chesapeake physician march/april 2015 issue

Maryland/DC/Virginia PhysicianYOUR PRACTICE. YOUR LIFE.

C H E S A P E A K E

VOLUME 5: ISSUE 2 MARCH/APRIL 2015

GI GAME CHANGERS FOR HEP C, COLON CANCER AND GERD

WEARABLES: BEYOND FITNESS TRACKING

BARIATRIC SURGERY: UNDERUSED TOOL FOR METABOLIC SYNDROME, OBESITY

chesphysician.com

10 GI Game Changers

16 Bariatric Surgery: An Underutilized Tool for Fighting Obesity and Metabolic Syndrome

F E AT U R E S

D E PA R T M E N T S

ContentsVOLUME 5: ISSUE 2 MARCH/APRIL 2015

2310 16

Cases | 7 | Body Contouring Following Bariatric Surgery

Solutions | 8 | The Impact of the ACA on Private Practice and Physician Happiness

HIT | 20 | Wearables: Beyond Fitness Tracking

Living | 23 | Travel to Charleston With a Little Help From Apps

Compliance | 31 | Open Payments/Sunshine Act Year Two: Guidance for Physicians

Policy | 32 | The Challenge of Controlling Healthcare UtilizationA Conversation With Jesse Pines, MD, MBA

Our Bay | 34 | Celebration of the Chesapeake Bay

On the Cover: Andrea Cox, MD, PhD, Johns Hopkins University, associate professor of Medicine, Oncology, and Immunology, and co-director, Viral Hepatitis Center

Computers used to be the size ofrooms, now they’re downsizing from smart-phones that fit in our pockets to wearables that fit on our wrists. Computers also are becominggame changers personally and professionally –managing our lives and your practices as well as keeping patients healthier.

When we first explored mHealth in March2012, it was challenging to find a physician familiar with mHealth let alone oneusing it in a medical practice. Today, mHealth is being called the new economy inhealthcare and there’s a race to be part of this technological boom. Big players likeNike and Apple are already in the space, while entrepreneurial scientists arepartnering with techies, creating products that can manage chronic diseases orpromote rehabilitation. While I was scoping out the latest in healthcare techdevelopments at the 2014 mHealth Summit for this issue’s Healthcare IT feature (see page 20), I met a lead researcher with Hewlett Packard. It’s his job to take HPinto the mHealth space. He made the point that one billion people are using HP’stechnology in 56 different countries and territories. That’s a lot of opportunity.

Game changing is a theme throughout the following pages. Most everyone isaware that obesity is an epidemic in the U.S. Not everyone is aware that bariatricsurgery has been validated as a valuable tool in fighting that epidemic. Of course,lifestyle changes that include a healthy diet and exercise should be the first line ofdefense, but studies support the value of bariatric surgery in maintaining long-termweight loss and managing obesity-related conditions (see page 16).

Our cover story spotlights game changers in the diagnosis, treatment andoutcomes of GI diseases. Of particular note are the latest treatments for treatinghepatitis C. Chronic hep C is estimated to affect close to 2% of baby boomers and ison the rise with millennials due to a heroin epidemic. There’s good news in DNAstool tests for colon cancer as well as new challenges in recognizing GERD – our #1online trending clinical topic for the last three-plus years (see page 10).

Moving away from this issue’s clinical news, spring will be upon us soon, thoughnot soon enough after our especially cold winter. If you’re ready to skip out of townfor a long weekend, my recommendation is to visit Charleston, South Carolina.Inspired by the mHealth Summit, I decided to plan and manage an upcoming visit to “Chucktown” with my iPhone and apps. I used apps to book my flight, reservemy Airbnb stay and my rental car, make dinner reservations while there. I even usedan app to organize my notes for Living (see page 23).

Lastly, a favor to ask of you. Please visit us at chesphysician.com and take ourshort reader survey. We’d like to make sure we’re writing and presenting the mostcompelling Chesapeake Region healthcare news we can. If you have more to saythan what our survey asks, please shoot us a message. There’s an app for that!

To life!

Jacquie Cohen RothFounder/Publisher/Executive [email protected]

@chesphysician

4 | CHESPHYSICIAN.COM

JACQUIE COHEN ROTHFOUNDER/PUBLISHER/EXECUTIVE EDITOR

[email protected]

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CONTRIBUTING WRITERAnne K. Sessions

COPY EDITOREllen Kinsella

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PHOTOGRAPHYTracey Brown, Papercamera Photography

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HOLLY DAHLMAN, MDGreen Spring Internal Medicine, LLC

PAUL W. DAVIES, MD, FACSKURE Pain Management

MICHAEL EPSTEIN, MDDigestive Disorders Associates

STACY D. FISHER, MDUniversity of Maryland Medical Center

DANILO ESPINOLA, MDAdvanced Radiology

GENE RANSOM, JD, CEOMaryland Medical Society (MedChi)

CHRISTOPHER L. RUNZ, DOShore Health Comprehensive Urology

VINAY SATWAH, DO, FACOICenter for Vascular Medicine

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PhysicianYOUR PRACTICE. YOUR LIFE.

C H E S A P E A K E

Maryland/DC/Virginia www.chesphysician.com

MARCH/APRIL 2015 | 7

WENTY-THREE-YEAR-OLD TJ HASstruggled with his weight throughout hislife. TJ tried to diet and exercise but thiswas not working. He consulted with theteam of physicians at the University ofMaryland Center for Weight Managementand Wellness in Baltimore, and enrolledin their comprehensive program. Heeventually underwent a sleeve gastrectomy.

After surgery, he began an exerciseprogram and strictly adhered to theprogram diet. TJ slowly lost 160 pounds,going from 330 to 170 pounds. Hewalked at first but was then able to jog.He was troubled by the overhanging skin and pannus as he ran. Under theexcess abdominal skin, he had rashesand recurrent skin infections, as well aslow back pain from the weight of thepannus. The extra skin of his breastscaused chafing and discomfort as he ran.He tried antibiotics, antifungal powders,clothing with wicking and compressiongarments, but symptoms persisted.

Twenty months following bariatricsurgery, TJ found that his weight lossstabilized. He consulted a plastic surgeonfor treatment of the areas of extra skinthat bothered him. His excellent physicaland nutritional status made him a goodcandidate for surgery. TJ was able tolook at photographs of the operationand the subsequent scars. He was toldabout the risks and benefits of surgery.He understood that this was a functionaloperation and that he would trade scarsfor contour.

TJ is not alone. Nearly 42,000 peopleunderwent a variety of body-contouringprocedures after massive weight loss in the United States, according to themost recent statistics from the AmericanSociety of Plastic Surgeons, compiled in 2013.

Body contouring removes excess skinand improves the overall body shape.Patients who have lost significant weightwill often have multiple areas theywould like to address with surgery: the abdomen, back, chest/breasts, arms,thighs and face. Generally the length of surgery is limited to six to eight hours,so patients will prioritize locations andchose two, sometimes three, areas at atime. The length of the procedure alsodetermines whether patients spend onenight in the hospital or can go home the same day. Patients are expected to be up and walking right after surgery to prevent blood clots.

Depending on the procedureperformed, patients return to workwithin one to three weeks after surgery,

and return to exercise six to eight weekspost surgery. In counseling patientsconsidering body contouring, it isimportant that their weight is stable andnutrition is optimal. This will improveboth the aesthetic result, ensuring thatthe maximal amount of excess skin isremoved, and optimize wound healing. It is important, likewise, that othermedical conditions are well controlled,and that the patient is a non-smoker, has realistic goals and is committed tomaintaining a healthy lifestyle.

For TJ, we submitted the details of the operation to his insurance for pre-certification and subsequently receivedapproval for a panniculectomy. Not all insurance companies cover bodycontouring after massive weight loss;

decisions are often made on a case-by-case basis. All insurers requiredocumentation of rashes and skininfection, as well as functional disability.TJ elected to pay for the cosmeticportion of the breast-skin removal.

After attaining a stable weight for sixmonths, TJ underwent a panniculectomyand breast-skin reduction. He stayed onenight in the hospital and returned homethe next day. He was up and walking the day of surgery to prevent blood clots.He had drains in his abdomen, which heemptied several times a day for a coupleof weeks. He took some pain medicationfor the first several days, switching thento acetaminophen. His scars are healingand are expected to lighten and softenover the next year.

TJ is very happy to have increasedmobility and to be able to exercisewithout discomfort. He no longer getsfungal infections in his skin creases as he sweats, and has an easier time withclothing and hygiene. TJ says he has arenewed sense of self and improvedconfidence. He has returned to runningand is currently training for a marathon.For TJ, this procedure was extremelysuccessful, resulting in a healthier, moreactive, and more confident young man. Rachel Bluebond-Langner, MD, is an assistant professor of surgery in the Division

of Plastic Surgery at the University of Maryland

School of Medicine in Baltimore and a plastic

surgeon at the University of Maryland Medical

Center. She can be reached at RBluebond-

[email protected].

TBody Contouring FollowingBariatric Surgery

By Rachel Bluebond-Langner, MD

Nearly 42,000 people underwent a variety of body-contouring procedures after massiveweight loss in the United States...

CASES


SOLUTIONS

The Impact of the ACA on Private Practice and Physician Happiness

he Wall Street Journal recentlyfeatured an editorial highlighting a trend of physicians selling their practicesto hospitals.

Scott Gottlieb, a physician andresident fellow of the AmericanEnterprise Institute, notes the AffordableCare Act’s proponents “view thisconsolidation as a necessary step toenable payment provisions that shift the financial risk of delivering medicalcare onto providers and away fromgovernment programs like Medicare.”

On the other hand, some see theconsolidation of medical practices asremoving the competitive forces thathave made our healthcare system one of the most advanced in the world. Theregulatory burdens from ICD-10, andincentive bundles from the PhysicianQuality Reporting System (PQRS) and electronic health medical records,principally favor larger institutions and the government.

Physicians Who Move to Private Practice are HappierPhysicians Practice reports “Doctorsmoving from employment to self-employment are happier than those who make the opposite move. In fact,70% of those who became self-employedsaid they are happier now.”

Naturally, one of the benefits ofworking for someone else is that you have fewer headaches fromadministrative tasks. And conversely,self-employed physicians enjoy greaterpractice autonomy.

Doctors moving from employment to self-employment are happier thanthose who make the opposite move.If staying in private practice is right foryou, the following best practices willhelp you secure your finances and your

T happiness. By benchmarking to the top-six best practices used by medicalbilling companies, physicians are well on the path to improving their cash flow and medical practiceprofitability:

z Prompt Claims Submission: Aim tosubmit claims within 24 hours toincrease your cash flow and reducebad debt expense.

z Active Monitoring of AccountsReceivable: Collect at least 75% of your receivables within 30 days. (The average medical practicecollects only 42% of receivableswithin 30 days.) Making this change alone will increase yourmedical practice’s cash flow by more than 25%.

z Assign a Dedicated Person to A/R:Someone within your medicalpractice should monitor medicalcollections/accounts receivables, and have sole responsibility for that task.

z Set up EFT: Implement ElectronicFunds Transfers from the payers thatoffer this service.

z Benchmark Your Medical BillingCosts to Outsourced Medical BillingCompanies: The average physicianincurs costs of $67,000 or more permedical biller (salary, overhead andsoftware) vs. $48,000 for companiesthat specialize in medical billing andcollections. By benchmarking tomedical billing companies, your

medical practice could reduce itsexpenses by 15% or more.

z Accept Credit Cards: Considerinvesting in a credit card paymentsystem (payment automation system)to enable your medical practice tosafely store a patient’s debit/creditcard information. The result shouldbe increased cash flow and lowercollection expenses. Many paymentautomation systems securely storecredit card information by usingtokens and only displaying the lastfour digits to your staff after thecredit/debit card information hasbeen entered.

While working for a large medicalgroup or hospital is enticing, physiciansare renowned for high achievement,motivation and ability to mastercomplex tasks. On the one hand, theadministrative burdens and pace ofregulatory change drives them to seekthe safe haven of a large employer. On the other hand, their autonomy and achievement motivation is stifledwhen they work for a large employer.

Fundamentally, our healthcare system

is at a crossroads; one that relies onmarket forces to spur innovation, or onethat relies on a select few to set policyfor the rest of us. Doctors who employbest practices, such as those used by topbilling services, should be able to remainin control of their destiny.Michelle Stahl, CPC, is the owner of Physicians Billing Service. She can be reached

at [email protected].

The average physician incurs costs of $67,000 ormore per medical biller vs. $48,000 for companiesthat specialize in medical billing and collections.

By Michelle Stahl

You’re the reason we’ll never stop building bridges to the future of health care.

Connecting you to a lifetime of wellness.Imagine a health care system built around you and your family.

That’s LifeBridge Health. Our Sinai and Northwest hospitals offer the latest, revolutionary medicine – in a personalized way that puts our patients at the center of their care.

Plus, our care extends beyond our hospital doors. From health and fitness to hundreds of community physicians, from urgent care to senior care, we are 8,000 people with a singular focus: a healthier you.

To find out how LifeBridge Health can help you, visit lifebridgehealth.org/future or call 410-601-WELL (9355).


BY LINDA HARDER • PHOTOGRAPHS BY TRACEY BROWN

GAME-CHANGING HEPATITIS C TREATMENTSThings have never looked better forthose with chronic hepatitis C, which is estimated to affect 1.6% (about 3.2 million) of Americans, especiallythose born between 1945 and 1965. Due to that high prevalence, the diseasehas been the primary cause of liverfailure and transplant. Since late 2014,three FDA-approved oral treatmentregimens have had a greater than 95%cure rate. Even better, a vaccine toprevent hepatitis C altogether may be available in the next few years,assuming current trials demonstrateefficacy.

There are seven genotypes of hepatitis C, and some are easier to treat than others. “Genotype 1 is thedominant type in the United States,including in this area,” notes AndreaCox, MD, PhD, associate professor of Medicine, Johns Hopkins UniversityViral Hepatitis Center. “It has also been the hardest to treat.”

Targeted AntiviralsShe explains, “We used to use antiviralmedications that were not specificallytargeted to hepatitis C. Basic science firsthad to characterize the proteins to allowdevelopment of these new drugs. Today,companies have designed direct-actingantivirals that specifically target the keyproteins in the hepatitis C virus lifecycle. Like HIV/AIDS drugs, thecombination drugs are from severaldifferent classes, so they target differentparts of the life cycle, reducing thechances the virus will become resistant.”

In late 2014, the FDA approved thefollowing oral combination therapies totreat genotype 1 infection: z Harvoni – a direct-acting antiviral

that combines ledipasvir, an NS5Ainhibitor, and sofosbuvir, apolymerase inhibitor, in a singletablet

z Simeprevir in combination withsofosbuvir provides a direct-actingantiviral combination therapy forgenotype 1 patients

GIGAMECHANGERS

From exciting new hepatitis C treatments and DNAstool tests for colorectal cancer to the changing faceof GERD symptoms,physicians havemore tools and challenges to treatcommon GI disordersthan ever before.

z Viekera Pak – ombitasvir,paritaprevir and ritonavir tablets co-packaged with dasabuvir tablets

Dr. Cox is bullish on the newtreatment regimens, recalling, “In thepast, treatment regimens werechallenging for both patients andphysicians. They required interferoninjections that were hard to tolerate andneeded to be taken by most patients for24 to 48 weeks, with only a 45%response rate for genotype 1 infections.In contrast, the new FDA-approved oraltreatment regimens cure the disease inalmost all who take them, with someregimens effective against manygenotypes while remaining equallyeffective against genotype 1. These newdrugs are miraculous.”

Good News Comes at High CostThe only bad news is the enormous costs of these new drugs, which maylimit access to those who can afford them. While costs vary widely, most cost$63,000 to $95,000 per treatment course.

“I hesitate to discuss costs becausethey’re rapidly in flux,” acknowledgesDr. Cox. “Fortunately, insurance usuallycovers the medications for the patientswho most need them and the drugmanufacturers and patient advocateprograms have been good to our patientswho are not fully covered by theirinsurance. So, most of our patients whoneed them have been able to get them.That said, the insurers are limitingaccess.”

Dr. Cox also notes that the cost of thenew cures is still lower than the cost of a liver transplant, and that not everyonewith the disease needs treatment. “Forexample, if a patient has had hepatitis Cfor 30 with no liver damage, you maynot want to treat them,” she says. The decision to treat is made on a case-by-case basis.

Patients undergoing liver trans-plantation also may be candidates forthese newer treatments. “Interferonwasn’t tolerated by very ill patients, sothose preparing for transplant couldn’tuse it to prevent infection of the new

transplanted liver. The new regimens areonly being used in test cases at present,but may keep hepatitis C fromdestroying the transplanted liver.”

Vaccines: VIP TrialAlong with the University of California,San Francisco, Hopkins is testing avaccine in a trial called Vaccination isPrevention (VIP). The trial aims to enroll 350 people who are at risk forhepatitis C, with a control group thatreceives a placebo.

“The vaccine has been tested inhealthy populations in England, but thisis the first time we’ve tested a vaccine in an at-risk population,” notes Dr. Cox, who is heading up the study here.“Enrollees receive extensive counselingand referral to a needle-exchangeprogram, but they’re at risk. Vaccinesare less expensive than drugs. We hopeto have data from the study in 2016.”

Screening Baby Boomers and Other at-Risk GroupsUnlike HIV/AIDs, where about 80%

Andrea Cox, MD, PhD, Johns Hopkins University, associate professor of Medicine,Oncology, and Immunology, and co-director,Viral Hepatitis Center

of those with the disease in the U.S.know they have it, only about half of those with hepatitis C are aware. That underscores the need for morewidespread screening.

“Everyone born between 1945 and1965 should be screened,” Dr. Coxrecommends. “The infection is often asilent one until liver disease is severe.With these effective, less oneroustreatment options, now is the time tofind out if patients have hepatitis C.Multiple studies have shown that many physicians did not screen forhepatitis C in the past, and I don’t

blame them because effective, well-tolerated treatments weren’t there. Buttoday, we can really save lives withminimal side effects. I urge physiciansnot to hesitate to screen.”

DNA TESTS: NEW SCREENING FOR COLORECTAL CANCERWith one in 20 Americans getting coloncancer, early detection and treatment iscritical. It’s the second-most diagnosedcancer in women, though men have a slightly higher risk. While hardlyreplacing the gold standard ofcolonoscopy, new DNA stool tests

can be another important tool to detectthese cancers earlier.

Julia Korenman, MD, a gastro-enterologist with the Digestive Diseasedivision of Capital Digestive Care, says,“American College of Gastroenterology(ACG) and American Cancer Societyguidelines call for people at average riskto have a colonoscopy every 10 years,starting at age 50. African Americansshould start at age 45, and those with a first-degree relative who had coloncancer should start at age 40 or sooner.Many gastroenterologists recommend a second colonoscopy in five to sevenyears, then every 10 years after two‘clean’ procedures.”

The FIT (fecal immunochemical test),which measures fecal hemoglobin, is anon-invasive screen for colon cancer.“It’s recommended to be done yearly ifyou’re not getting colonoscopy,” says Dr. Korenman. “Some physicians areuncomfortable with waiting 10 yearsuntil the next colonoscopy, so they might recommend FIT in between.”

Cologuard, a new multi-target stoolDNA test, combined with FIT, has beenavailable since August 2014, as the firststool-based colorectal screening test thatdetects the presence of red blood cellsand DNA mutations.

“When Cologuard was approved, theACG put out a statement emphasizingthe difference between detection testsand preventive tests,” Dr. Korenmanexplains. “Prevention tests, such ascolonoscopy, are preferred over detectiontests like Cologuard. It recommendscolonoscopy every 10 years as apreferred prevention test.”

Colonoscopy can prevent colon cancerby removing colon polyps before theybecome cancerous. Alternatives forscreening are an annual FIT test orCologuard every three years. A studypublished in the April 2013 issue of theNew England Journal of Medicinecompared a noninvasive, multi-targetstool DNA test with FIT for nearly10,000 participants at average risk for colorectal cancer. It found that theDNA test detected significantly morecancers in this group than did FIT(92.3% sensitivity compared to 73.8%)but also had more false positive results.

Patients should undergo colonoscopyif either the FIT test or Cologuard arepositive.

“When polyps are found, they areremoved and their size and type affectsthe timing of colonoscopy followup,”


Julia Korenman, MD, a gastroenterologistwith Digestive Disease Associates inRockville, Md.


notes Dr. Korenman. “If small polyps are found, we recommend a colonoscopyat five years. When multiple polyps with worrisome features are found,patients should receive a colonoscopy in one or three years. Patients shouldunderstand that removing polypsdecreases their cancer risk but doesn’teliminate it. Thus, follow-upcolonoscopies are needed.”

Any Screening is Better Than None“It’s important to increase the number of people being screened,” says Dr.Korenman. “If a patient is reluctant toundergo colonoscopy, use anotherapproach. Some people can’t take timeoff from work, or have difficulty gettinga ride to and from the facility. A benefitof using a DNA or FIT test is it’srelatively simple from the patientperspective – they get a kit, take a stoolsample, and send it in, with resultscoming back to their physician.”

She continues, “Of course, thepreparation for a colonoscopy alsomakes it challenging. We’re all seeking a prep that tastes okay but we haven’tfound that yet. I’ve changed my

preferred preps many times. Some aremore palatable than others but mostwork about the same.”

Virtual ColonoscopiesDr. Korenman doesn’t believe thatvirtual (CT) colonoscopies have manyadvantages over a visual colonoscopy.“Patients still need the prep, and theprocedure’s not comfortable because air and fluid are blown into the colon.Also, most insurers do not reimburse forthis procedure. Yet it can be useful forsome patients, such as those whoseanatomy prevents us from seeing theentire colon, or in patients at high riskfor bleeding or some with cardiacdisease. The decision should be made on an individual basis.” If polyps arefound on virtual colonoscopy, acolonoscopy is needed to remove them.

She urges more physicians to stress theimportance of colonoscopies. “PCPs canreinforce the need to get a colonoscopy.Surprisingly, I actually see many patientsreferred by gynecologists, not PCPs.Hopefully, electronic medical recordsreminders will increase the likelihood oftimely referrals,” she explains.

THE CHANGING FACE OF GERDGastroesophageal reflux disease (GERD)may be the reason behind some 450,000physician visits a year. Donald O’Kieffe,MD, FACG, FACP, a gastroenterologistwith the Metropolitan GastroenterologyGroup in Bethesda, Md., says, “Some 19 million people are affected, andGERD probably accounts for moreoffice visits than the common cold.”

Dr. O’Kieffe points out that reflux is a mechanical problem of the loweresophageal sphincter (LES) that allowsacid and digestive enzymes to regurgitateback into the esophagus. Medicationsreduce the acidity, but don’t address the mechanical problem. He notes,“Most people reflux because the loweresophageal sphincter is leaky. Often, thisis the result of a hiatal hernia displacingthe sphincter from under the diaphragmto above it, decreasing its tone. However,repairing the hiatal hernia may nottotally fix the sphincter.”

Lifestyle ChangesDr. O’Kieffe notes that many patientsresist one of the most helpful lifestylechanges – elevating the head of the bed.

Donald O’Kieffe, MD, FACG, FACP, gastroenterologist with the MetropolitanGastroenterology Group in Bethesda, Md.

“Other helpful lifestyle changes includelosing weight, not eating large meals and not reclining for four hours aftereating. Certain foods weaken the LESand stimulate acid secretion.”

‘Miracle’ DrugsReviewing the history of medicationsthat have been developed in the past fewdecades, Dr. O’Kieffe notes, “After yearsand gallons of liquid antacids, Tagamet(cimetidine), an H2 receptor antagonist,was the first pill that reduced gastricacid, and it was viewed as a miracle drugwhen it came out in the U.S. in 1979.Several other H-2 blockers followed itand all were blockbuster sellers untilPrilosec (omeprazole) came out in 1989. This drug was the first in theproton pump inhibitor (PPI) class and these have been the mainstay ofGERD management since.”

Articles in recent years have raisedconcerns about PPI safety. Effects on

bone density, blood levels of B-1,magnesium and iron, and possibleincreased risk of GI infections may be long-term consequences, but Dr.O’Kieffe believes they are for the most part safe and effective, and theirbenefits far outweigh the risks.

Testing for GERD Periodic heartburn can be treated withan initial trial of medical therapy. “When should we carry out endoscopyto look for complications of GERD?”asks Dr. O’Kieffe. “If the heartburn orGERD symptom occurs three times aweek, or requires daily medication tocontrol the symptom, I feel anendoscopy is warranted to look forimportant complications of reflux. Some patients who don’t do well ontreatment, or those who are obese orwho have diabetes, may need a gastricemptying study as well to see if that ispart of their problem.”

He adds, “Most physicians use atherapeutic trial of acid suppression to test. If symptoms improve, it is usuallyGERD. Testing the pH of the esophagus

with special probes can be useful if thetrial of treatment result is not clear."

Complications of GERD – Check for Barrett’sChronic exposure of the loweresophagus to acid and other digestiveenzymes can ulcerate and stricture theesophagus. Barrett’s esophagus isconsidered a pre-malignant complicationof reflux and an important condition to check for. Endoscopy is the best testfor assessment of these complications.

Alarm or Important Warning SignalsPain in the chest that persists despitetreatment, any evidence of internalbleeding and food sticking in theesophagus while swallowing are allimportant “alarm” symptoms that needfurther attention. Dr. O’Kieffe notes thatwhat is perceived as heartburn can be, in fact, a cardiac symptom or sometimesa referred gallbladder symptom.

Hiatal Hernia RepairsOn occasion, a mechanical solution to a mechanical problem is necessary.Surgical or laparoscopic Nissenfundoplication procedures have beencarried out for years with dramaticimprovement noted only about 50% of the time. Newer endoscopic andlaparoscopic techniques are beingutilized, but Dr. O'Kieffe feels the “jury is still out” regarding their long-term effectiveness.

A Surprising Impact on SleepA study published in the AmericanJournal of Gastroenterology in 2005 is one of several that found those withGERD may suffer from disrupted sleeppatterns which, in turn, may impactdaytime performance. Women appear to be more affected than men. “Eventhose with no reflux symptoms but who had sleep issues were put on aproton pump inhibitor and the quality of their sleep improved,” notes Dr.O’Kieffe. “Gastroenterologists agree that nocturnal GERD may have a sleepimpact. Waking with a sore throat that

goes away during the day can be a cluethat there has been nighttime reflux.”

LPR: the New Face of Reflux Dr. O’Kieffe comments, “The face of GERD has been changing over thepast two decades. For most of the 20th century, the typical symptoms of reflux were heartburn, indigestion and occasional acid in the mouth.However, as we neared the 21st century,GERD began to develop a new face. The GI specialist began being increasinglyconsulted by ENT, pulmonary specialistsand even dentists to see if symptoms in the pharynx, mouth and airway couldbe related to reflux.”

He continues, “This new set ofsymptoms (hoarseness, sore throat,constant throat clearing, cough,wheezing, recurring pneumonia and evensinus and dental problems) are now feltto be frequently related to reflux of acidhigh enough in the esophagus to affectthese structures. This set of symptomshas been termed laryngo-pharyngealreflux (LPR). Most GERD remedies are highly effective in relieving loweresophageal symptoms, but the LPRsymptoms are harder to diagnose andeffectively treat. The standard regimen of once-a-day PPI may not be sufficientto impact them.”

Silent RefluxDr. O’Kieffe concludes by saying, “The scariest form of reflux is silentreflux, where people have chronic refluxbut don’t know it. They are subject tothe same set of complications, includingBarrett’s esophagus and adenocarcinomaof the esophagus, but never had thesymptoms to bring them under medicalcare. We think today that maybe asmany as 15% of reflux patients havesilent reflux.”


Andrea Cox, MD, PhD, associate professor of Medicine, Johns Hopkins

University Viral Hepatitis Center

Julia Korenman, MD, a gastroenterolo-gist with Digestive Disease Associates

division of Capital Digestive Care in

Rockville, Md.

Donald O’Kieffe, MD, FACG, FACP, a gastroenterologist with the

Metropolitan Gastroenterology Group

in Chevy Chase, Md.

THE SCARIEST FORM OF REFLUX ISSILENT REFLUX, WHERE PEOPLE HAVECHRONIC REFLUX BUT DON’T KNOW IT.– Donald O’Kieffe, MD, FACG, FACP


Clinical FeaturesIn each issue, Chesapeake Physician interviews some ofthe region’s top specialists to spotlight the latest clinical developments, including leading-edge diagnostic and treatment options.

Healthcare ITChesapeake Physician explores ongoing major healthcareIT developments and the new care delivery models thatdepend on them, from interoperability issues to the lateston Meaningful Use, ACOs, Medical Homes, mobile health,hospital employment, mega groups, and more. Don't be left behind – read what Chesapeake physicians andhealthcare IT experts have to say that keeps you abreast of the latest technology changes in every size and type of medical practice.

In Every Issue and OnlineCases xSolutions xCompliance xPolicy

@chesphysician

Jacquie Cohen RothFounder/Publisher/Executive Editor

443.837.6948 x[email protected]

The Center for Eating Disorders at Sheppard Pratt offers comprehensive, individualized care for children, adolescents, and adults with eating disorders, including anorexia nervosa, bulimia nervosa, binge eating disorder, and compulsive overeating.

The Center, which has been a national leader in evidenced-based

treatment since 1989, provides highly specialized individual, group, family, occupational, art, and nutritional therapies and offers a full continuum of eating disorder treatment that is not found anywhere else in Maryland or the surrounding states.

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BARIATRICSURGERY

AN UNDERUTILIZED TOOL FOR FIGHTING OBESITY AND METABOLIC SYNDROME

BY LINDA HARDER • PHOTOGRAPHS BY TRACEY BROWN

Andrew Averbach, MD, director of Bariatric Surgeryat Saint Agnes Hospital in Baltimore

Primary care physicians (PCPs) havetheir work cut out for them, with ever-shorter office visits and a growinglist of required tasks for each appointment. That may be affecting their ability totalk to obese patients about their weight.A recent study published in BMJ Open,which examined 91,413 primary careelectronic health records from 2005 to 2012, found that 90% of overweightpatients and 59% of morbidly obesepatients had no recorded weight-management intervention.

Obesity has proven one of the leasttractable health issues; only 1% or fewerof those who use traditional medical and lifestyle changes to lose weight areable to keep it off in the long term. Incontrast to high recidivism rates withtraditional weight-loss approaches,however, studies have found thatbariatric surgery achieves much higherlong-term weight loss. Perhaps moreimportantly, long-term studies havedemonstrated its value for fightingobesity-related conditions.

That’s why Andrew Averbach, MD,director of Bariatric Surgery at SaintAgnes Hospital in Baltimore, andChristina Li, MD, director of Bariatricand Minimally Invasive Surgery atLifeBridge Health, also in Baltimore,encourage PCPs to refer more patientsfor one of the few effective measures for

long-term weight loss and resultanthealth improvements in morbidly obesepatients – bariatric surgery.

“Only 2–5% of patients who areeligible get bariatric surgery,” says Dr.Li. “If doctors had time to encourage itmore, patients would listen. Of course, a major barrier physicians face is thelack of time, and some patients avoidsurgery due to fear, cost or perceivedstigma. Others regard it as ‘the easy way out,’ which it’s not. But if PCPs canjust bring it up, we’ll do the rest.”

She adds, “We have a tool to make it easy for PCPs – a pamphlet thatprovides information and allows them to agree to be contacted so they can get their questions answered directly bya bariatric center.”

Indications Should Move Beyond BMIThe weight loss resulting from bariatricsurgery has been shown to decreaseblood glucose, hyperlipidemia, jointpain, blood pressure and polycysticovarian syndrome, while improvingfertility rates and testosterone levels.

An article published in the June 2014issue of the Journal of the AmericanMedical Association, based on the long-term Swedish Obese Subjects (SOS)study, found that bariatric surgery was80% more effective in achieving type-2

diabetes remission than traditionalweight-loss methods used in the controlgroup. Considering that the majority ofsubjects in this study underwent the ‘lapband’ procedure, which is now fallingout of favor, bariatric surgery may haveeven greater potential to impact diabetesand other comorbidities in the future.This study also found that bariatricsurgery was associated with a long-termreduction in overall mortality and theincidence of myocardial infarction,stroke and cancer.

An April 2012 New England Journalof Medicine study compared the resultsof bariatric surgery (both bypass andsleeve) plus medical therapy vs. medicaltherapy alone in 150 patients at the endof 12 months. It found that the use ofdrugs to lower glucose, lipid, and blood-pressure levels decreased significantlyafter both surgical procedures, butincreased in patients receiving medicaltherapy only.

Dr. Averbach says, “Bariatric surgeryprovides far more health benefits thanweight loss. It affects many metabolicdiseases, such as diabetes and fatty liver. Doctors agree that there’s no othertreatment that so effectively putsdiabetes in remission.”

“Every lost pound positively affectsblood pressure and blood sugar,” addsDr. Li. “Even patients who don’t lose aton of weight get the benefits of betterglycemic control.”

Dr. Li notes that bariatric surgery is endorsed by the American HeartAssociation, the American College ofSurgeons, the American MedicalAssociation and many other medicalgroups. “It’s really changed, due to itsproven safety and effectiveness,” shesays. “The death rate at Centers ofExcellence is less than 0.11% –comparable to removing yourgallbladder.”

She believes that the indications forbariatric surgery should extend beyondbody mass index (BMI). Dr. Averbachrecommends that bariatric surgeryshould be offered to patients with BMI 30-34.9 with comorbidities, due to


What adult doesn’t know that obesity isan epidemic here and in many developedcountries? Yet a recent study questionswhether primary care physicians are ableto sufficiently intervene to promote weightloss in overweight and obese patients.

its proven efficacy and ease of treatmentof stage-1 disease.

Lap Band Use Diminishing“The laparoscopic gastric banding or‘lap band’ procedure that was popularfrom about 2005 to 2008, has fallen outof favor because it provides less weightloss and more long-term side effects thanthe gastric bypass or the vertical sleevegastrectomy procedures,” notes Dr.Averbach. “Its revision rate is about25% and it requires significant follow-up care and compliance. We’ve foundthat switching to the sleeve procedure

provides across-the-board higher weightloss and health benefits.”

Dr. Li concurs. “The ‘sleeve’ isdefinitely a happy medium. It involvesless surgery than the bypass but providesmore consistent weight loss than theband. The duodenal switch has highermalabsorption and mortality rates, so it’s less common, but each surgicalapproach has its role, depending on thepatient’s needs.”

Dr. Averbach adds, “The sleeveprocedure is skyrocketing, accountingfor half or more of the procedures ourcenter does today. The main advantage is that is doesn’t require significantalteration of the GI tract, so it has alower rate of metabolic side effects.About 20% of patients, however, mayexperience reflux. It doesn’t improvemetabolic comorbidities as well asbypass does, but otherwise it’s a verygood first-line procedure for manypeople with BMI at or below 60. Bypasswill remain an option for those withsignificant BMI>60, advanced diabetesand significant preoperative GERD.”

The surgeons caution PCPs againstrecommending a particular surgicalapproach. “When physicians referpatients for bariatric surgery, they tendto recommend a specific procedure,” Dr. Averbach observes. “We prefer thatthey let the surgeon determine whichprocedure is ideal for that patient.”

On the HorizonOne of the more promising endoscopicbariatric procedures on the horizon istransoral sleeve gastroplasty, which usesan endoscopic suturing device to mimicsurgical sleeve gastrectomy. A small pilot study at the Mayo Clinic, publishedin the September 2013 issue ofGastrointestinal Endoscopy, found theprocedure to be safe and feasible. Asecond trial was launched to study the metabolic effects of this procedure.Potential advantages of less invasiveapproaches include reduced cost and the ability to serve those who areoverweight but not obese.

“Endoscopic sleeve procedures are not yet ready for prime time,” explainsDr. Li. “And intragastric balloonprocedures, in which a balloon-likedevice is placed into the stomach andinflated to decrease the size of thestomach, have the potential to be abridge to bariatric surgery for short-termweight loss, but would not replace it.”


ONLY 2-5% OF PATIENTS THATARE ELIGIBLE GET BARIATRICSURGERY. – Christina Li, MD

Christina Li, MD, director of Bariatric and Minimally Invasive Surgery at LifeBridge Health in Baltimore


Andrew Averbach, MD, director ofBariatric Surgery at Saint Agnes Hospital

in Baltimore

Christina Li, MD, director of Bariatric and Minimally Invasive Surgery at

LifeBridge Health’s Sinai and Northwest

Hospitals in Baltimore

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Dr. Averbach agrees. “No endoscopicprocedure has been proven effective todate. The gastric balloon has somepromise for those in the early stage ofobesity, with the potential to drop 15-20% of excess weight, but a side effect is nausea.”

Patients for a Lifetime“Surgery cannot work alone,” notes Dr. Averbach. “In addition to extensivepre-op education, patients need to beeducated and followed for at least a year after the procedure. They need tounderstand what healthy eating habitsare. This was somewhat overlooked inthe past, but now we pay far moreattention to that and to psychologicalissues. We do everything we can to help

them adhere to the plan and to maintaintheir weight loss. It’s easier to intervenewhen they come back sooner rather thanlater, which is why we have each patientsign a contract committing to their goodhealth pre- and post-surgery.”

Dr. Averbach adds, “Some patientsrequire treatment prior to surgery tostabilize their depression or bipolardisease. Sometimes we see a recurrenceof prior substance abuse, which canreplace the abuse of food. In about 10%of patients, their alcohol abuse increasesafter bariatric surgery. Having a strongsupport network is a critical piece ofbariatric surgery”

“There’s no doubt that patients canstill ‘out-eat’ all of these surgeries,”contributes Dr. Li. “Anecdotally,

education levels don’t correlate withsuccess – what does is persistence. Wesee some ‘addiction transference’ wherepeople addicted to food transfer theiraddiction to something else, such asalcohol. They have to be committed to a lifestyle change and work on it every day.”

She continues, “The key role PCPs canplay is to bring up the topic more often.And they should send the patient back tothe bariatric surgeon at least yearly. Wetake care of their labs and monitor theirvitamin levels. These patients should belifetime patients of their bariatric surgeon.Bariatric surgery can be a life-changingand life-saving measure for patients, yet sadly, we are reaching so few of them today.”

DOCTORS AGREE THAT THERE’S NOOTHER TREATMENT THAT SO EFFECTIVELY PUTS DIABETES IN REMISSION. – Andrew Averbach, MD

A CCORDING TO ABIResearch, a technology marketintelligence company, over 90 millionwearable devices, including GoogleGlass, Nike FuelBand and Fitbit Flex,shipped in 2014. While estimates varysignificantly among forecasters, ABIpredicts wearables will grow to 170million devices by 2017. Smartwatchesare among the newer entrants, with the Apple watch hitting the market inearly 2015. But according to a recentPricewaterhouseCoopers HealthResearch Institute report, the demandfor electronic wearables will dip slightlyin 2015 as the market suffers fromoverlapping devices.

At the 2014 mHealth Summit heldDecember 2014, Walgreens ChiefMedical Officer Harry Lieder, MD,MBA, FACPE, noted the following good news for wearable manufacturers:

z Some 21% of U.S. consumerscurrently own one.

z The market continues to grow.z More than half of survey

respondents believe the devices will increase their athletic ability,help them lose weight and increase their lifespan.

Conversely, he indicated that the badnews is: z Good controlled studies about

the impact of wearables on healthdon’t exist.

z Less than half of those who own a wearable use it regularly.

z Even if the wearable is free and therewere incentives to use it, surveyshave found that only 68% ofconsumers say they would use one.


HEALTHCARE IT

BY LINDA HARDER

Wearables: Beyond Fitness Tracking

Wearable fitness devices have been on the marketsince early in the 21st century. Only recently, however, have wearablesbegun expanding into exciting other health uses.The 2014 mHealth Summit in National Harbor, D.C., and the 2015 Consumer Electronics Show unveiledsome of the latest developments.


Improving Wearable UsageDespite the tendency for user ‘fatigue,’Dr. Lieder believes that wearable use canbe increased with gamification, humansupport and rewards. Walgreens isbetting that rewards will yield results –they have created Balance Rewards forHealth Choices, which users can redeemfor discounts on purchases at theirstores; over 155,000 people withwearables already have linked to theprogram. They eventually will be able to link in claims data to determine ifwearables affect health outcomes.

Joseph Kvedar, MD, vice president of Connected Health at PartnersHealthcare, noted that Microsoft,Samsung and Apple are all betting onsmartwatches to take off. However, heremarked that, while people check theircell phones constantly, it is difficult toget them to push a button to uploadtheir blood pressure several times a day.

“Participation is far higher if the datais uploaded passively,” he stated. “Tosucceed, these technologies must askpatients to do less, not more.” Dr.Kvedar further commented that makingwearables part of a social activity ishelpful, as “no one wants to look likethe unhealthy one.” Physicians can playa key role in motivating patients as well,because most don’t want to disappointtheir doctor.

Blood Glucose MonitoringDr. Lieder’s presentation included amention of a new grassroots wearablesolution developed by a group of menwhose children have diabetes. CalledNightScout, the tool allows diabeticadults to continuously monitor theirglucose levels, and permits parents ofdiabetic children to remotely track theirblood sugar levels in real time whilethey’re at a sleepover or out of town.

Medication Usage RemindersEach year, over half a million Americansare hospitalized because they skipped or took incorrect medication dosages. To improve compliance and safety,MediSafe Project, a company started by two brothers whose diabetic fatheraccidentally took an overdose of insulin,developed MediSafe, a medicationmanagement platform that connectspatients and health providers. The firstmobile app to sync medication remindersbetween devices of families and

caregivers, it has been downloaded over a million times.

The app is installed on a person’ssmartphone, tablet or other device, and automatically loads medicationreminders onto a smartwatch. Users can quickly record that they’ve taken the dose by swiping and tapping once on the reminder, or by shaking theirwrist left to right. If they forget to take a medicine, the app can notify a loved one.

Chief Marketing Officer Jon Michaelinotes, “We’re technologically agnostic,and are working on being available via landline phones, the web, etc., soconsumers can have access any waythey’re most comfortable. We’re doingpilots with physicians now, buildinginterfaces with hospitals, pharmacies,and others, and embarking onindependent research.”

Michaeli adds, “We also send patientspersonalized educational content, such as diabetes information, to help themimprove their health. There’s a digitalpillbox in the app that allows patients to see the shape and color of each pill,and we send positive messages toreinforce adherence.”

Continuously Measuring Vital SignsAt the mHealth Summit, Swiss company Sensogram Technologiesshowed off its new SensoSCAN, a devicesimilar to a pulse oxygen monitor thatfits on your finger to monitor bloodpressure, oxygen saturation, heart rateand respiration rate using biosensors that transmit data in real time tosmartphones or tablets via the cloud.

Vahram Mouradian, PhD, founderand CEO, said, “It provides a dynamicpicture of these vital signs, rather thanjust showing a single moment in time.SensoSCAN, which was FDA-approvedafter years of research and development,does not require separate reimbursement.We also developed a second device foractive patients called SensoTRACK. It fits over the ear like a Bluetoothheadset and monitors vital signs forwellness, fitness and sport uses.”

Dr. Mouradian discussed howSensoSCAN also can save healthcareproviders money. “When a patient ismonitored at home after a proceduresuch as cardiac surgery, CMS pays thehome monitoring company $2,400 for

their services, whether the patient ismonitored for a week or two months.“The monitoring company makes moneyfor the first five days, but then they startlosing dollars thereafter,” he said. “UsingSensoSCAN can save them 70% overother existing monitoring technologies,while improving care for patients.”

Monitoring Falls and Appliance UsageBill Rom, a managing partner at 151ADVISORS, a strategic consulting firm that helps fledgling technologycompanies take advantage of newmarket opportunities, stated, “Thechallenge is how to pay for thesewearable technologies. They’re gainingtraction in hospitals – where remotewireless scales and other monitoringdevices are taking off. KIWI is one of the companies we advise. After theirCEO fell, he decided to develop a multi-function sensor that detects motion and acceleration, so that userscan remotely monitor whether a lovedone has used the toilet or opened arefrigerator, for example. It’s based on a platform that can accommodatemultiple uses and customized solutions.”

Wearables in Outpatient Rehab CentersBrandon Tudor, assistant VP of access and administrative services at the MedStar Institute for Innovation,discussed their National RehabilitationNetwork’s undertaking to use activitytrackers in its outpatient physicaltherapy clinics. Beginning in early 2015,their physicians will ‘prescribe’ homeexercises that can be tracked bytherapists via a Fitlinxx Pebble.

At the mHealth Summit, Swiss company Sensogram Technologies showed off its new SensoSCAN.

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Tudor said, ‘We formerly had no wayto track whether or not patients wereperforming their home exercises, andthey often overstated their compliance to avoid disappointing their therapists.This will give us accurate data. Datasecurity, ease of use, connectivity withthe patient’s electronic health record andcost are all critical in making wearablesvaluable for practitioners.”

EEG Headsets For ALSPatients with limited movement, such as those who suffer from AmyotrophicLateral Sclerosis (ALS), may benefit from an emerging wearable technologydeveloped by Fjord, a division ofAccenture Interactive. Called EmotiveInsight, this wireless EEG headset detectsbrain commands, emotions and micro-facial movements. The developmentteam created a simple, efficient approachthat used thought patterns to completetasks such as making phone calls,sending emails or turning off connectedSmartTVs.

2015 Consumer Electronics Show (CES) WearablesThe 2015 CES also unveiled new waysto ‘wear’ electronic monitors, from

smart adhesive “bandages” that monitoran infant’s temperature and sendsmartphone alerts to parents, to Belty, an automated belt that contains apedometer and Bluetooth capabilities to monitor waistline trends. Belty wasnamed Best of CES.

Another wearable getting attention at CES was the HBox, a second-generation device from BlackBerry andNantHealth that uses a genomic signalto “interrogate” blood, cancer or

potential diseases and share data with a patient's physician. The device will be part of an upcoming clinical trial to help 100,000 patients manage pre-hypertension or hypertension.

Companies today are getting themessage that the key to makingwearables ‘sticky’ for patients is to makesure that they are trustworthy and thatthey simplify or organize an importantfacet of life. Certainly, that lesson has to apply to the provider side as well.

Emerging wearable technology developed by Fjord, a division of Accenture Interactive, called Emotive Insight.

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RECENTLY TRAVELED TOCharleston, South Carolina, to visit mydad with my daughter, Lindsay, whojoined me from her current home base of New York City. Over the last coupleof years, I’ve visited there several timesand am truly in love with “Chucktown.”Inspired by the plethora of apps at themHealth Summit this past December, I decided to let apps do the heavy liftingfor my travel plans.

I love them. Apps can keep ushealthier, they can also help us get a lotdone, including getting to places faster,more efficiently and cheaper. My airtravel was handily managed by mySouthwest Air app. They, like mostmajor carriers, have a smartphoneapplication to help with booking, check-in, changing or cancelling reservations,even car rental. Through this app Iaccessed my mobile boarding passes,checked flight status and set up alerts.Oh, and I kept checking their weatherreport. I was making a tee time.

At the Charleston InternationalAirport, I pulled up my car reservationand was soon on my way to Wild DunesResort, which Golf Digest named one of the best golf destinations in the state.The Links Course and Harbor Courseequal 36 holes of South Carolina

LIVING

Charleston, South Carolina:

I

With a Little Help From My AppBy Jacquie Cohen Roth

Famous for its lovingly restored architecture,Charleston will astound you with details likethese columns we discovered on our walkingtour of the historic district.


JACQUIE COHEN ROTH

beauty and challenge, and they are opento the public. OK, no app for that choice– it was recommended by a friend – butif you’re not interested in driving there,or anywhere in Charleston, Uber, theapp-accessed car service, is operating in the city, at least until June 2015.Accommodations were an easy choice,hello Airbnb, (for iOS, Android).

I booked a great little privately-ownedcondo, at a very good rate in the Ashleyneighborhood just outside the city. Myhosts, Ryan and Royce, based in SouthDakota, became my private concierges viaour conversation hosted on Airbnb. Ashort walk from the condo brought meto the very welcoming Blue Rose Café. Afull breakfast menu was complementedby extensive daily menus heavy on thecomfort soups, stews and baked goodsof Chef Denis O’Doherty’s Killarneychildhood. The owners of the Blue RoseCafe are also active in communityprograms, supporting local performancegroups, social charities and communityenvironmental goals. This charmingplace really lives into their proclamation,

Céad mile fáilte – a thousand welcomes.Charleston is a city that mashes

African, European, and now Asianinfluences in a melting cook pot that’sbeen stirred by the South. The results are groundbreaking food establishmentsthat reflect all this. To my point,nationally acclaimed restaurants featureJames Beard Foundation award winnerslike Low Country specialist Chef

Robert Stehling, of Hominy Grill, andChef Sean Brock, at Husk, which, Idiscovered, has a wonderful bar as well.Both Bon Appétit and Southern Livingdeclared Husk Best New Restaurant in2011. Our first night, we decided to goMediterranean and landed at Sermet’s

Downtown. It was Restaurant Week and we were fêted like royalty. UsingYelp (for iOS and Android) and UrbanSpoon (for iOS and Android) we alsofound and enjoyed Michael’s on theAlley, Hutson Alley specifically, and Eli’s Table at 129 Meeting Street for a lusty brunch.

All this culinary discussion should not detract from the active outdoor life

Charleston supports, and I stronglyrecommend trying out some of theseoptions during a visit. I mentioned thegolfing, but we also walked the RavenelBridge over the Cooper River, in thewell-planned bike and pedestrian lane.Each end of the bridge supports parking,

Take a walk and enjoy Charleston's famous restaurants and public murals. Then talk with sweetgrass crafters while art is created right before your eyes.

Charleston is a city that mashes African, European, and now Asian influences in a melting cook pot that's been stirred by the South.


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some private, some public. If you’rethere in April, register for the annual10K (6.2 mile) Cooper River BridgeRun, usually held the first weekend. Thispoint-to-point course starts in MountPleasant and finishes in downtownCharleston at Marion Square. There area number of running apps to help youtrain for that. Yelp can help you find abike rental and paddle boarding source,and even bowling, if that’s your cup ofSouthern Comfort. Take advantage ofthe usually lovely weather and TripAdvisor(for iOS and Android) to hire a walking-tour guide and get an up-close view ofthe city’s famous window boxes, iconicgates, and historic homes.

There’s a robust creative communityin Charleston, of which the best-knownevent is the Spoleto USA Festival. The 17-day festival showcases bothestablished and emerging artists in over 100 arts performances. Imaginewandering from program to program,indoors and outside, enjoying some of the world’s greatest artists.Complementing this is Piccolo Spoleto,which highlights local and regional

artists. This year it runs from May 22 to June 7. I confess I haven’t found anapp for this event, but their website will help you purchase tickets,spoletousa.org. And don’t leave townwithout purchasing one of thedistinctive, hand-woven sweetgrass itemssold on street corners, in the CityMarket, and even hawked, in the formof stemmed roses, by boys in the parks.In Colonial times, shallow, flat, wovenbaskets were used to separate rice seedfrom chafe. Today, the bulrush, from thesandy soils of coastal South Carolina, isused to create one of the most prizedcultural souvenirs in the nation.

During our trip, Lindsay and I decidedto venture out of Charleston to exploresome of the historical roots of the area. I tasked Lindsay with planning thatadventure and she came up with a trip to Drayton Hall, an 18th-centuryplantation located on the Ashley River about 15 miles northwest ofCharleston. Drayton is a preservedplantation, but not restored. Thisfascinating place resists any glossygentrification of the antebellum South

and honors the African enslavedcommunity that lived here, as well as the families of European descent. Visit the African-American cemetery for a fascinating guided or self-guidedtour and feel the history and heritage of the South.

For those who like to shop,Chucktown is nirvana from well-knownupscale national stores to uniqueboutiques. After hours of chatting onour self-guided walking tour of restoredmagnificent homes, using MapQuest(free for iOS, Android) to guide us, and a couple of hours of some seriouswindow shopping and quick stops into innumerable unique boutiques, Irealized I’d misplaced my purse AND my phone. Panic! Where?! I rememberedmy “Find My iPhone” app, and one ofthe boutique owners we’d met was onit – she opened up the app on her Macand we were able to zero in on the exactlocation of my purse and phone. Reliefwith retail and libation celebration werein order. On to Yelp and off we were!For more information on visiting Charleston,

visit charlestoncvb.com.


Physicians Physical Therapists

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C H E S A P E A K E


INCIRCULATION

Pelvic Pain C E N T E R F O R

o f V a s c u l a r O r i g i n

SPRING 2015 The Offi cial Publication for Center For Vascular Medicine™

A Division of the Center for Vascular Medicine

VOLUME 1 ISSUE 2

™

S P E C I A L A D V E R T I S I N G S E C T I O N

Greenbelt, MD – Lanham, Mary-land resident Charmaine Marti-nez had suffered with pain in her

pelvis for more than two years and saw multiple physicians before getting two correct diagnoses: Pelvic Congestion Syn-drome and May Thurner Syndrome. For-tunately, she found two experienced vas-cular specialists, Dr. Sanjiv Lakhanpal and Dr. Vinay Satwah, at the Center for Pelvic Pain of Vascular Origin, a division of the Center for Vascular Medicine (CVM), to diagnose and treat the cause of her pain.

Center for Vascular Medicine has been recognized as a national leader in the treatment of deep venous conditions, including disorders in the pelvic region. They are among a small group of facili-ties that can treat these conditions on an outpatient basis. Dr. Vinay Satwah, an in-ternational expert in the fi eld, was invited to speak at a vascular conference on this topic in 2014.

The 42-year-old Martinez, who has fi ve children and two grandchildren, has lots of company. Up to 15% of women aged 20 to 50 have Pelvic Congestion Syndrome, which is characterized by insuffi cient fl ow in the veins of their pelvis, somewhat like having varicose leg veins. As many as 60% of those women have pain that can be debilitating. Having multiple children can increase the risk of this condition. The problem can be diffi cult to diagnose, as lying down during the pelvic exam often relieves the congestion.

NEW HOPE FOR PELVIC PAIN

nez recalls. “I was crying every day.” However, her insurance refused to

pay for the venous procedure Martinez needed to fi x the second vein. In this pro-cedure, doctors insert a tiny balloon into the affected vein to open it up, then insert a metallic stent to keep it open. Martinez recalls, “While treating my leg veins, Dr. Lakhanpal asked how I was. I broke down and sobbed. I told him I couldn’t get out of bed and had to walk hunched over. He was so caring and considerate. He said he would take care of me. He reduced his fee and scheduled me for a stent procedure in September of 2014.”

After a brief recovery period, Martinez describes how having these two proce-dures has changed her life. “It was like my whole entire life was back again. I couldn’t believe that I could clean in hard to reach places, bend over, and do all of the activities I normally did again. I’m so happy. It was a miracle.”

www.cvmus.com

BEFORE AFTER

Martinez initially was treated for nu-merous varicose veins in her legs. A few years later, however, she began experi-encing pain in her pelvic area. The pain got so intense that she quit her job as a phlebotomist and she had to move from the third fl oor to the fi rst fl oor because she could not climb stairs.

After performing a thorough history and physical plus a highly specialized pelvic ultrasound, the doctors at CVM discovered an enlarged, compressed pelvic vein on her left side. They subse-quently performed a venogram to pin-point that the problem was located in the left ovarian vein. Minimally invasive treatment (involving an injection of medi-cine) that closed off the problematic vein relieved the pain for months.

The doctors found that a second vein, the common iliac vein, was also severely compressed and would need surgical treatment. “It was excruciating,” Marti-

CVM TO BEGIN DIALYSIS ACCESS PROGRAMCenter for Vascular Medicine is excited to announce that it will be providing dialysis access vascular services. The program will be led by Michael Malone, MD, FACS, who has extensive experi-ence in this area of vascular medicine. Dr. Malone is a board certifi ed vascular surgeon who has been providing this specialty service for over 17 years. He has worked in various hospitals in Ohio and New Jersey providing valuable and essential care to thousands of patients with end stage renal disease. As the dialysis patient population continues to grow, Center for Vascular Medicine will be on the forefront to meet demands, as a leader in outpatient based vascular care. OUTPATIENT SERVICES PROVIDED:

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Dr. Michael Malone joins Center for Vascular Medicine (CVM) with

a special interest in com-plex peripheral interven-tions, as well as open vas-cular surgical procedures. Prior to joining CVM, he was clinical assistant professor of sur-gery at the University of Toledo School of Medi-cine and the University of Medicine and Dentistry of New Jersey/ Cooper Hospital. Previously, he was an attending vascular surgeon at Blanchard Valley Health System and Mercy Hospital of Tiffi n for several years. Dr. Malone complements CVM with a wide breadth of signifi cant surgical knowl-edge and experience from numerous academic and hospital appointments. His work has been published in several vascular surgery journals and textbooks.

WELCOME JEANNE SANDERS

WELCOME DR. MICHAEL MALONE

www.cvmus.com

Cardiovascular diseases are the No. 1 cause of death in the United States. On average, one American dies every 39 sec-onds of cardiovascular disease – disorders of the heart and

blood vessels. Stroke, a disorder of the blood supply to the brain, is the third leading cause of death and the leading cause of disabil-ity in the country, with nearly 800,000 new strokes occurring annu-ally. According to the American Heart Association, the total direct and indirect cost of cardiovascular disease and stroke in the U.S. for 2010 was an estimated $503.2 billion.

Early detection of life-threatening heart disorders, stroke and other diseases is possible through the use of vascular testing pro-cedures performed within hospitals, outpatient centers and physi-cians’ offi ces. While these tests are helpful, there are many facets that contribute to an accurate diagnosis based on vascular testing. The skill of the technologist performing the examination, the type of equipment used, the background and knowledge of the inter-preting physician and quality assurance measures are each critical to quality patient testing.

Center for Vascular Medicine has been granted a three-year term of accreditation in vascular testing in the areas of Periph-eral Arterial Testing by the Intersocietal Accreditation Commis-sion (IAC).

Accreditation by the IAC means that Center for Vascular Medi-cine has undergone a thorough review of its operational and technical components by a panel of experts. The IAC grants ac-creditation only to those facilities that are found to be provid-ing quality patient care, in compliance with national standards through a comprehensive application process including detailed case study review.

IAC accreditation is a “seal of approval” that patients can rely on as an indication that the facility has been carefully critiqued on all aspects of its operations considered relevant by medical experts in the fi eld of vascular testing. When scheduled for a vas-cular testing procedure, patients are encouraged to inquire as to the accreditation status of the facility where their examination will be performed and can learn more by visiting www.intersocietal.org/vascular/main/patients.htm.

IAC accreditation is widely respected within the medical commu-nity, as illustrated by the support of the national medical societies related to vascular testing, which include physicians, technologists and sonographers. Vascular testing accreditation is required in some states and regions by the Centers for Medicare and Medic-aid Services (CMS) and by some private insurers. However, patients should remain vigilant in making sure that their vascular testing procedures are performed within accredited facilities, because for many it remains a voluntary process.

Jeanne brings a varied skill set and wide base of knowledge to Cen-

ter for Vascular Medicine (CVM), having over 18 years of experience in the health-care arena of business man-agement and development. Most recently, she served as CEO of Horizon Vascular Specialists in Maryland. Prior to Horizon, Jeanne was a corporate vice presi-dent of community care for the Adventist Health Care System and senior vice president of Shady Grove Adventist Hospital. Throughout her career, Jeanne has been instrumental in business plan-ning and development, successfully implementing growth strategies as well as being a key player in decisions involving day to day business practices. Jeanne is an integral part of the daily management of CVM in her multi-faceted role, which includes the oversight of Operations, Finance and Clinical Scheduling. She is a key player in the continued implementation of CVM’s core mission of ‘state of the art vascular care in a compassionate and cost effi cient manner.‘ Jeanne has a Bachelor’s Degree in Nursing from Washington Adventist University and a Master’s Degree Nursing/Health Care Ad-ministration from Georgetown University.

CVM RECEIVES VASCULAR TESTING ACCREDITATION BY THE IAC


Call today to make a referral:8 6 6 - 9 1 6 - 9 2 0 2

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Sanjiv Lakhanpal, MD

Tom Militano, MD

Gaurav Lakhanpal, MD

Krutiben Patel, PA-C

Rakesh Wahi, MD

Mike Malone, MD

Vinay Satwah, DO

Shekeeb Sufi an, MD

C enter for Vascular Medicine (CVM) is pleased to offer an additional modality to increase its ef-fi cacy in treating certain patients suffering from

lifestyle-limiting Peripheral Artery Disease (PAD). After an abnormal non-invasive diagnostic work-up, the pa-tient may need further invasive evaluation, in the form of an angiogram. This is traditionally performed with fl uoroscopy and injection of contrast into the arterial system, likely in the angiography suite by an Interven-tional Vascular specialist.

However, there exists a subset of patients who have severe allergic reactions to iodinated contrast, in which special consideration should be made to avoid exposure. Additionally, in patients who have abnormal baseline kidney function, with elevated blood urea nitrogen (BUN) levels and/or creatinine levels, minimization of contrast administration is important. Some patients may have known Chronic Kidney Disease (CKD), but have not shown the progression of disease to the point where hemodialysis is required. It is critical to be conservative with the amount of contrast usage in these patients as they are at increased risk for contrast-induced nephropathy (CIN).

Therefore, in an effort to provide the highest quality of vascular care to all patients, Center for Vas-cular Medicine (CVM) has incorporated the utilization of carbon dioxide (CO2) in performing invasive diagnostic studies and interventions. When injected into the vascular system, CO2 gas has chemical properties that allow the visualization of vessels under fl uoroscopy. This allows an alternative approach to angiography while avoiding contrast exposure. With the availability of high-resolution digital sub-traction angiography (DSA) and a reliable gas delivery system, CO2 angiography has become widely used for vascular imaging and guidance during endovascular procedures, including angioplasty and stent placement, transcatheter embolization, and endovascular abdominal aortic aneurysm (AAA) re-pair. Since CO2 is a colorless and odorless gas, and it cannot be visually distinguished from air, pressur-ized cylinders are used to contain the gas. Unlimited amounts of CO2 may be used for vascular imaging because the gas is effectively eliminated by means of respiration. Although very useful, the overall quality of CO2 vascular images is slightly less than that obtained with contrast medium. Therefore, rou-tine use is not desirable for complex interventional procedures, requiring precision in imaging quality.

It is important to note that incorrect application of technique may result in air contamination, which may cause serious complications. Therefore, a thorough understanding of the unique physical proper-ties of CO2 is necessary for the safe and effective performance of CO2 angiography. The highly skilled and board-certifi ed physicians at Center for Vascular Medicine (CVM) have received specialized training in performing CO2 angiography.

REFERENCES:Moos JM, Ham SW, Han SM, et al. Safety of carbon dioxide digital subtraction angiography.

Arch Surg. Dec 2011;146(12):1428-32.

Nadolski GJ, Stavropoulos SW. Contrast alternatives for iodinated contrast allergy and renal dysfunction: options and limitations. J Vasc Surg. Feb 2013;57(2):593-8.

CVM INTRODUCES C02 ANGIOGRAPHYBY VINAY SATWAH, DO

Carbon dioxide guided stent placement of right renal artery stenosis. A. CO2 DSA demonstrates orifi ceal stenosis of right renal artery (arrow). B. DSA with the injection of CO2 through the sheath demonstrates the stent in good position (arrow). C. After stent deploy-ment, the renal artery is widely patent.

8:16 PM



COMPLIANCE

Open Payments/Sunshine Act Year Two: Guidance for Physicians

By Theodore M. “Ted” Doolittle

N JUNE 30, 2015, THECenters for Medicare and MedicaidServices (CMS) will publish the first full-year report of payments tophysicians from pharmaceutical andmedical device manufacturers. Physicianswho want to review their data beforepublication can register with CMS.These data are being published pursuantto the Sunshine Act portion of theAffordable Care Act, which requiresmost pharmaceutical and medical devicemanufacturers to report a wide range ofpayments to physicians and academicmedical centers. In September 2014,CMS, which calls the program “OpenPayments,” published the first officialreport, but it covered data only from the last five months of 2013.

The Open Payments program reportsa wide range of payments to physicians.Some examples of common paymentcategories are:

z Speaking engagementsz Travel expensesz Mealsz Entertainmentz Giftsz Educational materials such as

textbooks or journal reprintsz Participation in a paid advisory boardz Royalties, consulting fees, research or

other grants, etc.

Pre-publication review of the OpenPayment data is important to individualphysicians for several reasons. First, theinitial set of data contained a largeamount of incorrect, mismatched, orotherwise misleading data, which insome cases created the impression that a doctor had received payments that infact were not made. Second, manyhospitals or other physician employershave used the Open Payments site to

validate compliance by employedphysicians with the hospital’s own ethics or conflict-of-interest policies.

Third, patients and consumer oradvocacy groups can access this dataeasily, which may result in questions tothe physician about payments he or shehas received. These kinds of questionscan only be expected to increase in 2015, because CMS has madeconsiderable refinements andimprovements to the website, which willmake this information easier for patientsand others to access and analyze.

The best way to respond to suchquestions is to know in advance whatdata is on Open Payments, and betteryet, to correct any misleading orincorrect data before it is evenpublished. Fortunately, individualphysicians do have the opportunity in advance of publication to review, and if necessary, dispute, anyinformation about them reported by amanufacturer. The so-called “Reviewand Dispute” period lasts 45 days.During the first program-year, due tothe difficulties associated with startingup a new program, CMS announced thevarious program deadlines on a rollingbasis. On February 2, 2015, CMSannounced that it anticipated the 45-dayReview and Dispute period would starton a date to be determined in April2015 to accommodate the June 30publication date.

The first step for physicians who wish to review their information beforeit becomes public, and who also wish to receive notification of importantdeadlines such as the start of the Review and Dispute period, is to createan account at the CMS Enterprise Portal page at portal.cms.gov/wps/portal/unauthportal/home/. Furtherinformation about the next steps in the

registration process can be found atcms.gov/OpenPayments/Program-Participants/Physicians-and-Teaching-Hospitals/Registration.html.

When a physician chooses to disputeany data they find during the Reviewand Dispute period, the Open Paymentsystem triggers communication betweenthe physician and the relevantmanufacturer, and if a mutuallyagreeable resolution is reached beforethe date of publication, CMS willpublish the corrected data. If a mutuallyagreeable resolution is not possiblebefore the publication deadline, CMSwill not mediate between a physicianand a manufacturer. The data will be published as reported by themanufacturer, but marked as “disputed.”

As CMS continues to refine the system and make it easier to access and understand the data, physiciansshould expect an increase in questionsstemming from payments they havereceived from drug and medical devicemanufacturers. Much as the rise ofwebsites such as Zillow, which containsreal estate pricing data, have made iteasier for individuals to access house and mortgage information nearlyeffortlessly, so should doctors nowexpect that patients, malpracticeinvestigators, potential employers, andeven just the idly curious will be able toaccess a full slate of information regardingpayments from drug and medical devicemanufacturers? Physicians are thereforewell advised to make it an annual ritualto visit the Open Payments site pre-publication. This will enable the physicianto prepare written or oral responses toquestions about his or her data, and/orto dispute the content if necessary.Theodore M. “Ted” Doolittle is a partner at LeClairRyan. He can be reached

at [email protected].

O

BY LINDA HARDER


Q: Can the ACA be dismantled at this point? That would be difficultsince many provisions of the ACA have been implemented and would be challenging to undo.

Q: How has the ACA impactedemergency care? First, emergency carehas been affected by the ACA’s insurancereform, which we know is associatedwith an increase in the use of emergencydepartment (ED), primary care andhealthcare services in general. We knowthat having insurance increases the useof all medical care, including ED use.

The problem is that Medicaid patientsstill face major barriers to care fromoutpatient doctors because manyphysicians don’t accept Medicaid.Especially in places like Maryland andD.C., where Medicaid has expanded,we’ve seen an acceleration of ED visitsand a growth in the percentage ofMedicaid patients.

Second, payment reform has

affected emergency care. A key element of the ACA was to create the Centers for Medicaid and Medicare Services(CMS) Innovation Center, which has the ability to change the way physiciansand hospitals are paid without goingthrough the congressional rule-makingprocess. We’re seeing a move away from strictly fee-for-service payments to new payment forms, such as those in Accountable Care Organizations(ACOs), episode-based payments andbundled payments. They provide anincentive to deliver care more efficiently.

While the impact of these sorts ofpayment models on how emergencyphysicians get paid is yet to bedetermined, we do know that ED visitsoften result from poor care coordinationand that ED discharges also mustcoordinate care. New incentives for EDs and hospitals will promote this,especially in Maryland, where hospitalsessentially receive a fixed payment for hospital-based care, makingcoordinating care and keeping people

healthy priorities, particularly when they have multiple chronic conditions. In the old model, doctors didn’t talk to each other much and that didn’tbenefit patients. In the future, this will change.

Q: Can more primary care addressthe issue? Unfortunately, there’s a realshortage of primary care physicians dueto the unfavorable economics. And thatdoesn’t fundamentally change with theACA. Very few medical students areelecting a primary care path. I recentlyasked a group of about 25 third-yearmedical students whether any of themwere planning to choose primary care.

POLICY

The Challenge of Controlling Healthcare Utilization

Jesse Pines, MD, MBA, a board-certifiedemergency physician, is the director of the Officefor Clinical Practice Innovation and a professorof Emergency Medicine and Health Policy at the George Washington University School ofMedicine and Health Sciences. He is an authorityon the impact of the Affordable Care Act (ACA)on the current acute care system, and costcontainment/utilization approaches.

A conversation with Jesse Pines, MD, MBA, Director of the Office of Clinical Practice Innovation at George Washington University


Only one hand went up, and thatstudent admitted she was only justthinking about it. The rest were planningto become specialists. To have moreprimary care, the economics must change.

Q: Does better care coordinationreduce use? In EDs today and in thefuture, there will be more of a push tocoordinate with primary care physiciansand multiple specialists outside the ED.It creates more work but may be lesscostly because hospital admissions are so expensive.

Q: What impact have globalhospital budgets, such as the ones inMaryland, had on the ED? When ahospital is operating under a globalbudget, as Maryland hospitals are nowdoing under the waiver, admitting acomplex patient becomes a cost driver,not a revenue driver. In the ED, that ismanifesting as longer, more complicatedwork-ups to keep people out of thehospital.

I wrote an article on the earlyexperience of the Total Patient Revenue(TPR) hospitals in which we looked atthe impact on EDs. A lot of good thingsresulted – social work and caremanagement services increased, forexample – but there were alsounintended consequences. At leastanecdotally, I heard that hospitals underglobal budgets would transfer some ofthe complex patients out to hospitalsthat were paid under fee-for-service.With all Maryland hospitals now onglobal budgets, it will be interesting tosee how this evolves.

One issue with payment reform thatwe know is that it can set up conflictingincentives between physicians, who arestill largely paid on a fee-for-servicebasis, and hospitals that are paid on aglobal budget. In the TPR program,many inpatient specialists left to go tonon-TPR hospitals. From what I’veheard, the CMS Innovation Center’slong-term plan is to put everyone onglobal payments. Until that happens,there will continue to be a push to movecare, where possible, into unregulatedspaces such as the outpatient setting.

Q: It seems like urgent care centersare on every corner these days.Doesn’t that help with ED utilization?

Urgent care centers and retail clinics are a great example of unregulated space. The issue is that these tend to be built insuburban areas that have a good case mix,not in poorer areas such as inner cities.

The other issue with building moreclinics is supply-induced demand. It’slike our traffic problems on thehighways. We assume traffic willimprove if we add more lanes, but thatin turn attracts more drivers to remotesuburbs, and traffic gets worse again. Ina similar way, building more urgent carecapacity attracts more patients, so itcould potentially induce more demandfor care rather than drawing patients outof EDs. The issue now with urgent careand retail clinics is that some don’taccept Medicaid, and there’s not muchregulation of their quality.

I previously served as an advisor forthe CMS Innovation Center. I rememberone of my first meetings. We weretalking about decreasing costs and Iasked, “Haven’t you been trying to dothis for the last 30 to 40 years?”

The response was, “Every time we try to decrease healthcare costs, it’s likesqueezing a balloon – you push on oneend and the other end gets bigger.” Newpayment models are trying to grab abigger part of the balloon. If part of thesystem is unregulated, there’s always aplace for the balloon to expand.

Q: Don’t high-deductible plansdiscourage ED use? A high deductibledoes provide a disincentive to use theED, but those with Medicaid have nosuch disincentive. And for those withoutMedicaid, such as those with “bronze”plans who have low incomes and high-deductibles, it discourages not only ED use, but any healthcare use.

Q: Would a single-payer approachbe a better option to controlutilization and costs? Single-payer is a great idea and works in many othercountries, but the question is how we get from here to there. Vermont recentlytried to implement a single-payer system,but ultimately did not because it would

cost too much. Several years ago, weexamined data from several countriesthat had a single-payer system, and, with few notable exceptions (includingDenmark), they all had ED crowding.ED visits in France, for example,doubled from 1990 to 2010. Justchanging the payment system doesn’tsolve the delivery-system problem.Delivery-system reform needs to drivepayment reform, not the opposite.

The other factor to consider is theprice of American healthcare. Costequals volume times price. For somehealthcare services, prices in this countryare three to five times higher thanelsewhere. Even current global paymentsare based on historical payments, so they aren’t really addressing the priceside of the equation. Once we create a

more efficient system, we’ll have toaddress price, or we won’t be able tobring down costs.

Q: Are there any strategies thatwill work? On the positive side, with theACA, we’re undergoing a major culturechange, and physicians increasinglyunderstand that resources are finite.There’s a lot of grassroots changeoccurring. Six months ago, I was in thetrauma bay, and a resident told me thathis patient didn’t need a CT scan. When I asked him why he thought that, he cited evidence-based tools. He was right,but it was still shocking to hear him sayit. That’s one example of that culturechange having a positive impact on costs,though it does increase the risk of patientsafety problems. Some healthcare iseffective and less costly. The challenge isfiguring out what care is most efficient.Jesse Pines, MD, MBA is principal investigatorfor Urgent Matters (urgentmatters.org), a GW

School of Medicine program that disseminates

information on best practices in emergency

care and has extensive experience in quality

improvement, patient safety, operations

research and clinical epidemiology. He has

served as a senior advisor at the Center for

Medicare and Medicaid Services Innovation

Center in Baltimore, and a consultant to the

National Quality Forum on patient safety and

emergency care in Washington, D.C.

Once we create a more efficient system, we’llhave to address price, or we won’t be able tobring down costs.


OUR BAY

Maryland’s Cross Island Trail spans Kent Island, east to west, in Queen Anne’s County with some

truly exceptional views of the Chesapeake Bay.

JACQUIE COHEN ROTH


Pelvic Pain C E N T E R F O R

o f V a s c u l a r O r i g i n

I S Y O U R PAT I E N T F R U S T R AT E D W I T H

Chronic Pelvic Pain?

Pelvic Congestion Syndrome (PCS) is a condition which is associated with varicose veins in the pelvic area, lower abdomen and thighs.

Often accompanied by chronic pelvic pain, it is estimated that this condition affects 15% of women between the ages of 20-50.

outpatient-based endovascular techniques.

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C E N T E R F O R VA S C U L A R M E D I C I N E I S A N AT I O N A L L E A D E R I N T H E T R E AT M E N T O F P C S

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