encephalopathy syndrome: asso- Neuroradiol. 2008; 29(6):1036-42. ciated clinical and radiologic findings.Mayo Clin Proc. 2010; 85(5):427-32. 4. Hinchey J, Chaves C, Appignani B, Breen J, Pao L, Wang A, Pes- sin MS, Lamy C, Mas JL, Caplan LR. A reversible posterior leu- 14. Shaharir SS, Remli R, Marwan AA, Said MS, Kong NC. Posterior koencephalopathy syndrome. N Engl J Med. 1996; 334(8):494- reversible encophalopathy syndrome in systemic lupus erythe- 500. matosus: pooled analysis of the literature reviews and report of six new cases. Lupus. 2013; 22(5):492-6. 5. Casey SO, Sampaio RC, Michel E, Truwit CL. Posterior revers- ible encephalopathy syndrome: utility of fluid-attenuated inver- 15. Akins PT, Axelrod Y, Silverthorn JW, Guppy K, Banerjee A, sion recovery MR imaging in the detection of cortical and sub- Hawk MW. Management and outcomes of malignant posterior cortical lesions. AJNR Am J Neuroradiol. 2000; 21(7):1199-206. reversible encephalopathy syndrome. Clin Neurol Neurosurg. 2014; 125:52-7. 6. Legriel S, Schraub O, Azoulay E, et al. Critically Ill Posterior Reversible Encephalopathy Syndrome Study Group (CYPRESS). 16. Li R, Mitchell P, Dowling R, Yan B. Is hypertension predictive of Determinants of recovery from severe posterior reversible en- clinical recurrence in posterior reversible encephalopathy syn- cephalopathy syndrome. PLoS One. 2012; 7(9):e44534. drome? J Clin Neurosci. 2013; 20(2):248-52. 7. Yoon SD, Cho BM, Oh SM, Park SH, Jang IB, Lee JY. Clinical and 17. Pavlakis SG, Frank Y, Chusid R. Hypertensive encephalopathy, radiological spectrum of posterior reversible encephalopathy reversible occipitoparietal encephalopathy, or reversible pos- syndrome. J Cerebrovasc Endovasc Neurosug. 2013; 15(3):206- terior leukoencephalopathy: three names for an old syndrome. 13. J Child Neurol. 1999; 14(5):277-81. 8. Dhillon A, Velazquez C, Siva C. Rheumatologic diseases and Authors posterior reversible encephalopathy syndrome: two case reports and a review of the literature. Rheumatol Int. 2012; 32(12):3707- Wendy H. Wong, Resident in Emergency Medicine 13. Nathan Hudepohl, Assistant Professor of Emergency Medicine 9. Hugonnet E, Da Ines D, Boby H, Claise B, Petitcolin V, Lanna- Bruce Becker, Professor of Emergency Medicine reix V, Garcier JM. Posterior reversible encephalopathy syn- drome (PRES): features on CT and MR imaging. Diagn Interv William Binder, Assistant Professor of Emergency Medicine Imaging. 2013; 94(1):45-52. Corresponding Author 10. Provencio JJ. Ch 22 Etiologies of Posterior Reversible Encepha- lopathy Syndrome and Forms of Osmotic Demyelination Syn- William Binder, MD drome. In: Manno EM, editor. Neurology in Practice: Emergency [email protected] management in neurocritical care. Chichester, West Sussex: Wi- ley-Blackwell; 2012. p.197-203.
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Uninsurance is only half the problem: Underinsurance and healthcare-related financial burden in RI 46 Dora Dumont, PhD, MPH; Tara Cooper, MPH; Yongwen Jiang, PhD 49 EN
In both Rhode Island and the nation, political leaders are and healthcare-related financial burden. Respondents who concerned with the public burden of health care costs. There answered “No” to “Do you have any kind of health care cov- has been less discussion among political and medical leader- erage?” or “None” to “Are you currently covered by any of ship about the financial burden of health care on individuals the following types of health insurance or health coverage and families. The weight of medical expenses makes some plans?” were identified as uninsured. Adults who identified people forego necessary care and contributes to over half of one or more sources of health care coverage were identified household bankruptcies (1). as underinsured if they met one of the following criteria: they Most of the national discussion on reducing financial were unable to see a doctor due to cost in the past year; they barriers to health care has focused on uninsurance, but were unable to take prescription medications due to cost in underinsurance is similarly associated with reduced access the past year; or they had been without insurance at some to care and financial duress (2-5): only 22% of people filing point in the past year. The latter is based on previous studies for medical bankruptcies were uninsured, and 60% of them that used gaps in coverage as an estimate of underinsurance had private coverage (1). Underinsurance is operationalized and findings that a recent spell of uninsurance increased risk in different ways (2, 6, 7), but a typical definition is “hav- of foregoing care or not filling prescriptions (8). We identified ing insurance that does not adequately meet an individual’s health care as constituting a financial burden if (regardless need”(3). Underinsurance is primarily a function of copays of insurance status) respondents met one of the following and deductibles, though other mechanisms may also play a criteria: they were unable to see a doctor due to cost in the role (2). Nationally, underinsurance rates have risen steadily past year; they were unable to take prescription medications as comprehensive coverages plans have declined (2). due to cost in the past year; or they currently had medical The Affordable Care Act (ACA) has been framed largely bills they were paying off over time. in terms of reducing uninsurance, and expectations of its We examined several demographic and economic factors effects on underinsurance are mixed. Expanded coverage of to construct a profile of people who in some way did not behavioral health services addresses a critical gap in many have adequate coverage (either underinsured or carrying pre-ACA plans. At the same time, copays and deductibles healthcare-related financial burden). Work status was cate- are a primary component of plans on the state and federal gorized as working; out of work or unable to work; home- exchanges. Woolhandler points out that silver plans on the maker or student; and retired. People over 65 who said exchange cover about 70% of average medical expenses, they were out of work were categorized as retired. Type of compared to 80% of the average job-based policy (1). We insurance coverage was categorized as uninsured, privately analyzed data from the 2013 Rhode Island Behavioral Risk insured, Medicaid, Medicare, and military /any other source Factor Surveillance System (RI BRFSS) to assess the finan- of coverage. If people reported two or more sources of cov- cial burden of health care on adults in RI on the eve of erage (most commonly a combination of Medicare and pri- implementing the state health exchange, in order to encour- vate insurance), their category was assigned according to age discussion of what further reforms need to follow the the following order of priority: Medicaid, Medicare, private reduction in uninsurance. insurance, military/other. Race/ethnicity was categorized as Hispanic; non-Hispanic black; and non-Hispanic white. People who indicated any other racial/ethnic identity were Methods included in analyses but are not reported separately, given The Rhode Island Behavioral Risk Factor Surveillance the heterogeneity of this “other” category. Because only System (RI BRFSS) is a telephone-based survey conducted landline interviews included a question on the number of annually by the RI Department of Health with funding and people in the household, we could not determine per-cap- technical support from the Centers for Disease Control and ita income; for the full sample, instead, household incomes Prevention (CDC). Additional information on RI BRFSS were categorized as under $25,000, $25,000-49,999, $50,000- methodology is available at http://www.health.ri.gov/data/ 74,999, and $75,000 or above. behaviorriskfactorsurvey/index.php. 2013 was the first year the RI BRFSS contained the ques- We constructed several measures of insurance status tions of interest. The survey is conducted over the course
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of the full calendar year as part Table 1. Uninsurance and underinsurance rates among RI adults, 2013 of its randomization. In order to Uninsured Underinsured Adequately insured avoid “contaminating” the sample 18.2% (n=592) 13.3% (n=584) 68.5% (n=3496) with early effects of the ACA, we n Weighted % (95% CI) restricted the sample to interviews completed no later than October Age group 1, 2013, the date HealthSource RI 18-34 675 29.3 (24.9-33.7) 15.5 (12.2-18.8) 55.2 (50.4-60.0) (RI’s health care exchange) became 35-64 2683 18.4 (16.3-20.4) 13.5 (11.8-15.3) 65.7 (61.8-69.6) operational for a final n=4971. With 65 or older 1562 1.7 (0.7-2.6) 9.3 (7.1-11.5) 89.0 (86.7-91.4) the exception of income (15%), no single variable had more than 6.3% Sex missing observations. We conducted Female 3021 15.2 (13.2-17.2) 15.0 (13.1-16.9) 69.8 (67.3-72.2) bivariate analyses and multivariate Male 1950 21.6 (18.8-24.4) 11.4 (9.4-13.5) 67.0 (63.9-70.0) logistic regressions in SAS 9.3, using Race/ethnicity survey weights and strata informa- tion provided by the CDC to account Hispanic 371 45.3 (38.6-52.1) 17.2 (11.9-22.5) 37.5 (31.1-43.9) for complex sampling methodology. Black, non-Hispanic 181 32.6 (22.6-42.7) 10.4 (5.1-15.6) 57.0 (46.9-67.1) White, non-Hispanic 4076 12.9 (11.2-14.6) 12.5 (11.0-13.9) 74.6 (72.6-76.6)
Results Income In addition to the 18.2% of adults <$25,000 1185 39.7 (35.6-43.9) 15.6 (12.7-18.4) 44.7 (40.7-48.7) who reported having no health insur- $25,000-49,999 1070 19.0 (15.4-22.6) 17.7 (14.4-21.0) 63.3 (59.1-67.4) ance at the time of their interview, $50,000-74,999 665 7.5 (3.8-11.1) 14.0 (10.3-17.7) 78.6 (73.8-83.3) another 13.3% (representing about >=$75,000 1304 3.9 (2.0-5.8) 7.1 (5.0-9.2) 89.0 (86.3-91.7) 79,400 people) reported having insur- ance but meeting one of our criteria Employment status for underinsurance. They included Working 2482 18.1 (15.8-20.5) 13.2 (11.2-15.1) 68.7 (66.0-71.3) 15.5% of people who said they had Out of work/unable to work 673 37.6 (32.3-43.0) 22.1 (17.9-26.4) 40.2 (35.2-45.3) private insurance and 26.6% of peo- Homemaker/student 342 16.1 (10.8-21.5) 10.9 (6.5-15.3) 73.0 (66.5-79.5) ple on Medicaid (Table 1). Rates were not significantly better for people in Retired 1436 3.0 (1.7-4.2) 8.1 (6.3-9.9) 89.0 (86.8-91.1) the workforce, of whom 68.7% had Type of insurance adequate coverage. Private 2134 — 15.5 (13.2-17.7) 84.5 (82.3-86.8) Nearly a third (31.7%) of adults Medicaid 388 — 26.6 (20.5-32.7) 73.4 (67.3-79.5) had some form of healthcare-re- lated financial burden Table( 2). As Medicare 1600 — 13.9 (11.4-16.5) 86.1 (83.5-88.6) expected, the rate of financial bur- Military/other 212 — 20.4 (12.0-28.9) 79.6 (71.1-88.0) den was highest (67.5%) among the uninsured, but even the lowest rate (among people with military/other coverage) was 20.8%. Discussion One in four (25.2%) people with private insurance also Measuring state progress is complicated in the changing reported one or more criteria for medically-related financial coverage landscape. Rhode Island generally matches or sur- burden. Bivariate analyses also revealed profound racial/eth- passes US averages on health care access indicators such nic disparities, with well over half (55%) of the state’s His- as uninsurance or failure to access medical care due to panics and 43% of blacks experiencing financial burden. cost (9). Even so, RI results point to the serious problems After controlling for income, sex, age, and race/ethnicity, with benefit design in both private and public plans under type of insurance (public or private) was not associated with the ACA. Merely reducing uninsurance is not sufficient to being underinsured or carrying healthcare-related financial either remove all financial barriers to health care or prevent burden (Table 3). Controlling for income and other covari- health care from constituting a serious financial burden on ates also eliminated the associations with race/ethnicity individuals. seen in bivariate analyses (data available on request). Unsur- Ongoing reform of the health care system will need the prisingly, people who were uninsured had 3.61 (95% CI cooperation of health care users, as well as systems and the 2.52-5.18) the odds of bearing medical costs relative to peo- government. However, the argument that cost-sharing in the ple with private insurance, while people with military/other form of copays and deductibles will increase cost-conscious- insurance were about half as likely (AOR 0.53 [0.32-0.87]). ness and responsibility in decision-making among clients (7)
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Table 2. Prevalence of healthcare-related financial burden among RI may be putting excessive financial burden on people who do adults, 2013 need ongoing health care. The problem may be especially Financial burden acute for the newly-insured who forwent care while unin- 31.7% (n=1236) sured; 80% of respondents who had no insurance in 2013
Weighted % (95% CI) had been uninsured for a year or longer (data available on request). Low-income families in particular may feel the Age group need to simply choose the plan with the lowest premium 18-34 41.2 (36.4-45.9) and hope they will not need medical care, but our data sup- 35-64 32.8 (30.4-35.2) port previous studies indicating that middle-income fami- lies too are highly vulnerable to underinsurance (5, 7, 10). 65 or older 15.4 (12.8-18.0) In revisiting Woolhandler’s warning that the ACA may Sex unintentionally increase underinsurance and thus the finan- Female 31.3 (28.9-33.8) cial burden of health care (1), we draw attention in particular to its application to both private and public coverage. Over Male 32.3 (29.1-35.3) one-quarter of Medicaid recipients already experience finan- Race/ethnicity cial hardship associated with health care, so efforts to reduce Hispanic 55.0 (48.3-61.8) state Medicaid expenses by increasing cost-sharing might backfire by making recipients delay care until the condition Black, non-Hispanic 43.0 (33.3-52.7) has progressed and become more expensive to treat (3, 11). White, non-Hispanic 27.2 (25.1-29.2) There are several limitations to our analysis. The utili- Income zation of interviews only prior to the opening of the state health exchange may have introduced some sort of seasonal <$25,000 47.1 (43.0-51.3) bias in the data, though there is no evidence that respon- $25,000-49,999 37.7 (33.6-41.8) dents differ over the course of the calendar year. The ques- $50,000-74,999 29.9 (24.3-35.4) tions in the BRFSS Health Care Access Module may capture only a limited portion of actual financial burden, and in par- >=$75,000 16.0 (12.9-19.2) ticular provide no data on the age and scale of medical debt. Employment status Results on some questions in the module also suggest con- Working 32.3 (29.6-35.0) fusion on the part of respondents. Despite these limitations, even conservative interpretations of the data reflect a real Out of work/unable to work 53.9 (48.7-59.1) need for medical, public health, and policy professionals to Homemaker/student 25.9 (19.2-32.6) ensure that health care reform continues beyond the mere Retired 15.1 (12.6-17.5) reduction of uninsurance. Type of insurance
Private 25.2 (22.5-27.9) References Medicaid 29.7 (23.2-36.2) 1. Woolhandler S, Himmelstein DU. Life or debt: underinsurance in America. J Gen Intern Med. 2013;28(9):1122-4. Medicare 21.3 (18.3-24.4) 2. Lavarreda SA, Brown ER, Bolduc CD. Underinsurance in the Military/other 20.8 (12.7-29.0) United States: an interaction of costs to consumers, benefit de- sign, and access to care. Annu Rev Public Health. 2011;32:471- None 67.5 (62.5-72.6) 82. 3. Magge H, Cabral HJ, Kazis LE, Sommers BD. Prevalence and predictors of underinsurance among low-income adults. J Gen Table 3. Adjusted odds ratios of underinsurance and healthcare-related Intern Med. 2013;28(9):1136-42. financial burden by type of insurance coverage 4. Kogan MD, Newacheck PW, Blumberg SJ, Ghandour RM, Singh GK, Strickland BB, et al. Underinsurance among children in the Type of insurance Underinsured Financial burden United States. N Engl J Med. 2010;363(9):841-51. Private 1.00 (Ref) 1.00 (Ref) 5. Perrin JM. Treating underinsurance. N Engl J Med. 2010;363 (9):881-3. Medicaid 0.97 (0.61-1.54) 0.73 (0.47-1.13) 6. Link CL, McKinlay JB. Only half the problem is being addressed: underinsurance is as big a problem as uninsurance. Int J Health Medicare 0.75 (0.47-1.20) 1.39 (0.85-2.26) Serv. 2010;40(3):507-23. 7. Schoen C, Collins SR, Kriss JL, Doty MM. How many are under- Military/other 1.25 (0.66-2.35) 0.53 (0.32-0.87) insured? Trends among U.S. adults, 2003 and 2007. Health Aff (Millwood) 2008;27(4):w298-309. None — 3.61 (2.52-5.18) 8. Schoen C, DesRoches C. Uninsured and unstably insured: the Adjusted for income, sex, age, and race/ethnicity. importance of continuous insurance coverage. Health Serv Res. Boldface indicates statistical significance. 2000;35(1 Pt 2):187-206.
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9. State Health Access Data Assistance Center (SHADAC). Data Authors Center Web Page. Available at: http://datacenter.shadac.org. Last Dora Dumont, PhD, is a Senior Public Health Epidemiologist in updated 2015. Accessed 10 Feb 2015. the Division of Community, Family Health and Equity at the 10. DeVoe JE, Tillotson CJ, Wallace LS. Insurance coverage gaps Rhode Island Department of Health. among US children with insured parents: are middle income children more likely to have longer gaps? Matern Child Health J. Tara Cooper, MPH, is the Health Surveys Manager in the Center 2011;15(3):342-51. for Health Data and Analysis at the Rhode Island Department 11. Saunders MR, Alexander GC. Turning and churning: loss of of Health. health insurance among adults in Medicaid. J Gen Intern Med. Yongwen Jiang, PhD, is a Senior Public Health Epidemiologist in 2009;24(1):133-4. the Center for Health Data and Analysis at the Rhode Island Department of Health, and Clinical Assistant Professor in the Department of Epidemiology, School of Public Health, Brown University.
www.rimed.org | rimj archives | APRIL webpage APRIL 2015 Rhode Island medical journal 49 VITAL STATISTICS Public health Nicole E. Alexander-Scott, md director, rhode island department of health compiled by Colleen A. Fontana, State Registrar
Rhode Island Monthly Vital Statistics Report Provisional Occurrence Data from the Division of Vital Records
REPORTING PERIOD OCTOBER 2014 12 MONTHS ENDING WITH OCTOBER 2014 VITAL EVENTS Number Number Rates Live Births 978 11,305 10.8* Deaths 841 9,903 9.4* Infant Deaths 3 57 5.0# Neonatal Deaths 2 47 4.2# Marriages 786 7,063 6.7* Divorces 273 3,168 3.0* Induced Terminations 222 3,051 269.9# Spontaneous Fetal Deaths 55 582 51.5# Under 20 weeks gestation 43 481 48.6# 20+ weeks gestation 12 78 6.9#
* Rates per 1,000 estimated population # Rates per 1,000 live births
REPORTING PERIOD APRIL 2014 12 MONTHS ENDING WITH April 2014 Underlying Cause of Death Category Number (a) Number (a) Rates (b) YPLL (c) Diseases of the Heart 219 2,282 216.7 3,197.0 Malignant Neoplasms 184 2,401 228.0 6,190.0 Cerebrovascular Disease 27 394 37.4 547.5 Injuries (Accident/Suicide/Homicide) 59 746 70.8 11,154.0 COPD 63 474 45.0 425.0
(a) Cause of death statistics were derived from the underlying cause of death reported by physicians on death certificates. (b) Rates per 100,000 estimated population of 1,051,511 (www.census.gov) (c) Years of Potential Life Lost (YPLL).
NOTE: Totals represent vital events, which occurred in Rhode Island for the reporting periods listed above. Monthly provisional totals should be analyzed with caution because the numbers may be small and subject to seasonal variation.
www.rimed.org | rimj archives | APRIL webpage APRIL 2015 Rhode Island medical journal 50 It’s a new day.
The Rhode Island Medical Society now endorses Coverys. Coverys, the leading medical liability insurer in Rhode Island, has joined forces with RIMS to target new levels of patient safety and physician security while maintaining competitive rates. Call to learn how our alliance means a bright new day for your practice. 401-331-3207 RHODE ISLAND MEDICAL SOCIETY
Working for You: RIMS advocacy activities
March 2, Monday Conference call, Connecticut State Medical Society, legal counsel and staff regarding potential RIMS member benefit event in May 2015 Bryant University Physician Assistant Program ribbon cutting, RIMS staff attending Governor’s Medicaid Reform Workgroup, RIMS staff attending Chairman Shekarchi Fundraiser March 3, Tuesday Physicians Health Committee, Herbert Rakatansky, MD, Chair Meeting with RI Podiatric Medical Association, RIMS staff attending DOH Health Services Council meeting Legislative Hearings March 4, Wednesday OHIC Administrative Simplification Workgroup; RIMS staff attending On March 24, approximately 50 Alpert Medical School students attended a luncheon to learn RI Academy of Family Physicians about civic engagement. Grayson Armstrong, MD’15, (above) discussed the importance of Legislative Advocacy Day, organized medicine at both the state and national levels. Megan Turcotte, RIMS Director of RIMS staff attending Member Services, explained ways that RIMS provides local opportunities for involvement and Legislative Hearings offers free membership in both the AMA and RIMS for first year medical students March 5, Thursday Tobacco Free RI Volunteer Recognition event; RIMS staff Newell E. Warde, PhD; and Steven R. DeToy recognized Legislative Hearings Senator Goldin fundraiser; Rep. Regunberg fundraiser, Rep. Ruggeiro fundraiser; RIMS staff attending March 6, Friday Meeting with speakers, staff, regarding legislation; RIMS Public Laws Chair Michael E. Migliori, MD, and RIMS staff attending March 9, Monday Department of Health Hearing, E-cigarette regulations; RIMS staff attending March 10, Tuesday Immediate Past President Elaine Jones, March 11, Wednesday Meeting with Secretary of the Executive MD, and RIMS Public Laws Chair Board of Medical Licensure and Discipline Michael Migliori, MD, made House Calls Office of Health and Human Services Meeting with OHIC legal counsel at the State House (EOHHS); Peter Karczmar, MD, Russell regarding RIMS legislative agenda Settipane, MD, RIMS staff attending Representative Edwards fundraiser; Meeting with RI Quality Institute RIMS staff attending State Innovation Model Steering regarding legislation Committee meeting, RIMS staff attending Legislative hearings Legislative hearings
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March 12, Thursday March 19, Thursday HealthSource RI Joint Advisory Board Meeting with Chief Administrative Meeting with RI Quality Institute meeting; RIMS staff attending Officer, Board of Medical Licensure regarding Current Care; Health Services Council, and Discipline, regarding medical RIMS staff attending RIMS staff attending record copy fees Committee Hearings Medical Student event on civic DOH Health Services Council meeting Chairman Felag Fundraiser, involvement, RIMS staff attending Legislative hearings RIMS staff attending (photos previous page) Legislative Hearings March 16, Monday March 20, Friday E. Christine Brousseau, MD; and Governor’s Opioid Overdose Taskforce Conference call, American Medical Phillip R. Rizzuto, MD; made House meeting, RIMS staff attending Association regarding potential S Calls at the State House Conference call, American Medical GR legislation Rep. Marcello fundraiser, Association regarding potential March 23, Monday RIMS staff attending SGR legislation Meeting with American College of RIMS Board of Directors Meeting Emergency Physicians, RI Chapter March 25, Wednesday OHIC Administrative Simplification March 17, Tuesday (RI ACEP) Executive Committee; RIMS staff attending meeting, RIMS staff attending OHIC Health Insurance Legislative Hearings Advisory Committee AMA Advocacy Resource Center Executive Committee conference call, Chairman Gallison fundraiser, Legislative Hearings RIMS staff attending RIMS staff attending March 18, Wednesday RIMS Finance Committee meeting, Sen. Nesselbush fundraiser, DOH Primary Care Physician Advisory Jose R. Polanco, MD, Chair RIMS staff attending, RIMPAC Chair Committee, Department of Health Michael Silver, MD, and RIMS staff March 24, Tuesday attending OHIC Administrative Simplification Meeting with physical therapists, meeting occupational therapists, et al. al., March 26, Thursday Health Professional Student Loan regarding Governor’s budget; Mental Health and Substance Abuse Program, RIMS staff attending RIMS staff attending Coalition meeting, RIMS staff attending Workers Comp Advisory Committee, Meeting with State Director of Meeting RICARES and other RIMS staff attending Administration and the YMCA alliance advocates on Good Sam legislation, Legislative Hearings of Rhode Island regarding state employees’ RIMS staff attending health insurance; RIMS staff attending Meeting with Congressman Cicilline’s Chief of Staff, RIMS staff attending Legislative Hearings Chairman Gallo fundraiser, Medical Odysseys Available! Rep. Kazarian fundraiser, Rep. Jacquard fundraiser; Medical Odysseys: A Journey through the Annals of RIMS staff attending the Rhode Island Medical Society, was published for March 27, Friday the Society’s Bicentennial in 2012. RIMS Exhibits at RIAFP 23rd Annual Family Care Conference; A limited number of copies remain. Readers of Dr. RIMS staff attending Stanley Aronson’s uniquely erudite and entertaining March 30, Monday essays on medicine, medical history, language and Meeting with BCBSRI; Peter Karczmar, forensic folklore will cherish this compilation, MD; Russell Settipane, MD; and which also includes commentaries by Dr. Joseph RIMS staff attending Friedman, executive editor of the Rhode Island Nominating Committee meeting; Peter Karczmar, MD, Chairman Medical Journal, as well as essays on aspects of RIMS’ history by RIMJ managing editor Mary Korr. March 31, Tuesday Board of Medical Licensure and The cost is $15 and includes postage. Discipline community review of proposed regulatory changes, Please contact Sarah at the RIMS office: RIMS staff attending [email protected] or 401-528-3281. Legislative Hearings
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www.rimed.org | rimj archives | APRIL webpage APRIL 2015 Rhode Island medical journal 54 You’re Invited to a free Rhode Island Medical Society and Baystate Financial Educational Event designed specifically for physicians.
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Dr. Alexander-Scott Named Director of the Department of Health
PROVIDENCE – Today, Dr. Nicole Alex- Hepatitis, STDs, and TB at the Rhode ander-Scott begins in her new role Island Department of Health in the as Director of the Department of Health, Division of Infectious Diseases and succeeding Dr. Michael Fine, who Epidemiology. announced his resignation last month. “I’ve had the opportunity to work “Dr. Alexander-Scott brings tre- with Dr. Alexander-Scott, and I believe mendous experience from her work at she is the best of the best,” said Dr. Rhode Island Hospital, the Department Fine. “The Governor has made an of Health, and Brown University,” said excellent choice for our state, and I Secretary of the Executive Office of look forward to working closely with Health and Human Services Elizabeth Dr. Alexander-Scott over the coming Roberts. “She was a tremendous asset weeks to ensure a smooth transition.” to our state during the recent meningi- “It is a privilege to have this oppor- tis outbreak at Providence College, and tunity to work with so many talented will be a great addition to our team as health care and public health profes- we work to provide all Rhode Islanders sionals to strengthen our care system with access to the information and care across the state,” said Dr. Alexan- they need to be healthy.” der-Scott. “My passion is advancing Dr. Alexander-Scott is board certi- public health across all ages, economic fied in pediatrics, internal medicine, backgrounds and communities. I am pediatric infectious diseases, and adult committed to helping to ensure all infectious diseases. She is an assistant Rhode Islanders receive the kind of professor of pediatrics and medicine at care they deserve.” the Alpert Medical School, serving in She received her bachelor of science the Divisions of Pediatric and Adult degree from Cornell University and her Infectious Diseases at the affiliated medical degree from SUNY Upstate hospitals in Rhode Island. She also Medical University at Syracuse. She Dr. Nicole Alexander-Scott with Governor serves as a consultant medical direc- also holds a master of public health Gina Raimondo tor for the Office ofHI V/AIDS, Viral degree from Brown University. v
Rhode Island Hospital Offers First Fellowship in Addiction Medicine in RI
PROVIDENCE – Rhode Island Hospital has established a fel- and skill of our own physicians in addressing substance use lowship program in addiction medicine, the first of its kind problems,” said Peter D. Friedmann, MD, MPH, FASAM, in the state. Funded in part by a grant from CleanSlate FACP, director of the new fellowship based in the division of Addiction Treatment Centers of Massachusetts, the new fel- general internal medicine at Rhode Island Hospital. lowship is one of the ways the hospital is responding to the The physician fellows will work with physicians certified public health crisis posed by addiction in Rhode Island and in addiction medicine and addiction psychiatry as well as southern New England. those trained in internal medicine, family medicine, obstet- According to the Centers for Disease Control and Preven- rics and gynecology, pediatrics and emergency medicine. tion (CDC), Rhode Island is perched at the top of the list The fellows will work with varied populations, including for illicit drug use and has the third highest rate of alcohol but not limited to youth, veterans, patients with HIV, health poisoning deaths in the nation. Opioid abuse is rampant, professionals and those within the criminal justice system. including not just heroin but prescription opioids such as “We’re actively recruiting candidates from all specialties Vicodin, Percocet, methadone, and oxycodone. Heroin is the who will help us make evidence-based addiction prevention most commonly cited drug among primary drug treatment and treatment more available to those who need it,” said admissions in the state. Tobacco addiction is also on the list Dr. Friedmann. of the most difficult substances to quit, and 20 percent of Rhode Island Hospital was one of four new fellowship pro- Rhode Island’s adult population smoke cigarettes. grams accredited recently by the American Board of Addiction “Training doctors in addiction medicine serves not only Medicine Foundation (ABAM). In all, ABAM has accred- to improve public health, but also to advance the knowledge ited 27 addiction medicine training programs in the U.S. v
www.rimed.org | rimj archives | APRIL webpage APRIL 2015 Rhode Island medical journal 56 IN THE NEWS
Brain Day Showcases Clinical, Basic Research at Brown, Hospitals Nobel Laureate Dr. Richard Axel delivers keynote on the sense of smell
PROVIDENCE — At Brown University’s second annual MindBrain Research Poster winners Day held last week, more than a hun- Undergraduate dred university and hospital-affiliated 1st place, Hayley Bounds researchers showcased their work at a 2nd place, Uday Agrawal poster exhibition in Sayles Hall. Top- Graduate Students ics spanned a wide spectrum in the 128 1st place, Zeyang Yu posters, from state-of-the-art develop- 2nd place, Molly Boutin ments in neurophysiology and adaptive devices, gene therapies, treatment of Research Assistants brain diseases, substance abuse, weight 1st place, Daniella Amri C ol u mb i a U ni v er s t y loss, developmental screening in chil- 2nd place, Christina D’Angelo dren, depression and the elderly, just to of a large gene family, comprised of Clinical Psychology Residents name a few. some 1,000 different genes (three per 1st place, Jessica Peters After the exhibition, Nobel Laureate cent of our genes) that gives rise to an 2nd place, Marisa Sklar equivalent number of olfactory recep- Dr. Richard Axel of Columbia Uni- Psychiatry Residents tor types. versity delivered the keynote address, 1st place, Jorge Almeida Dr. Axel described how the sense “Order from Disorder: Internal Repre- 2nd place, Brian Theyel sentations of the Olfactory World,” in of smell is perceived by these special- Postdoc (basic science depts) Salomon Hall. ized receptors located on cells in the 1st place, Abigail Polter In 2004, he and co-Nobel recipient upper part of the nasal epithelium of 2nd place, Ernest Ho Linda Buck were recognized for their the “peripheral olfactory organ” (aka discoveries of odorant receptors and the the nose). Different receptors perceive Postdoc (clinical depts) organization of the olfactory system. a banana, others a ripe strawberry 1st place, Jared Saletin They published their findings jointly or a good wine. Nerves message the 2nd place, Laura Hancock in 1991, which reported the presence odor information to glomeruli in the ry K o rr photos : M a ry Last week, a poster exhibition at Brown’s Sayles Hall showcased the Poster 11, by faculty member Patrick Bedard, PhD, et al, depicted the examina- work of university and hospital-affiliated researchers in celebration of tion of neuroplasticity involved in limb-substitution learning associated with learn- the second annual MindBrain Research Day held March 25. ing to control the DEKA Arm, an advanced, foot-controlled prosthetic device.
www.rimed.org | rimj archives | APRIL webpage APRIL 2015 Rhode Island medical journal 57 IN THE NEWS
olfactory bulb in the brain, which is then translated by other parts of the brain, forming a pattern. The recognition of odors is trans- lated into an internal representation of sensory quality in the brain and, according to Dr. Axel, this leads to meaningful thoughts and behavior, allowing humans and animals to dis- tinguish good smells from bad ones; i.e., a bad clam or a fragrant lilac or a burning building. After the keynote address, win- ners of the poster competition were announced. The event was sponsored by the Brown Institute for Brain Science; the Norman Prince Neurosciences Insti- tute (NPNI); the Departments of Neu- rology; Neurosurgery; Neuroscience; Molecular Pharmacology, Physiology and Biotechnology (MPPB); and Psychi- Poster 64, by clinical psychology resident Douglas Long, MA, et al, described the development of atry and Human Behavior. v a new measure of therapist skill in Acceptance and Commitment Therapy (ACT).
Kent Hospital Receives State Approval to Perform Coronary Angioplasty
WARWICK – Care New England has Data presented to the state Depart- cardiology at Kent and the leader of the received approval from the Rhode ment of Health during the approval Brigham and Women’s Cardiovascular Island Department of Health to develop process demonstrated that patients Associates at Care New England, exec- and implement a coronary angioplasty residing south of the metro Provi- utive chief of cardiology at CNE. program at Kent Hospital in Warwick. dence area (more than 300,000 Rhode “As the second largest hospital in It is expected the elective angio- Islanders) would benefit greatly from Rhode Island and with nearly 70,000 plasty program will be operational after expanded access to coronary angioplasty emergency department visits annually, several months of clinical preparation via the new program at Kent Hospital. it is vitally important that we be able including staff training at Brigham and Data presented during the approval to provide this life-saving service to the Women’s Hospital in Boston. Also, the process also showed that for many more than 300,000 people in the imme- 24-hour, emergency angioplasty ser- patients in parts of Kent County and diate service area of Kent and points vice would follow approximately six further south it is possible that trans- south. We look forward, through our months later upon the completion of portation to a current facility capable clinical affiliation with Brigham and construction of a second cardiac cath- of providing this treatment could add Women’s Hospital, to developing this eterization lab. upwards of 20 minutes travel beyond critical program for our community,” “On behalf of Care New England and Kent Hospital, thereby delaying criti- said Dr. Dacey. Kent Hospital, I would like to thank cal treatment for some 300,000 Rhode “The cardiology program across the Rhode Island Department of Health Islanders. Care New England, and here at Kent, for its thorough review and approval of “For patients having a heart attack, has grown tremendously over the past our application for a certificate of need 20 minutes and even 10 minutes, is several years to provide access to and to perform coronary angioplasty at an enormous amount of time and can treatment for general and complex car- Kent Hospital,” said Michael Dacey, be the difference between someone diovascular care. Today’s approval is Jr, MD, Kent Hospital president and living or dying. Reducing this time to another important step in providing COO. “This standard-of-care proce- open a closed artery will clearly save the community and patients with the dure will result in lives saved because lives starting in year one,” said Ches- best possible care close to home,” said of decreased travel time to access this ter Hedgepeth, MD, PhD., chief of Dr. Hedgepeth. v critical treatment.”
www.rimed.org | rimj archives | APRIL webpage April 2015 Rhode Island medical journal 58 Specialized financing for a successful practice.
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Bradley Hospital Awarded $168K in Federal Funding to Support Medical Residency Training
EAST PROVIDENCE – During a recent press conference at Brad- other children’s psychiatric teaching hospitals should have ley Hospital. Senators Sheldon Whitehouse and Jack Reed the federal support they need to train doctors equipped to announced that the hospital will receive $168,354 from the treat mental illness. I am pleased we were able to finally Children’s Hospitals Graduate Medical Education (CHGME) reach an agreement to address the omission of children’s Payment Program. psychiatric teaching hospitals because it is essential to end The funding was made possible by the CHGME Support discriminatory funding policies against children with men- Reauthorization Act of 2013, which included a provision tal health issues,” said Reed. authored by Sen. Whitehouse to expand the program to “As the number of children in need of mental health care include children’s psychiatric teaching hospitals. services continues to skyrocket, the ratio of children seek- Bradley Hospital first sought CHGME funding in 2002 ing services versus the number of mental health care provid- but was informed that the hospital did not qualify for the ers remains one of the largest disparities in the entire field program because only children’s hospitals – not children’s of medicine,” said Daniel J. Wall, president of Bradley Hos- psychiatric hospitals – were eligible. Whitehouse and Reed pital. “Research has proven the value of early diagnosis and have been fighting for years to expand the eligibility of the treatment in mental health outcomes in children, so funding CHGME program to include children’s psychiatric hospi- to support the training of medical students to practice in the tals, and succeeded in changing the law last year. The funds field of psychiatry is not only important, it is essential to the announced were a direct result of that change. health and wellbeing of our children.” “Mental health care is just as important as physical health The CHGME funding will be used to support Bradley’s care, but is too often forgotten or ignored,” said Whitehouse. medical residency training program, including the 2-year “This funding will support Bradley Hospital’s training program Child and Adolescent Psychiatry Fellowship and its 5-year for medical residents which prepares them to treat children’s Triple Board Residency program, which leads to board eligi- mental and behavioral health conditions. I was proud to work bility in pediatrics, general psychiatry, and child and adoles- with Senator Reed to include children’s psychiatric teaching cent psychiatry. The Triple Board program is one of only ten hospitals in the CHGME program, and I congratulate Brad- such programs in the United States. ley Hospital on the receipt of this much-deserved funding.” The CHGME Support Reauthorization Act of 2013 reau- “This is a smart investment in boosting mental health thorized the CHGME Payment Program for five years, and parity and helping children’s hospitals train the next gener- for the first time allowed children’s psychiatric teaching ation of highly qualified pediatricians. Bradley Hospital and hospitals like Bradley Hospital to compete for funding. v
Care New England’s Quin and Marran Selected to Participate In National Fellows Program
PROVIDENCE – Matthew Quin, RN, similar missions and understand the and behavioral health services since MSN, vice president of patient care unique challenges of the safety net.” 2013. She also serves as the executive services at Women & Infants Hospital Quin has served as the vice president manager for operations, planning and of Rhode Island, a Care New England for nursing operations at Women & business development as well as the Hospital, and Mary Marran, MS, Infants Hospital since 2013. A graduate director of informatics for Butler Hospi- OT, MBA, vice president of service line of Saint Anselm College in Manches- tal, also a Care New England Hospital. integration for orthopedics and brain ter, NH, Quin earned a master of sci- Marran started her career with Butler and behavioral health services for Care ence in nursing at Simmons College. Hospital as a staff occupational thera- New England Health System, recently He is a member of the American Asso- pist in 1985. She received her bachelor were notified of their selection to par- ciation of Critical Care (AACN) and its and masters of science degrees in occu- ticipate in the 2015 America’s Essential Greater Boston Chapter, Organization pational therapy from the University Hospitals Fellows Program, Innovative of Nurse Leaders of MA and RI (ONL), of New Hampshire and her MBA at and Adaptive Leadership: Essential in and Sigma Theta Tau International, the the University of Phoenix. Marran is Times of Change. National Nursing Honor Society. a member of the American College of Quin and Marran were among many Quin has received numerous awards, Healthcare Executives (ACHE) and a candidates who were nominated from including the AACN Circle of Excel- member of Leadership RI Theta II Class America’s Essential Hospitals member lence Award for Nurse Leadership, the of 2012. organizations. According to Ameri- AACN Gold Beacon Award and the Marran is a recipient of the Irene ca’s Essential Hospitals Senior Vice Partners in Excellence Award from Allard Clinical Educator of the Year President for Leadership and Innova- Partners Healthcare Institutions. Award awarded by the New England tion, David Engler, PhD, this program, Marran has served as Care New Occupational Therapy Education “provides a valuable opportunity to England vice president of service line Council and is a former Butler Hospital network with colleagues who share integration for orthopedics and brain Employee of the year. v
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Hospitals Are an Economic Engine to Rhode Island Economy Hospital Economic Activity Generates DON’T BE LATE FOR A VERY IMPORTANT DATE! 41,000 Jobs and $6.9 Billion
CRANSTON – The Hospital Association of Southern New England Rhode Island (HARI) released its annual economic impact report recently, which detailed $6.9 billion in economic Heart Ball contributions. Highlights of hospitals’ economic impact in 2013 include: • Employing 19,900 health care professionals • Supporting 21,400 jobs with economic activity • Paying $1.8 billion in wages • Generating $2.8 billion for the local economy through purchasing goods and services • Dedicating $167 million to improving facilities and Marble House, Newport RI upgrading technology sneheartball.heart.org “Our industry is vital to the state’s economy and health,” said Michael R. Souza, HARI president. “Hospitals Event Chair: support one in ten jobs in Rhode Island. Rajiv Kumar, MD We’re an economic engine that is pro- viding Rhode Islanders with well-pay- ing jobs and supporting local business. Heart Hero Ambassador: State leaders must make the appropri- Annika, Age 7 ate investments to secure our role in the state’s economy.” The report was produced in collabo- Open Your Heart Chairs: ration with the Healthcare Association Jessica and Nino Granatiero of New York State using data reported annually by hospitals to the Centers for Medicare & Medicaid Services. v Join us for an evening of imagination while funding lifesaving cardiovascular research and education.
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1 800 69-SHRED • www.shredit.com IN THE NEWS
Students Celebrate Match Day Nicholas Canelo Diana Escobar UC-San Diego Medical Center Stony Brook Teaching Hospitals One hundred and two Alpert Medi- UC-San Diego School of Medicine Stony Brook University School of Medicine Family Medicine Anesthesiology cal School students celebrated Match Yi Cao Angela Esquibel Day on March 20th when they ripped Roger Williams Medical Center La Crosse-Mayo, Mayo Clinic open envelopes to find out where they Boston University School of Medicine Family Medicine Medicine - Prelim will begin their residency training; 12 Beth Israel Deaconess Medical Center Brendon Esquibel Gundersen Lutheran Medical Foundation Harvard Medical School matched at Rhode Island hospitals. University of Wisconsin School of Radiology Many students matched to special- Medicine and Public Health Ivy Chang Surgery ties as varied as radiology, ophthalmol- New York Presbyterian Hospital Columbia University College of Physicians & Surgeons Justina Gamache ogy, emergency medicine, surgery, and Olive View – UCLA Medical Center Emergency Medicine neurology. A total of 19 matched to David Geffen School of Medicine Gina Chen Medicine residences in internal medicine and 19 Boston University Medical Center Boston University School of Medicine Rafael Gonzalez more matched to the primary care dis- Brigham & Women’s Hospital, Harvard Medical School Medicine - Primary ciplines of family medicine or primary Obstetrics/Gynecology Daniel Cho medicine. Another dozen will pursue University of Washington Affiliated Hospitals Zachary Grabel Emory University School of Medicine University of Washington School of Medicine pediatrics. v Orthopedic Surgery Plastic Surgery Zunaira Choudhary Alma Guerrero Rhode Island Hospital, Alpert Medical School North Shore-Long Island Jewish Health System Medicine Hofstra North Shore-LIJ School of Medicine Medicine Robert Heinl Nigar Ahmedli Grace Chow Emory University School of Medicine Einstein/Montefiore Medical Center Medicine North Shore-Long Island Jewish Health System Albert Einstein College of Medicine Hofstra North Shore-LIJ School of Medicine Ryan Heney Otolaryngology Obstetrics/Gynecology Memorial Hospital of Rhode Island, Alpert Medical School Erica Alexander Alice Chuang Family Medicine Hospital of the University of Pennsylvania Santa Clara Valley Medical Center Ijeoma Iko University of Pennsylvania Health System Stanford University School of Medicine UC-Davis Medical Center, UC-Davis School of Medicine Surgery -Prelim Medicine Obstetrics/Gynecology Radiology Waihong Chung Deidrya Jackson Veronica Alexander Icahn School of Medicine at Mount Sinai St. Vincent’s Medical Center Tulane University School of Medicine Medicine (Research) Frank H. Netter MD School of Medicine Triple Board Avery Clark Medicine - Prelim Tariq Ali Medical University of South Carolina Boston University Medical Center Hospital of the University of Pennsylvania MUSC College of Medicine Boston University School of Medicine University of Pennsylvania Health System Ophthalmology Emergency Medicine Medicine Caitlin Cohen Hannah Janeway Andre Anderson Harbor-UCLA Medical Center Massachusetts General Hospital, Harvard Medical School New York Presbyterian Hospital David Geffen School of Medicine Emergency Medicine - Primary Columbia University College of Physicians & Surgeons Medicine Emergency Medicine Robert Cook Swedish Medical Center Helen Johnson Ted Apstein Vidant Medical Center, East Carolina University University of Washington School of Medicine Maricopa Medical Center Surgery Family Medicine University of Arizona College of Medicine Allison Kay Emergency Medicine Justine Cormier University of Washington Affiliated Hospitals Rhode Island Hospital, Alpert Medical School Grayson Armstrong University of Washington School of Medicine Medicine - Prelim Cambridge Health Alliance,Harvard Medical School Obstetrics/Gynecology Yale-New Haven Hospital, Yale School of Medicine Transitional Neurology Amrin Khander Mass Eye & Ear Infirmary, Harvard Medical School Mount Sinai Icahn School of Medicine Ophthalmology Crystal-Rose Cuellar Obstetrics/Gynecology Baylor College of Medicine Gregory Barnett Houston Baylor College of Medicine Tendo Kironde Cambridge Health Alliance, Harvard Medical School Pediatrics University of Washington Affiliated Hospitals Psychiatry Ami Cuneo University of Washington School of Medicine Catherine Berger Pediatrics University of Washington Affiliated Hospitals University of Chicago Medical Center University of Washington School of Medicine Calvin Lambert Pritzker School of Medicine Neurology Howard University Hospital Pediatrics Rahul Dalal Howard University College of Medicine Honora Burnett Obstetrics/Gynecology Hospital of the University of Pennsylvania UC-San Francisco Medical Center University of Pennsylvania Health System Amie Leaverton UCSF School of Medicine Medicine Oregon Health & Science University Pediatrics Ella Damiano OHSU School of Medicine John Butler Obstetrics/Gynecology Dartmouth-Hitchcock Medical Center Rhode Island Hospital, Alpert Medical School Geisel School of Medicine Emily Li Pediatrics Obstetrics/Gynecology BI Deaconess Medical Center-Brockton Keith Butts Gregory Elia Harvard Medical School University of Utah Affiliated Hospitals Transitional Rhode Island Hospital, Alpert Medical School University of Utah School of Medicine Yale New Haven Medical Center. Yale School of Medicine Orthopedic Surgery Anesthesiology Ophthalmology
www.rimed.org | rimj archives | APRIL webpage April 2015 Rhode Island medical journal 63 IN THE NEWS
Kevin Liou Jerry Nnanabu Nathan Sison New York Presbyterian Hospital University of Chicago Medical Center University of North Carolina Hospitals Weill Cornell Medical Center Pritzker School of Medicine UNC School of Medicine Medicine - Primary Medicine Family Medicine Joy Liu Catherine Paniszyn Corey Spiro Beth Israel Deaconess, Harvard Medical School Yale-New Haven Hospital, Yale School of Medicine Massachusetts General Hospital, Harvard Medical School Medicine Medicine - Primary Anesthesiology Carolyn Luppens Christina Panton David Stat University of Utah Affiliated Hospitals Loma Linda University Memorial Hospital of Rhode Island, Alpert Medical School University of Utah School of Medicine Loma Linda University School of Medicine Family Medicine Surgery Obstetrics/Gynecology Taylor Stayton Kelly MacDonald Hannah Park UC-Davis Medical Center, UC-Davis School of Medicine Walter Reed National Military Medical Center New York University School of Medicine Emergency Medicine Psychiatry NYU School of Medicine Bianca Stifani Medicine - Prelim Courtney Mannino Einstein/Montefiore Medical Center New York University School of Medicine UC-Los Angeles Medical Center Albert Einstein College of Medicine NYU School of Medicine David Geffen School of Medicine Obstetrics/Gyneoclogy Neurology Pediatrics Sarah Swanson Isha Parulkar Shannon Marrero UC-Los Angeles Medical Center St. Vincent Hospital University of Washington Affiliated Hospitals David Geffen School of Medicine University of Massachusetts Medical School Medicine - University of Washington School of Medicine Medicine Prelim Pediatrics Rhode Island Hospital, Alpert Medical School Jamille Taylor Elizabeth Marshall Dermatology MedStar Franklin Square Medical Center UC-San Francisco Medical Center University of Maryland School of Medicine Aidan Porter UCSF School of Medicine Family Medicine University of Pittsburgh Medical Center Medicine - Primary University of Pittsburgh School of Medicine Pediatrics Gretel Terrero Tracey Martin Beth Israel Deaconess Medical Center Sarah Rapoport New York University School of Medicine Harvard Medical School Georgetown University Hospital Medicine Medicine Georgetown University School of Medicine Alexander Mayer Otolaryngology Jonathan Thorndike Virginia Commonwealth University Health Systems Rhode Island Hospital, Alpert Medical School Juliann Reardon VCU School of Medicine Emergency Medicine University of Massachusetts Medical School Plastic Surgery Pediatrics Olivier Van Houtte Madeline McKeever Abington Memorial Hospital Satyajit Reddy Swedish Family Medicine Residency Temple University School of Medicine Temple University Hospital University of Colorado School of Medicine Surgery Temple University School of Medicine Family Medicine Medicine Kary Vega Shakir McLean Florida Hospital, University of Central College of Medicine Daniel Resnick-Ault St. Vincent’s Medical Center Pediatrics Boston University Medical Center Frank H. Netter School of Medicine Boston University School of Medicine Jason Wade Medicine - Prelim Emergency Medicine Rutgers RW Johnson Medical School Oregon Health & Science University Surgery Anesthesiology Rachel Rome Rhode Island Hospital, Alpert Medical School Joanne Wang May Min Medicine Case Medical Center University of Massachusetts Medical School Case Western University School of Medicine Medicine Rohit Sangal Orthopedic Surgery Hospital of the University of Pennsylvania Aron Mohan University of Pennsylvania Health System Claire Williams Hospital of the University of Pennsylvania Emergency Medicine Rhode Island Hospital, Alpert Medical School University of Pennsylvania Health System Triple Board Medicine Terra Schaetzel-Hill Rhode Island Hospital John Williams Suresh Mohan Alpert Medical School University of Washington Affiliated Hospitals Massachusetts Eye and Ear Infirmary Medicine - Primary University of Washington School of Medicine Harvard Medical School Neurological Surgery Otolaryngology/Research Sara Schlotterbeck Boston University Medical Center Edgar Woznica Patrick Mulvaney Boston University School of Medicine Johns Hopkins Hospital Beth Israel Deaconess Medical Center Family Medicine Johns Hopkins University School of Medicine Harvard Medical School Psychiatry Medicine - Prelim Joseph Schmidhofer Massachusetts General Hospital, Harvard Medical School Rhode Island Hospital, Alpert Medical School Michael Xiong Dermatology Pediatrics Christiana CareJefferson Medical College Transitional Nicholas Nassikas Matthew Schwede Stony Brook Teaching Hospitals Rhode Island Hospital, Alpert Medical School UC-San Francisco Medical Center Stony Brook University School of Medicine Medicine UCSF School of Medicine Dermatology Lindsey Negrete Medicine Samuel Yang Scripps Mercy Hospital-San Diego Joanna Sharpless Ohio State University Medical Center UC-San Diego School of Medicine Einstein/Montefiore Medical Center Ohio State University College of Medicine Transitional Albert Einstein College of Medicine Med/Peds UC-San Diego Medical Center Family Medicine UC-San Diego School of Medicine Jacquelyn Silva Radiology University of Chicago Medical Center Pritzker School of Medicine Pediatrics
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Recognition
Cardiologist Thomas Drew, MD, Honored with Milton Hamolsky Outstanding Physician Award
PROVIDENCE – The medical nominated Dr. Drew. “But if he were, we are willing to bet that staff of Rhode Island Hospital he would have been delighted by this year’s choice, Milton’s awarded cardiologist Thomas own physician. Tom is an amazingly talented and energetic man Drew, MD, the 2014 Annual who has been at the heart of medical care and cardiology care Milton Hamolsky Outstanding for a long time. He has done so with grace and vision. He has Physician Award. Dr. Drew supported us in who we are and helped us forward with a vision was honored for his dedication of who we should be.” to ethical practice, outstand- Dr. Drew, of Providence, is also a clinical associate profes- ing clinical skills and commit- sor of medicine at The Warren Alpert Medical School of Brown ment to medical education. University. During his career he has volunteered his time to nu- The award is the highest honor merous professional associations including the Bristol County the medical staff bestows on Medical Society, University Cardiology Foundation (formerly one of its own. Rhode Island Hospital Cardiology Foundation), and the Amer-
n Life spa “Dr. Drew is an extraordi- ican College of Cardiology. He is a prolific author of medical nary physician who has inspired other physicians through his academia and a frequent presenter on cardiac medicine. dedication to excellence, unparalleled medical skills and com- After graduating from Columbia University’s College of Phy- passionate care,” said Latha Sivaprasad, MD, chief medical of- sicians and Surgeons and completing his residency, Dr. Drew ficer of Rhode Island Hospital. “On behalf of all of the Rhode served a two-year stint with the United States Public Health Island Hospital physicians, it is my distinct honor to recognize Service Center for Disease Control. He joined the staff of Rhode Dr. Drew for his integrity and commitment to medicine.” Island Hospital in 1977. “For more than four decades, Dr. Drew has been an accom- The Milton W. Hamolsky Outstanding Physician Award plished cardiologist and educator, and has contributed enor- is presented each year to a doctor who has made exceptional mously to the field of cardiology,” said Samuel Dudley, MD, contributions to patient care and leadership. Milton Hamolsky, PhD, chief of cardiology at Rhode Island and The Miriam hospi- MD, who passed away in January, 2014 at age 92, was an en- tals, and director of the Cardiovascular Institute. “He has always docrinologist who came to Rhode Island Hospital in 1963 and offered his time, wisdom and support to colleagues throughout served as the first full-time physician-in-chief.D r. Hamolsky his career and inspires all to emulate his professionalism.” served as the chief administrative officer of the Rhode Island “Milton Hamolsky is no longer here to present the award Board of Medical Licensure and Discipline and was a noted that was named in his honor,” said Daniel J. Levine, MD, who pioneer of medical education in Rhode Island. v
W&I’s Dr. Star Hampton Brings Specialty Care to Women in Rwanda PROVIDENCE – Each year in sub-Saharan IOWD mission. Two gradu- surgical approaches. Dr. Africa, it is estimated that more than ates from the Women and Raman also ran a fourth- 33,000 women develop obstetric fistulae Infants fellowship, Dr. Blair degree laceration work- and subsequent urinary and/or fecal in- Washington and Dr. Peter shop that was attended continence. Unfortunately, these women Jeppson, are now attendings by more than 60 Rwandan are currently not able to be adequately re- on the surgical team after care providers. paired by local physicians due to lack of experiencing this as senior During this trip, Dr.
training and resources. fellows with Dr. Hampton. a n ts Hampton’s team evaluat- Recently, Dr. Star Hampton and The team from Women & ed more than 130 wom- her senior fellow, Dr. Sonali Raman, Infants Hospital worked in en with fistula who were
of the Division of Urogynecology and Re- Kigali, Rwanda, where they w om en & inf waiting for them and their constructive Pelvic Surgery at Women served for two weeks at Star Hampton, MD skilled surgical hands. The & Infants Hospital traveled to Rwanda Kibagabaga Hospital with a team was able to success- with the International Organization for team of American surgeons, anesthesiolo- fully operate on over 50 of these women. Women and Development (IOWD) as gists, and nurses. They collaborated with “Our team was able to provide basic and part of a fistula repair team. Dr. Hamp- and trained Rwandan physicians, medi- advanced care to the women in Africa, ton has been travelling to Africa each cal students, and nursing staff, teaching women whose lives were definitely im- year since 2005, when she was a urogy- them post-surgical care for the women, proved. We worked hard to tackle difficult necology fellow at NYU, and she is now as well as basic anatomy, surgical prepa- surgical cases and to create meaningful the team leader and lead surgeon for the ration, sterility concepts, evaluation, and results for the women of Rwanda.” v
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Appointments
Ziya Gokaslan, MD, Named Chief of Neurosurgery at RIH, Miriam Hospitals; Neurosurgery Chair at Alpert Medical School
PROVIDENCE – Ziya L. Gokaslan, treatment of both primary and metastatic spinal tumors, sacral MD, FACS, has been appointed chief neoplasms and spinal cord tumors. He developed many novel of neurosurgery at Rhode Island approaches for resection of pancoast tumors, spinal neoplasms, Hospital and The Miriam Hospital, as well as sacral tumors, including total sacrectomy and com- and chairman of the Department of plex spinal and pelvic reconstruction. Dr. Gokaslan transformed Neurosurgery at The Warren Alpert the surgical treatment of spinal neoplasms and devised tech- Medical School of Brown Universi- niques rendering certain tumors resectable once deemed in- ty, effective July 1, 2015. operable. These led to significant improvement of survival in In this role, Dr. Gokaslan, who patients with various neoplastic conditions. His basic research n Life spa comes to Rhode Island from Johns focuses on the development of new animal models to study the Hopkins University School of Medicine, will lead all clinical, pathophysiology of neoplastic spinal cord compression and to research and teaching efforts in neurosurgery across the entire define the roles of proteolytic enzymes in tumor invasion and Lifespan system. In addition, he will serve as the clinical direc- to devise novel therapeutic approaches to treat spinal tumors. tor of the highly regarded Norman Prince Neurosciences Insti- He is a prolific researcher serving as principal investigator and tute where he will be responsible for continuously enhancing collaborator on numerous projects regarding spinal oncology and collaboration and advancement among the institute’s neurosci- surgery. He has authored over 300 peer-reviewed papers and pre- ences faculty and the Brown Institute for Brain Science. sented more than 250 national and international lectures since “We are thrilled to welcome Dr. Gokaslan, an internationally 1996. He has authored and co-authored four book and numerous renowned neurosurgeon, to Lifespan,” said Timothy J. Babineau, book chapters. He serves on the editorial boards of top academ- MD, president and chief executive officer of Lifespan. “Dr. Go- ic journals, including the Journal of Spinal Disorders & Tech- kaslan’s remarkable achievements and expertise will further ad- niques, European Spine Journal, Nature Reviews in Neurology, vance Lifespan’s commitment to becoming a national leader in the Journal of Surgical Oncology, and World Neurosurgery. He the area of neurosurgery and neuroscience. We were fortunate to also served as co-editor of Journal of Neurosurgery-Spine from be able to attract one of the very best in the country to Lifespan 2012 to 2013. He is a member of numerous prestigious societ- and Rhode Island.” ies, notably the Society of Neurological Surgeons, the Cervical “Dr. Gokaslan is a skilled surgeon, a talented educator and sci- Spine Research Society, the American Society of Clinical On- entist, and he understands the strength of academic medicine,” cology, the American Association of Neurological Surgeons, the said Jack A. Elias, MD, dean of medicine and biological sciences Congress of Neurological Surgeons and the North American at Brown University. “His mentorship of medical students, res- Spine Society as well as Scoliosis Research Society. He is also idents and fellows is well known, and we admire his dedication a past president of the American Association of Neurological to the advancement of knowledge in the neurosciences.” Surgeons/Congress of Neurological Surgeons’ disorders of the Most recently, Dr. Gokaslan has served as the vice chairman spine and peripheral nerves section. of the department of neurosurgery, director of the neurosurgical Dr. Gokaslan was recently awarded the Leon Wiltse Clinical spine program, director of the neurosurgical spine metastasis Research Award by the North American Spine Society for his center and a professor of neurosurgery, oncology and orthopedic excellence in leadership and clinical research in spine care. surgery at the Johns Hopkins University School of Medicine in Dr. Gokaslan earned his medical degree from the Universi- Baltimore, Maryland. Prior to joining Johns Hopkins, Dr. Go- ty of Istanbul, Turkey. He completed an internship in general kaslan was an associate professor of neurosurgery at the Uni- surgery, a fellowship in neurotraumatology and a residency in versity of Texas MD Anderson Cancer Center in Houston and neurosurgery at Baylor College of Medicine in Houston, Texas. served as deputy chair of its department of neurosurgery. From 1993 to 1994, he was a fellow in clinical spinal surgery at Dr. Gokaslan’s clinical practice focuses on the radical surgical New York University Medical Center. v
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Appointments Michael Stanchina, MD, Named Medical Director of RWMC’s Sleep Renee Eger, MD, Named Disorders Center Medical Director of PROVIDENCE – Michael L. Women’s Primary Care Center Stan-china, MD, FCCP, has PROVIDENCE – Renee Eger, MD, of Sha- been named medical director of ron, MA, has been named medical director the Sleep Disorders Center of for the Women’s Primary Care Center of Roger Williams Medical Center. Women & Infants Hospital of Rhode Is- He is a pulmonary/sleep medicine land, a Care New England Hospital. physician with University Pul- a n ts “Dr. Eger brings extensive clinical and monary Associates and Asthma administrative experience to the position Center in East Greenwich. as well as a passion for teaching and pa- He received his medical degree from West Virginia University w om en & inf tient care. Her enthusiasm and vision for School of Medicine. Dr. Stanchina served a residency in internal women’s health and improving health care delivery will serve medicine at New England Medical Center, where he was chief our patients and community well,” said Maureen G. Phipps, medical resident. MD, MPH, chief of obstetrics and gynecology at Women & In- Dr. Stanchina completed a clinical research fellowship in pul- fants Hospital, executive chief of obstetrics and gynecology at monary/sleep medicine from Brigham and Women’s Hospital. Care New England, Chair and Chace-Joukowsky Professor in He also completed a Fellowship in Clinical Pulmonary/Critical the Department of Obstetrics & Gynecology and assistant dean Care Medicine with rotations at Massachusetts General Hospi- for teaching and research in women’s health at The Warren Alp- tal, Brigham and Women’s Hospital, Beth Israel Deaconess Hos- ert Medical School of Brown University, and professor of epide- pital, and the West Roxbury VA Hospital. miology at the Brown University School of Public Health. He is a member of numerous professional societies including Dr. Eger has been serving the health care needs of the women American Academy of Sleep Medicine and the American Sleep of Rhode Island and southeastern Massachusetts for more than Disorders Association. Dr. Stanchina is a clinical assistant pro- 20 years. A graduate of Brown University and Tufts University fessor at the Alpert Medical School of Brown University. He has School of Medicine, Dr. Eger completed her residency at Women served as president and is a charter member of the Rhode Island & Infants Hospital and is board certified by the American Board Thoracic Society, ATS Chapter. He holds a number of profes- of Obstetrics and Gynecology. In 2013, she was certified by the sional licenses and board certifications including as a diplomate Center of Excellence in Minimally Invasive Gynecology. v with the American Board of Sleep Medicine. v
Recognition
Kate Lally, MD, Named Inspirational Leader in Hospice and Palliative Medicine
PROVIDENCE – Kate Lally, MD, FACP, has the best possible care for our patients through- been named an inspirational leader in hospice out their lives,” said Dr. Lally. “We work closely and palliative medicine under the age of 40 by with our patients and their families to ensure we the American Academy of Hospice and Palli- are providing care that is consistent with their ative Medicine (AAHPM). AAHPM asked its wishes. To be recognized for our collective efforts 5,000 members to nominate individuals who are around such an important topic is an honor.” the young leaders in the field. Dr. Lally is one of In 2012, under Dr. Lally’s leadership, Care New these physicians recognized by her peers for inno- England became a pioneer sponsor of The Con- vation in and dedication to the medical specialty versation Project, a public campaign co-founded of Hospice and Palliative Medicine and AAHPM. by Pulitzer Prize-winner Ellen Goodman and Dr. Lally is the director of palliative care at Care developed in collaboration with the Institute
New England, hospice medical director at the VNA C a re N ew E n gla nd for Healthcare Improvement. The Conversation of Care New England, and clinical assistant professor of medi- Project is a public campaign with a simple and transforma- cine at the Warren Alpert Medical School of Brown University. tive goal: to have every person’s end-of-life wishes expressed “All of us at Care New England are committed to providing and respected. v
www.rimed.org | rimj archives | APRIL webpage April 2015 Rhode Island medical journal 68 people
Obituaries
Alphonse R. Cardi, MD, 100, of Cranston, passed Louis Anthony LaPere, MD, 88, of Westerly, away on March 6, 2015 at home surrounded by his RI, died peacefully on March 17, 2015 at his home, loving family. He was the beloved husband of the late Elvira M. surrounded by his loving family. He was the beloved husband (Ritacco) Cardi for 63 years. Dr. Cardi was a graduate of LaSalle of Mary F. (Healy) LaPere for over 31 years. Academy, Providence College and Born in Westerly on May 25, 1926, Georgetown University School of he was the son of the late Frank Medicine. and Josephine (Albamonti) LaPere. Upon completion of his medical Dr. LaPere attended Westerly residency, with WW II in progress, schools, and, after serving in the along with many of his colleagues Army Air Corps during World War he entered into active military ser- II, attended the University of Rhode vice. For three life altering years he Island through his GI Bill benefit, served in the Army Medical Corps, majoring in premed. He attended joining the 29th Division, 115th medical school at the University of Infantry as a battalion surgeon. Bologna in Italy, and was the first He was one of the extraordinary specialist in the field of obstetrics members of the “Greatest Generation” who participated in the and gynecology to open a practice in Westerly. He practiced storming of Omaha Beach - Dog Red in Normandy on D-Day, and medicine here in his hometown of Westerly for 30 years and was recognized by the French government for his participation delivered more than 9,000 babies. in the liberation of France. He subsequently served as head of a In addition to his wife he will be sadly missed by his 7 chil- hospital in Germany following the liberation of the concentra- dren; Paula LaBarre (Mark) of Taftville, CT.; Frank LaPere (Car- tion camps. For his participation in military service he received oline) of Tucson, AZ; Laura White (Jeffrey) of Westerly, Maresa a Purple Heart, Oak Leaf Cluster to the Purple Heart, Combat Pray (Scott) of Higganum, CT; Thomas, Amy, and Sarah LaPere Badge, Bronze Star, Bronze Arrowhead for Invasion of Norman- all of Westerly. He was the loving “Poppie” to 7 grandchildren dy and Combat Medic Badge, achieving the rank of captain. and 7 great-grandchildren. He was the brother of Barbara Gen- In 1946, upon his discharge from military service, Dr. Cardi carella of Westerly and the late Bertha Morrison. He leaves returned to Cranston and opened his medical practice retiring in many nieces and nephews. His former wife, Beverly LaRiviere 2002 at age 88. Remarkably, he maintained his medical license Hitchman, also survives him. until his death. During his long medical career, he served as In lieu of flowers, donations may be made to Home and Hos- the Director of the Department of Family Practice at St. Joseph pice Care of Rhode Island, 1085 N Main St, Providence, RI Hospital (now Fatima) for 23 years. He was a Charter Fellow of 02904 or the Louis A. LaPere, MD, Memorial Scholarship Fund, the American Academy of Family Physicians and a member of which for the last 14 years has been awarded to a graduating se- numerous national and local medical associations. He was an nior from Westerly High School who intends to pursue a career ordinary man who accomplished extraordinary things. He was a in the medical field. Donations to the scholarship fund may be proud patriot whose life was defined by courage and devotion to sent in care of Laura White, 3 Bellevue Ave, Westerly, RI, 02891. faith, family and medicine. He was a strong advocate for education, establishing various academic scholarships most notably at Saint Mary’s School, Providence College and St. Joseph’s Hospital School of Nursing. He was the devoted father of Alphonse R. Cardi, Jr. of Cranston, Carol A. Troncoso and Vera Lee Sharoff, both of New Jersey, Elizabeth Cardi Talwar of East Greenwich, and Patricia M. Car- di (Calabrese) of New York City; loving grandfather of Christine, Alphonse, Alex, Elizabeth, Stephen, Nisha, Anand, Gia, Carrie Lynn, Jeffrey and the late Stephanie Cardi; loving great-grand- father of Bella, Bailey, Angela and Jack; dear brother of Mary Barone, Elizabeth Paolella and Dr. Erminio Cardi and the late Rev. Roland Cardi, Irene Quintavallo, Angelina Cantone, Peter, Paul and Nicholas Cardi. Memorial donations may be made to Disabled American Veterans (DAV), 1 Capitol Hill, Providence, RI 02908.
www.rimed.org | rimj archives | APRIL webpage April 2015 Rhode Island medical journal 69 Books
New Book Explores Acceptance and Mindfulness Therapy for Psychosis A look at applying a novel form of psychotherapy offering new hope for patients with psychosis
PROVIDENCE – In his new incredible interest from book, Incorporating Accep- clinicians who want to tance and Mindfulness into learn more about using the Treatment of Psychosis: these therapies given Current Trends and Future the limitations of cur- Directions, editor Brandon rent approaches.” The Gaudiano, PhD, a clinical research into mindful- psychologist at Butler Hos- ness and acceptance pital and faculty member in therapies is increasing the Department of Psychi- at a rapid pace, so the atry & Human Behavior at Bu tl er H osp i tal book will aid readers in Brown University, provides a compre- staying up-to-date with these cutting- hensive look at the history and appli- edge interventions. cation of mindfulness and acceptance Mindfulness and acceptance ther- psychotherapies in the treatment of apies are based on the premise that psychotic disorders, including schizo- excessive avoidance or struggle with phrenia. The book, recently published psychotic symptoms such as halluci- by Oxford University Press, delves into nations and delusions can make them the history and evolution of mindful- worse over time. Instead, patients are ness and acceptance interventions for taught exercises that help them to cope Compiled and edited by Dr. Gaudi- psychosis, and explores their applica- better by being more aware, open, and ano, the book also features contribu- tion by reviewing current research and accepting of psychotic experiences, tions from numerous other top experts describing several clinical case studies. and to disengage from them to focus in the field. The book includes a section “Despite research supporting their more on living a valued and meaning- that focuses on six distinct treatment efficacy as complimentary thera- ful life despite any ongoing symptoms. models that incorporate mindfulness pies for patients with psychosis, Dr. Gaudiano explains, “Mindfulness and acceptance therapies for psychosis psychotherapeutic interventions incor- and acceptance strategies have also and a section that provides a synthesis porating mindfulness, acceptance, been found to be effective for treating and analysis of these approaches. and compassion-focused strategies are anxiety, depression, chronic pain, and The book concludes with recom- not widely used as part of treatment other common problems, but fewer mendations for moving research and for this patient population,” said Dr. people are aware that these therapies practice in this area forward in a con- Gaudiano, who hopes that this book can be adapted for patients experienc- structive and responsible way. “This will help educate other mental health ing more severe symptoms such as volume is designed to provide a useful providers and the public about the ben- psychosis.” Recent research on mind- resource for clinicians, researchers, and efits that newer psychosocial interven- fulness and acceptance therapies shows students interested in gaining a deeper tions can offer patients. “The adoption that they can improve coping with psy- understanding of mindfulness- and of mindfulness and acceptance strate- chosis and even reduce future rehos- acceptance-based approaches and newer gies into the treatment for psychosis is pitalizations better than medication psychosocial treatments for severe still in its infancy, but there is already treatment alone. mental illness,” said Dr. Gaudiano. v
For more information on Incorporating Acceptance and Mindfulness into the Treatment of Psychosis by Dr. Gaudiano: global.oup.com/academic/product/incorporating-acceptance-and-mindfulness-into-the-treatment-of-psychosis-9780199997213
www.rimed.org | rimj archives | APRIL webpage April 2015 Rhode Island medical journal 70 When you hear hoof beats, it could be zebras.
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100 Years Ago, First EKG Machine Arrives in RI Dr. Frank Taylor Fulton buys it himself and installs at RIH
Mary Korr RIMJ Managing Editor
Dr. Frank Taylor Fulton (1867– His interests in medical specialties first treatise on the novel science of 1961), who became a pioneer in elec- were wide and varied. In the early electrocardiography. trocardiography in Rhode Island, grew 1900s, Dr. Fulton became interested Dutch physiologist Willem Eintho- up on a farm in Pennsylvania. To pay in infectious diseases and tuberculosis ven invented the machine, and Dr. for college and medical school at Johns prevalent in factory workers in RI, and Lewis pioneered its use in clinical set- Hopkins, he traversed the rural roads he presented at many world congress tings. While working with Dr. Lewis in of his home state during summer vaca- TB symposiums. England in 1914, Dr. Fulton ordered an tions selling encyclopedias and kitchen In 1912 and again in 1914, he went EKG machine, and purchased it at his ranges to farm families. to England to work with two promi- own expense. The machine arrived in Following his graduation from Hop- nent cardiologists, Sir James McKen- Rhode Island by ship; it was the size kins in 1899, he did a post-graduate zie and Sir Thomas Lewis. The former of an upright piano. This signaled the year at Boston City Hospital in pathol- was a pioneer in the use of polygraphs development of the Heart Station at ogy, which led to his appointment as and the study of arrhythmias and RIH, which opened in 1915, with the the first fulltime pathologist at Rhode the latter published the book, Clini- first EKG machine in the region and Island Hospital, in 1900. cal Electrocardiography, in 1913, the the third in the country. ry o f Medi c ine i o n al Li b r a ry Nat
This photo was taken by a Dr. William Miles on a visit to Professor Willem Einthoven’s laboratory in Leiden, Holland, on June 18, 1920. The inventor is shown standing behind his original EKG machine. He was awarded the Nobel Prize in Medicine in 1924
www.rimed.org | rimj archives | APRIL webpage April 2015 Rhode Island medical journal 72 heritage
In 1918, Dr. Fulton served in the Army medical corps, but the majority of his 45-year career was spent in the practice of internal medicine with a special interest in cardiology and edu- cation. In 1932, Dr. Fulton established a residency training program at RIH, Rho de Isla nd H osp i tal and the Heart Station played a vital educational role. He also served as president of the Providence Medical Association, the Rhode Island Medical Society and the New England Heart Association. Dr. Fulton retired several years before his death, in 1961, at the age of 93. His nephew, Marshall N. Fulton, MD, in a memoriam, recalled his uncle, with whom he lived while an undergraduate at Brown, this way: “He himself would cherish no tribute more than the state- A teaching seminar at the Rhode Island Hospital Heart Station in 1957. ment that his life and career bore wit- ness to Osler’s teaching that hard work Electrocardiogram taken with Einthoven’s original string galvanometer, is the ‘master word’ of medicine.” v predecessor to his EKG machine. ry o f Medi c ine i o n al Li b r a ry Nat
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